Monday, December 27, 2010

the shoulders

I have often been told that as a student, we all have a "hang up", a scenario that we fret over. For some it is a postpartum hemorrhage, a surprise vaginal breech, a serious baby resuscitation, etc. For me it was always a shoulder dystocia, a complication where the baby's shoulders become 'stuck' behind the mothers' pubic bone. It can be a potentially serious situation involving long term damage to both Mother and Baby. I have always been drawn to reading anything and everything that I could about this situation. Whenever I have been at conferences or gatherings of midwives, I was always present at discussions about 'shoulders'....always trying to suck up and store any tidbits of wisdom. As a student, I thought that I had had two cases and then I thought that I had another two cases as a midwife. The optimal part of those cases is that "I thought" I had had 4 shoulder dystocia's. My first clue to the error in my thinking should have been the number.....4 is a lot of these to have in a short period of time, as this is a relatively uncommon complication. Additionally, in all four situations the problem was resolved pretty quickly, less than 30 seconds, and with very mild intervention. You see, before Jenny's birth, I thought I had dealt with 'shoulders' before.....

Jenny was a first time mama, a sweet petite little lady with a supportive and tall, lanky husband. Her labor was nice....lots of moving and grooving, moaning and singing. She progressed nicely and at a good pace. Then she entered second stage and her nice progression stalled. She pushed and pushed and fought for every little gain. Finally, Jenny had worked her little one to crowning, and still the progress slowed. Of course, this second stage pattern is a classic 'warning sign' for shoulder dystocia, so I was mentally preparing for it. Running the drills in my head, telling the nurse to be ready with oxygen and to help with interventions. We were 'on alert' and ready. Then we were given the "turtle sign" from the babe...this is when the head emerges and then quickly retreats back into the perineum, like a turtle retreating into its shell. This is the ultimate and supremely classic sign of a shoulder dystocia, and I had never witnessed such a clear and obvious example of it!

Very quickly, we had Jenny get into McRoberts position, which for my previous 4 cases had worked like a charm. Absolutely no descent from baby. Very quickly we had Jenny move to the Gaskin (hands and knees)...again, absolutely no improvement. I passed my hands into Jenny's vagina to attempt and feel the baby's shoulders...I ran my fingers up the neck...and up and up...I could not feel the shoulders!!! They were so far back, that I could not feel them. This is when I realized that this was my first true shoulder dystocia and the tense set in. In certain situations I have experienced that time can simultaneously speed up and slow down...this happened on this night. My vision became crystallized and focused, like intense tunnel vision, the world became Jenny, her baby and her vagina...nothing else existed. In some ways, I switched to auto pilot...the drills, so long practiced and held in my mind, became my only thoughts. I worked through several maneuvers and could not get the shoulders down, could not find the arms. Jenny was amazing and followed my every direction to a tee and my nurse was fantastic...however, this baby would not budge. I had to remind myself to breathe...time ticked by...baby was not coming....after the failed attempts to free the shoulders, my hands took over. I reached deep inside Jenny, the baby held between my palms like a prayer...please Creator, help me, help this Mama and her Baby, please work through me, please, please...and then I finally found it, the baby's posterior arm. I was then able to both pull that arm out and rotate the baby like a corkscrew and with one final big push from Jenny, baby was free! What seemed to have been an eternity had lasted for three minutes...baby was stunned and needed a little encouragement, but came around nicely. He weighed in at 9# 13 oz....pretty big for a petite little Mama. Amazingly, somehow, Jenny's vagina and perineum were intact! Jenny and her husband were elated and Jenny's husband made a comment about how when he was born, he had gotten stuck and the doctor had to break his collar bone to get him out! (The nurse and I both had a little nervous laughter fit over that one later.) The new "little" babe wasted no time in locating his mothers' breast and then camped out there for hours, happily nursing away.

So, there was my biggest fear....faced and, at least for this time, conquered. Jenny loved her birth and remembers the nurse and I being very calm, focused and reassuring during the experience. I am eternally grateful for all the books I had read, all the midwives wisdom that I had soaked up and for the support of divinity in the room.....

8 comments:

  1. Giiiiiiirl... you and me both. I was at a birth awhile back (I'm assisting/apprenticing right now) and was talking to my mentor midwife about how SD is my "irrational midwife fear." Basically, until the baby comes out, I'm fearful EVERY time that the baby is going to be stuck at the shoulders. Anyways, a few hours later, I witnessed a real, 3 minute long SD and was 1) terrified, and 2) affirmed of the truth that I must take every birth as a learning experience. I hope to God I never see another one, but pray that when I do I'll have the mental acuity to put the training to work. GREAT JOB sister midwife!!!

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  2. Yeah, a true SD is so scary...and a good example of why midwives are so important. Most of the time we aren't needed...but when we are...we really are! Fear is deffinitely a constant hurdle to overcome, and through learning, observing and with time we can do just that. Thanks for the kind words and continued luck to your on journey.

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  3. Thanks for your experience, and for this mom it was a good thing that you had done so much research on this potential birth complication! Congrats on a healthy baby :)

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  4. Yes, the research was helpful. I believe that I was drawn to all research for this baby and his Mama. I also believe that I had some help from divine intervention.

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  5. Reading this gave me chills. I found myself holding my breath until you said the baby was free. I too am terrified of shoulder dystocia. I hope to experience one as a student, not that I would ever wish that on any Mama. But I'd like to have that experience with the support of an experienced behind me. Thanks for sharing. Now I have to go read about shoulder dystocia!
    ~Heather, Student nurse midwife

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  6. Heather, thanks for your comment. Yes, please read up on SD ;) I completley understand your desire to have these experiences as a student...that is normal, and while I also don't hope these situations on any Mom, it is good to have help with them.

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  7. Your writing is beautiful and carries such knowledge. The tunnel vision gave me chills. It's amazing what our minds and hands can do. Thank you for sharing your story!
    Apprenticing midwife

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  8. Erica, thanks for visiting my blog and reading my stories, it means a lot to me. Good luck to you on your own journey!

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