Resolving Shoulder Dystocia

FlipFOLP for shoulder dystociaResolving Shoulder Dystocia in the Active, Mobile Woman

Gail Tully, CPM, became interested in communicating to midwives and doctors about Shoulder Dystocia after observing a higher incidence following the labors in which OP babies rotated to OA before emerging. (Incidence is actually less likely in babies who emerge OP.) **Scroll down to see the trailer for her Resolving Shoulder Dystocia video.

Gail developed a memory tool called FlipFLOP to help birth attendants free the stuck shoulders with little chance of birth injury. Non-drugged birthing women have more options to put their pelvis to work to free the shoulders from the pelvis. It would be helpful for women birth attendants to learn techniques that give them the leverage to rotate the baby's shoulders free. See how to do it after the trailer for Resolving Shoulder Dystocia.

 

 


Here is a brief description of the techniques in FlipFLOP

Flip the mom over (this is the Gaskin Maneuver); Lift her leg; rotate the shoulder to the Oblique; and bring out the Posterior arm.

 

Flip the mom over (this is the Gaskin Maneuver)

A traditional method is to flip the mom onto hands and knees. Its now known as the Gaskin Maneuver. Ina May Gaskin, world renown midwife, popularized the simple method of helping a woman to flip over onto her hands and knees. The movement of rotating the mother will often free the shoulders.

In situations when more techniques are needed, start with Gaskin's and go step-by-step through 3 subsequent techniques.

 Lift her leg  Dr.McRoberts' introduced a way to  nutate the pubic bone in women who were on their backs by lifting both bent legs so that the mother's knees are pulled up towards her ribs (arm pits). But with the mom on Hands and Knees, its easy to lift one knee to the ribs and put that same foot on the mattress (or floor) to nutate one side of the pubic bone. It also opens up the pelvis on that same side by moving aside the ischial tuberosity. Now you have room to slip a hand in along the mother's thigh to do the next step -if still necessary.  

Rotate the shoulder to the Oblique

Dr. Wood's introduced rotation in the 1940s.  Dr. Ruben noted that if you rotate the shoulder towards the chest you could use less force while making the baby be in the smallest diameter (seem smaller). The oblique diameter is the diagonal angle of the pelvis, from "2 o'clock to 7 o'clock" or from "10 o'clock to 4 o'clock," for instance. You must brace the baby's scapula (shoulder blade) with your palm inside the mother and push the shoulder towards the baby's chest. Brace the baby's upper arm with your first two fingers to prevent it from breaking. This might take all your might, or might be just a bit of a shove. 

Bring out the Posterior arm

Dr. Sarah Poggi began a conversation about the benefits of bringing the posterior arm out of the pelvis in 2004. Finally, we have two articles out in 2011 praising the success of bringing out the baby's posterior arm. You can think of Gail's memory tool, FlipFLOP, as a very effective way to bring out the posterior arm.

 

Click here to Download the single page FlipFLOP pdf file (1.19 mb)

 

Subject: Worked like a champ!

Hi Gail,

Wanted to tell you my colleagues & I took your shoulder dystocia workshop in VA and had the opportunity to use it last week. We flipped mom to hands and knees- no baby, right leg in running start- no baby. Switched the running start to left leg and it was like a cork out of a bottle. There were a couple of tense moments as I never felt a shoulder... just lots of neck, but the running start did the trick! The grandmother was very complementary saying we looked like a well oiled machine jumping into action. AND mom didn't even have a laceration!

Thank you so much for taking time out of your full life to share your gift with us! You are welcome back any time.

Blessings,

T**

 

 

How to use FlipFLOP 

First, move the mother to move the baby.

Running Start in two views with rotation towards chest

Flip the mom on to her hands and knees. This can be done quickly and even on a hospital bed that is "broken." The rotation of the movement may dislodge the shoulder(s). 

After the mother has flipped over using Gaskin's Maneuver onto her Hands and Knees position most babies will be born spontaneously. However, if the baby isn't born immediately, the midwife or her assistant directs the next move as the next contraction begins or before.

Lift the leg to the "Running Start" position. With the midwife's direction (and the touch of her assistant) the mother lifts one leg and sets her foot flat on the mattress or floor where she is birthing. Her knee is up near her ribs, near her arm pit and her foot is flat, not up on her toes. Please notice the positioning of the leg, so that the knee isn't away from her body.

Running Start rolls the baby's anterior shoulder off the pubic bone as the movement twists (nutates) one half of the symphysis pubis. The pubis shifts from the movement of putting the leg into the "Running Start" position (knee to arm pit). It is like half the McRoberts' maneuver, which is done with the mother on her back. Half the pubic bone is rolled as the leg is lifted. Another set of babies will be born spontaneously with the addition of "Running Start" to the Hands and Knees position. If the mother gave birth to the baby's head while already on her Hands and Knees, she moves directly into "Running Start" without flipping over. If the arm can not be rotated (due to fists being locked into each inner elbow crook, then flip the mom into McRoberts position. But moving on to the next maneuver is faster.

Rotate the arm into the Oblique diameter. If the baby doesn't come right out with the contraction after assuming "Running Start," the midwife slips her hand into the mother, starting near her thigh, until she finds the back of baby's posterior shoulder. (The mother at this point is in hands and knees position.) She rotates the posterior shoulder towards the baby's chest into the oblique diameter of the mother's pelvis. There is the most room in the oblique diameter of the pelvis. Another set of babies will birth readily from rotating the posterior shoulder into the oblique diameter. [The repetition is intentional. Practice with a doll.]

If the baby fills up the mother's pelvis so much that the baby doesn't come right out with the shoulder rotation to the oblique diameter, than the midwife will continue efforts.

Bring out the Posterior arm. This is done best if the midwife splints the posterior humerus (upper arm bone) with her index and middle finger and sweeps the arm towards the baby's chest. Now she reaches her index finger into the bend of the inner elbow. This will flex the arm, meaning it will make the arm bend. Now the midwife can grasp the baby's wrist and work the hand up to the light of day (or lamp of night). Then the whole arm can be wiggled out carefully. This reduces the diameter of the baby's body by 2 cm. If that isn't enough, the baby is rotated 180 degrees so that the previously anterior arm is now posterior and that arm is brought out. Now the mom can push and the baby will come out.

FlipFLOP works probably 80-90% of the time. Try it and let me know. But notice the lie of the shoulders, too, and report both. Rotation usually works before you have to bring out the arm.

PAC Pull for shoulder dystocia when baby's shoulders are transverse

 

Rarely, the baby is too big and the mother's pelvis too small for the attendant to reach inside to bring the posterior arm out. The midwife can use PAC Pull. Posterior Axillary Crease Pull, here's how its done:  Brace the first two fingers behind the posterior axillary crease and, while rotating, pull the baby around and out. As long as the baby isn't overlapping the pubic bone, you can pull in this way, and this way only,  without fear of brachial plexus injury. Pulling from the front of the baby's arm pits is dangerous and could harm the nerves to the arm(s). Never pull without rotation. And its better to rotate rather than pull. Slow down and pay attention to the steps of freeing the shoulders. Don't begin yanking! See this in birth footage and with a doll and pelvis in the Resolving Shoulder Dystocia video.

 

 

McRoberts is handy for women  on their back whose baby's shoulders are stuck in the front to back (AP) diameter. McRoberts is useless for babies stuck in the transverse diameter or who are below the inlet.

Learn when McRoberts works, how to do it correctly and how to assess when McRoberts won't work -and what to do then in the video.

Anne Frye

 

  • Please read Anne Frye's Holistic Midwifery Volume II for a thorough description of Shoulder Dystocia. You can also find reference to FlipFLOP and other comments I've made - how cool is that?!
  • Order her groundbreaking text at www.midwiferybooks.com/



 

 

 

There are far more details in Resolving Shoulder Dystocia than are listed here, of course. Gail can not promote unassisted homebirth because of the risks when an unexpected emergency arises. Sometimes what a midwife can do simply can save a life that would be lost if a trained person were not at the birth. Seeing several births is not the same as being taught from your teacher or preceptor (and having them to step in if needed). Stuck shoulders are really stuck! 

Precise and determined action is needed and needed immediately.

We can trust birth when we listen to the signals that tell us what is needed in any unique birth. We can trust birth when communication within the birthing team is open and honest. Our response-ability is in responding to those signals appropriately.

 

 

 Occasionally, Pregant women tell me their doctor's are concerned about a possible shoulder dystocia: 

 "Five Steps to Free a Shoulder" for Birthing Women

  1. STOP pushing!
  2. Flip yourself (and your epidural tubing if you're on an epidural) over to your hands and knees. This is Gaskin's Maneuver (the flipping over).
  3. Lift your Right leg and put your knee in your ribs and that same foot flat on the mattress. This is Running Start position.
  4. Arch your back (do a pelvic tilt and hold it) so that you flatten the curve in your lower back. This makes room at the top of your pelvis. 
  5. If your baby isn't free with the next contraction, switch legs, putting your right knee back down and lifting your left knee into your ribs (at your side) and putting your left leg down.
This will help baby's shoulder off your pubic bone or, off your pubic bone and sacral promontory. Being on hands and knees also allows your sacrum to actually move outward from your baby (don't blame your doctor if she hasn't been taught this).
Once you feel the shoulder shift down you can push. 

6. This position is also easier for your doctor to reach in and bring out your baby's posterior arm (the arm in back) which will help the doctor get the rest of your baby out if that is even needed after your movement. 
 
Alternative 6. Some providers will want to flip you back on your back and do McRoberts with Suprapubic and that is effective for an inlet dystocia that isn't fixed by the "Five Steps to Free a Shoulder."

 

 

Dr. Carol Phillips, DC, relaxes the round ligament of a pregnant woman with the Webster TechniquePossible prevention of shoulder dystocia

There may be a  possible correlation of the long arc rotation with shoulder dystocia.  A good explanation is in the video. A birth is shown as well as an explanation with doll and pelvis. During labor, there may be an advantage to having body work or doing self care to overcome tension and restrictions in the pelvic ligaments and joints.

Inducing labor to prevent the baby having time to grow big is not statistically found to reduce the incidence of shoulder dystocia. That may be because the powerful effect of Pitocin, the artificial hormone to make strong uterine contractions to induce labor, moves the baby down fast enough that a few of these babies, though smaller, don't have time to rotate their shoulders for birth. Meanwhile, inducing to force the birth before baby finishes growing is a common, and risky, occurrence.

Moving the mother as the head is crowning may also interfere with proper shoulder rotation. This occurs when a mother is crowning while on the toilet and she is encouraged to move back to the bed, or when the mother is crowning on a birthing stool and she is offered and helped into the birthing tub, or some such move as that. Interference, whether by people who want to help the mother or help themselves, can interfere with the baby's own efforts to birth smoothly through the pelvis.

Laying down on the back to push a baby out, pushing before the urge to push, and the use of a vacuum or forceps during birth might be associated with a shoulder dystocia. Sometimes interventions to help overcome chronic problems from lifelong habits become necessary. We all do the best we can with what we know at the time.

I suggest a diet with more live foods, meat with fat, and organic if possible, salt, seaweed, dark leafy greens, yellow veggies and only a fruit a day, rarely fruit juice. Skip the breads and noodles. Have whole grains, such as brown rice and oatmeal, quinoa, and millet, iron-rich fava beans, and similar healthy carbohydrates. Avoid sugar and regular use of milk, cheese, peanut butter and processed foods. Move. Move your body more. Yoga stretching and walking. Body work and upright positions in labor. Relaxing the broad and round ligaments and helping baby into an optimal position in the 7th and 8th months so the arms can get settled in front of the chest before labor starts. Using a pregnancy belt in labor for women with a pendulous uterus and wearing it during pushing until the baby is out!  Avoid cowboying out (wrestling for every mm of descent for hours of 2nd stage, which is different than simply a long 2nd stage) a large baby through an adroid pelvis, especially if there isn't a team of experienced people with this complicaton. These, to me, are ways to avoid shoulder dystocia.

I do not believe that simply having a homebirth or changing providers will avoid this particular complication! Shoulder dystocia can happen when women are free to move and "undisturbed," also.  Shoulder Dystocia is a cause of death in "free" births without a midwife more often than those births with an experienced, trained midwife.

A medical review for trying to prevent shoulder dystocia in labor can be viewed on this link, http://apps.who.int/rhl/reviews/CD005543.pdf

A chart of methods to resolve shoulder dystocia.

Here is a chart of maneuvers being developed to go with my upcoming book, Resolving Shoulder Dystocia. It won't make sense to those who haven't studied shoulder dystocia in the literature. Use my video to understand it much better.. Click here to Download the Shoulder Dystocia Maneuvers Chart. (56 kb)  

 Midwifery Today published a brief article which I wrote: Shoulder Dystocia; The basics Midwifery Today (Summer 2003).

 

 

The Resolving Shoulder Dystocia class

Set up for Resolving Shoulder Dystocia in Duluth, MNI've developed a Resolving Shoulder Dystocia class to give you a step by step understanding of

  • How the shoulders lie in the pelvis when stuck
  • Normal shoulder rotation to judge stuck shoulders by
  • Reliable solutions to use with each type of shoulder dystocia
  • You will know when to use which technique and how to use them safely
  • Hands on practice with a doll and either a specially fitted manikin or pelvic box (when flying in)
  • Practice together to improve communication and charting during a shoulder dystocia
  • Slide show with photos and film clips of normal birth and shoulder dystocia
  • Good handouts of types and techniques
  • 3 MEAC CEUs for the 3 hr version.

 

 

You may buy the video through this website. There is unique footage, perspective and reassurance in the video. Its not superficial, and its not academic. Its practical, indepth explanations made easy to understand. You will learn good, useful techniques and understand why and how they work. 

 

Bring out the posterior arm!  in Texas

Find a workshop on the "Spinning Babies and...  Gail's Events" page. If you see a Spinning Babies Workshop without a Resolving Shoulder Dystocia workshop in your area, please  contact Gail to set up a Resolving Shoulder Dystocia class that very evening, 2 hours after Spinning Babies. Its a three hour class with MEAC CEUs.  Help bring this class to all providers.


 

Gail Tully in New Jersey with Vicki Hedley Resolving Shoulder Dystocia


McRoberts with Suprapubic at the Resolving Shoulder Dystocia workshopFlipFLOP from Gaskins to going for the posterior arm, Resolving Shoulder Dystocia Vicki Hedley's class with Gail Tully

These are photos from Gail's classes, Texas Midwives show a raise of hands from the small group favoring Posterior arm removal (removal from the pelvis, not the baby!). The next three photos are at VIcki Hedley's class in NJ. We used the womb-anikin in three different poses depending on the type of dystocia. Vertical for an outlet dystocia; McRoberts with suprapubic for the unilateral inlet dystocia in a mom with an android pelvis; and hands and knees for inlet and outlet both. 

 

"I absolutely don't fear shoulder dystocia anymore. There's a respect there, but not a fear." -Maureen Dahl, CPM, after resolving a double inlet dystocia using class techniques.

Maureen Dahl gives me a hands while I prepare my visual aids.

Maureen gives me a hand as I prepare for class. I wish I'd thought to photograph the pelvis set up with the uterus and round and broad ligaments.

Maureen continues, "Before the class, I had a system, but there was still some anxiety. But after being trained by you there is no anxiety. There's a take-action response, a proactive approach with what I've learned. 

"That last one was a true shoulder dystocia. This was a double inlet dystocia [both shoulders stuck at the brim]. That one was going to end in tragedy. She'd had unassisted births and was pushing the baby out before I got there. She was in the tub as I walked in. She said, 'There's something wrong, there's something wrong. The baby's not coming.' I asked her to get out of her tub, I hated to, but I had to. 

"I got her in an exaggerated McRoberts' to get the head to come down. It was coming very slow and then, Arghh! [Turtle sign: The shoulders pull the emerged head back in a bit so that the baby looks like a turtle retracting the head.]

"I got her immediately into Gaskins' and immediately into Running Start. Then I tried [to rotate the posterior shoulder to the oblique diameter but couldn't get it to budge] I found the back with my right hand. It was extremely way up there. Maureen practices FlipFLOP with modelsI put my whole hand in, past the wrist, and tried to compress the shoulder forward [Maureen is describing in her own words how she tried Rubin's rotation] Then I backed off because I had an urge to hook the armpit with my finger and knew not to do that.

"I tried the PAC Pull but, no.  So, I put my left hand inside and went for the anterior shoulder. It was way up there, I lifted the shoulder [pushed the shoulder higher up back into the pelvis with her finger tips] and then g0t behind it and pushed it forward [in Rubins] to the oblique. Then they were freed from the impingement. 

"Then, I had her push." [Mothers don't push until the shoulders are free so they don't push the shoulders on to the bones they are stuck on.] The baby was ten pounds and Apgars were 9 at one minute and 10 at five minutes.