Shoulder Dystocia

This article was reproduced from Midwifery Today. E NEWS 1:3

Let the Shoulders Birth Spontaneously
– from “A six-year retrospective analysis of shoulder dystocia and delivery of the shoulders” by Vivien R. Mortimore and Mary McNabb, Midwifery magazine, 1998

When birth takes place under water and when women choose to give birth on all fours, squatting, kneeling or standing, the shoulders are usually born spontaneously a few minutes after the birth of the head. This occurs despite the fact that a “hands off” approach to the birth of the shoulders is common practice at such births, as access is often restricted. In comparison, when women are delivered in a recumbent position, traction appears to be required more often, particularly when the mother has epidural analgesia.

Delivery techniques may actively influence the mechanisms of labor. If traction is applied to the shoulders before they have had time to rotate, it is possible that this interferes with the outlet mechanisms and hinders the spontaneous birth of the shoulders. It has been suggested that in cases of difficulty, the use of traction may only serve to increase the degree of impaction and the likelihood of neonatal injury. If such interventions run the risk of causing difficulties with the delivery of the shoulders and injury to the baby, the common practice of applying traction needs to be questioned. These problems may be reduced, if time is allowed for the shoulders to be born spontaneously, by waiting for a uterine contraction and for the mother to bear down.

Many birth attendants are anxious that, by waiting for shoulders to be born spontaneously, birth will be prolonged significantly and the baby will become asphyxiated. A study was carried out on 100 women and compared an active with an expectant approach to the delivery of the shoulders. The mean time for the birth of the head to expulsion of the body was 18 seconds (range 4-40 seconds) in the active group and 50 seconds (range 9-150 seconds) in the expectant group. In this small study prolongation of the expulsive process in order to achieve spontaneous birth of the shoulders did not compromise neonatal outcome. There was no neonatal birth injury in either group.

It would appear that when there is less interference and the shoulders are allowed time to rotate and are born spontaneously, the posterior shoulder is more likely to be born first. This was the case in the early part of the century when a less intrusive, expectant approach to the birth of the shoulders seems to have been the norm. It would appear that a technique that was initially reserved for cases of difficulty has been gradually adopted routinely for normal births The reason for this is unclear, but it is possible that it was used to hasten birth or possibly because obstetricians, accustomed to using this technique in more difficult cases, began to employ it before difficulties with the shoulders were encountered.

Research to date has associated the use of traction at delivery with injury to the baby. If women were allowed time to give birth to the shoulders spontaneously, there is no evidence to suggest that neonatal mortality or morbidity would be increased and the problems associated with the use of traction would be avoided. It may be more appropriate for women to give birth to the shoulders unaided, and for the midwife to adopt a hands off approach unless otherwise indicated.

– from “A six-year retrospective analysis of shoulder dystocia and delivery of the shoulders” by Vivien R. Mortimore and Mary McNabb, Midwifery magazine, 1998