As certified birth doulas, you are not a medical provider performing clinical tasks. However, you are supporting families who may need medical care. This makes it important to understand potential medical situations such as shoulder dystocia.
Though rare, shoulder dystocia is something many birth attendants will see at least once if they attend enough births over the years. It is considered an emergency and requires immediate and efficient intervention to resolve.
What is Shoulder Dystocia?
During a typical labor, it is normal for a baby’s head to be born and there to be a bit of time before the body follows. However, during a shoulder dystocia the head has been born and the body is unable to follow due to one or both shoulders being stuck.
During labor, ideally the birthing person can move, shift, and be upright to help facilitate baby getting into an optimal position to be born after dilation is complete. Baby must descend through the birth canal, navigating past the birther’s pelvic bones.
Once a baby’s head is born, the body rotates sideways to allow the shoulders to pass the pubic bone. In cases of dystocia, one or more of the shoulders is unable to pass the pubic bone. This is a true birth emergency.
Why is a Shoulder Dystocia and Emergency?
Typically, once baby’s head is born, the body will be born within a couple minutes. When this does not occur, there is an increased risk of hypoxia. Hypoxia is a lack of oxygen. With a dystocia, the umbilical cord can become compressed, compromising oxygenated blood from flowing to baby. The angle they are stuck can also prevent baby from being able to take any breaths.
“After delivery of the fetal head, the fetal trunk, including the chest, abdomen, and umbilical cord, becomes compressed within the vaginal canal resulting in decreased fetal oxygenation due to reduced blood flow through the umbilical cord.” That reduced flow can lead to hypoxia.
The faster a dystocia is resolved, the less likelihood of hypoxia. In rare circumstances, a dystocia can be fatal. However, qualified birth attendants (e.g. midwives, physicians, etc.,) are trained to help resolve this issue. As doulas, we are not trained to resolve but rather support families as the qualified attendants work to resolve the situation.
What Are The Risk Factors for Shoulder Dystocia?
Shoulder dystocia is a rare. Having a risk factor does not mean dystocia is likely but rather that one has an increased risk. Remember, an increased risk is not a guarantee. Risks simply help us be a bit more aware of the potential, though dystocia could occur in any circumstance.
Current data shows: “The most significant risk factors are maternal diabetes, previous shoulder dystocia, and fetal macrosomia. Maternal diabetes causes elevated glucose levels in the fetus, which stimulates it to produce excess insulin, insulin-like growth factors, and growth hormone, potentially leading to large for gestational age infants or infants with larger shoulders and increased abdominal-to-head circumference ratios.”
Having gestational diabetes does not mean one is likely to have a shoulder dystocia. However, having difficulty controlling gestational diabetes with a large for gestational age does increase the risk. Type 1 diabetes is a significant risk factor as maintaining blood sugar levels is less predictable and not something that can ever be managed with diet and lifestyle alone.
How Can You Reduce the Risk of Shoulder Dystocia?
For those with gestational diabetes or type 2 diabetes, it is important they work with their healthcare team to manage their blood sugar levels. Increasing activity, monitoring diet, and using insulin when indicated, can help manage baby’s growth.
Patients with Type 1 diabetes are typically followed with high-risk care and additional monitoring. Paying close attention to managing might reduce increased growth in the baby.
Remember, a baby being large is not always indicative of a problem. Some genes simply equal a larger baby that can still easily pass through the birth canal. With maternal diabetes, the baby could be larger than their genetics would have typically allowed.
For those at an increased risk of dystocia, careful monitoring, and remaining mobile throughout labor is important. Neither the baby nor the birther’s pelvis are fixed and solid. Being able to move during labor and pushing can create more space for baby to safely descend and reduce the risk of dystocia.
Occasionally, having one or more risk factors for dystocia, alongside consistent measurements showing a large baby, might lead to the suggestion to induce early or opt for a c-section. As doulas, our role is to help parents find more information and support them in making an informed decision. It is not our role to suggest one type of birth over another.
How is a Shoulder Dystocia Resolved?
In the event of a dystocia, you are likely to notice an “all hands on deck” approach in the room. You can help support the parents by letting them know the team is working to help keep them and baby safe. Pay attention to any directions the midwife, physician, or nurses give as they might instruct you to help the birthing parent move into another position.
When a parent has not had an epidural or still has good control over their legs, often the first step is assisting the parent into another position.
Some positioning includes:
- McRobert’s Maneuver: most common technique, involves flexing the person’s legs toward their shoulders as they lie on their back. This opens up the pelvis creating room for the baby’s shoulders to be born.
- Suprapubic Pressure: often used with McRobert’s, pressure is applied at the pubic bone to release the baby’s shoulder.
- All Fours: Also referred to as the “Gaskin Maneuver” it is a position where the birthing person is on their hands and knees with their back arched to widen the pelvic outlet. Note, Gaskin learned this maneuver from Indigenous midwives in Guatemala. Therefore, not everyone still refers to it as the Gaskin maneuver.
- Woods Maneuver: sometimes called the corkscrew, the provider puts their fingers inside the birth canal onto baby’s shoulders, and pushes around and out.
- Rubin Maneuver: Similar to Woods, the fingers are placed behind the shoulder. Then they are pushed in the direction of baby’s eyes to line up the shoulders.
- Zavanelli Maneuver: a last resort when other methods failed. The baby’s head is pushed back inside the birth canal to prepare for a c-section.
As a doula, your role during a medical emergency such as this is to provide support for the parents. Doing your best to be a calm presence during chaos, while also supporting the healthcare team if they ask you to aid in positioning. Fortunately, dystocia is rare. But as a doula, it is important to be familiar with complications so you can support all births.
Author: Aliza Juliette Bancoff
Aliza Juliette Bancoff is a well-known doula and doula trainer who has been providing doula services to families for over a decade. She is the founder of Main Line Doulas, a doula group providing doula support in the great Philadelphia area for the last decade, the International Doula Institute, which provides online doula training and lactation training and certification programs and the International Breastfeeding Institute which provides lactation training and certification. She is the co-founder of United Birth, a company devoted to increasing access to doulas across the country to make the perinatal time safer both physically and emotionally. “Every birthing person deserves access to quality doula support. And we are working to make that a reality across the country. The work we are doing to get doulas to every birthing person will decrease the black infant and maternal mortality rate significantly by 2030.” Says Bancoff. Aliza is known for her compassionate and empowering approach to doula work, and she has been featured in numerous media outlets, including United Nations Maternal Health Report, Parent Magazine, CafeMom, theBump and many more. Aliza's journey into doula work began when she gave birth to her first child and felt a strong calling...