Shoulder!! The importance of prenatal care
“SHOULDER!” This is one of the absolute scariest things you can hear on a labor and delivery floor.
The mother had come in with no prenatal care, already well in labor. There was no time to get an ultrasound to see if the baby was big, no time for an epidural anesthetic or to get any labwork. There was nothing to do but deliver the baby. This was one of my earlier deliveries when I came to Duluth from Seattle, it was in the middle of the night and I was working with one of the newer resident physicians. The resident and I talked over the delivery before going into the room, but nothing can really prepare you for a shoulder dystocia. There were a lot of unknowns right from the start with this delivery and we just had to make the best of it. The mother was in a good contraction pattern and the baby’s heart tones looked OK. The mother’s mother was there for support and was talking her through the contractions. I had been talking with both of them all along so they knew what to expect.
The delivery was progressing well, the head was starting to show and the resident was getting ready to deliver the baby. She gently guided the baby’s head and properly held the head back slightly to avoid any tears to the mother’s birth canal.
Normally, once the head is out, the baby’s mouth and nose are suctioned out and a quick check is made to see if the umbilical cord is wrapped around the baby’s neck. With gentle traction on the baby’s head, the shoulder is guided down below the mother’s pubic bone and the rest of the baby follows easily.
But not with a shoulder dystocia. A shoulder dystocia means the baby is stuck in the birth canal. The head comes out OK, but then it pulls back tightly and the leading shoulder gets stuck behind the mother’s pubic bone. The longer you wait, the more the baby becomes stuck. The baby had been getting oxygen through the umbilical cord, but the cord was now compressed in the birth canal and the baby is unable to breathe. This is a flat out emergency and all the available help comes running: nurses, residents, everyone. Time is very short to avoid a bad outcome. Permanent neurological damage can happen if a baby isn’t delivered quickly at this point.
The resident was very bright and had studied hard for just this situation, but the first time this happens it’s hard to know how hard to pull on the baby. This is an emergency and seconds count, sometimes it means breaking a baby’s collarbone to allow the shoulder to come out.
Once we called out “shoulder!,” help was there immediately. The mother’s legs were pulled back so her thighs were on her abdomen to make more room in the birth canal; this is called a McRobert’s maneuver. One of the nurses applied gentle pressure to the area just above the mother’s pubic bone to push the baby’s shoulder down as another nurse pushed on the mother’s abdomen. This is not a time to be delicate, everything is done firmly but gently and as quickly as possible.
I was standing beside the resident and I reached over and put my hands over hers. She was going to move out of the way, but I told her to stay where she was. I applied traction to the baby’s head and pulled the head downward to bring the shoulder past the mother’s pubic bone. With the help of the nurses doing the McRobert’s maneuver and applying pressure, I could feel the baby’s shoulder slide past the mother’s pubic bone and the baby started moving.
The rest of the delivery went well, the resident finished suctioning the baby’s mouth and nose, clamped and cut the cord and handed the baby to me. I took him to the warmer and the nurse and I rubbed him briskly with linens to get him to cry. His hands and feet were initially blue but turned pink within a few seconds and his cry was vigorous and strong. He was looking around as I finished the rest of his exam. This was a very big baby and weighed a few ounces shy of ten pounds. I talked with the mother and her mom about what an emergency the delivery really was, they both understood this after we talked and were grateful the baby was OK.
The resident and I were finishing the chart work in the nurse’s station after the delivery. Both of us were drenched in sweat, not from the physical labor, but from the sheer stress of the delivery. I dictated a delivery note and we went over the orders for the mother and the baby.
Why do we do prenatal care? To avoid deliveries like this. This could have turned into a very bad situation if we would have been unable to get the baby delivered quickly. The mother turned out to have gestational diabetes, which means she was diabetic during her pregnancy only. The fetus gains weight rapidly when exposed to high blood sugars. Normally a baby’s head is the biggest part of the body and the head opens the birth canal so the rest of the baby can deliver easily. A baby born to a diabetic mom has a large body and the head doesn’t open the birth canal enough to allow the rest of the baby to come out easily. Regular prenatal visits would have picked this up early on as well as other pregnancy related complications.
The whole shoulder dystocia part of the delivery lasted less than a minute, but it was one of the longest minutes of my life. As I was leaving the hospital to go back home to try to get some sleep, the resident caught me in the hallway. “Dr. Vainio, I’m so glad you were there.”
I thought back to my own residency and a delivery exactly like this one. I was the resident, full of knowledge and eager to learn. I had great nurses to learn from and the delivery was going well. When the shoulder dystocia happened to me, I didn’t know how hard I could pull on the baby. Peter Talbot, MD is the medical director at the Seattle Indian Health Board and has been there since 1976. He has delivered countless babies, many in Alaska with no other doctors to back him up. Peter was with me that night when I was unsure of myself and he reached over and put his hands over mine. I felt him pull the baby free and the rest of the delivery went well.
Dr. Talbot, I’m so glad you were there.
Arne Vainio, M.D. is a Family Practice Physician at the Min-No-Aya-Win Human Services Clinic on the Fond du Lac Ojibwe Reservation in Northern Minnesota. He can be reached at email@example.com.