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.....