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Discussion About Arrested Midwife (and shoulder dystocia)

Answering questions from another website about the midwife who was arrested for a fetal death during an apparent shoulder dystocia:

A couple three things:

1. Any death, someone looks at it. Almost always, the state is the investigating party when a midwife has reportable events. I felt the article implied it was the parents' choice, but it wasn't very clear.

2. With regards to HIPAA, I can imagine the midwifery organization midwife was asked after the mom's name was already publicized... I can imagine the press could ask, "if a woman was pounds, had a history of shoulder dystocia, , would a midwife take her as a client?" And that midwife saying, "no, she would be turned down as a potential client." I can also imagine the press got a hold of court records and made it sound like they did the interview instead of reading the records. All that said, IF it came out as reported, that she either said her name to the press OR stated the woman, if they used her name and she did not, had previously sought care from someone and was turned down, I agree... yes, that would be a HIPAA violation.

3. With regards to drills about shoulder dystocia, many of us midwives do the same thing. A drill might look like this for a physician/nurse:

(most of the activity happens within the first minute... very, very fast... and depending on experience and learned-instinct, some steps might be in a different order once the head is born)

- slooowwwww head presentation... begin considering calling for help... consider, then do, episiotomy

- head born with turtling (coming out and pulling back in again up to the baby's chin), hit the "panic" button to get enough others in the room

- if episiotomy not done earlier, do it or enlarge the one already cut- get mom flat in the bed

- push moms legs back into her ears (this is McRobert's Maneuver)

- have mom PUSH while doctor "encourages" rotation with hands (nervous docs pull on the baby's head at this point)

- push hands in to find anterior shoulder to push it in one direction or the other to try to get it unstuck from behind the pubic bone

- try to find an armpit to hook to pull the impinged arm outward (usually breaks the clavicle)- suprapubic pressure; a technique where someone uses both hands and all of their weight directly on the upper part of the top of the pubic bone (where the shoulder is stuck behind in a true shoulder dystocia) and presses directly downward at the same time as the doctor does the spin and pull down the shoulder trick

- break one or both clavicles to "fold" the baby's wings inward to lessen the width of the shoulders (this sounds horrendous and while it isn't the most fabulous thing to do, nor a first step, it *can* save the baby's life and does not (usually) require anything more than pinning the baby's shirtsleeve to the shirt for a couple of weeks to repair the damage

- if all that fails, push the baby back in and do a cesarean (I have never heard of anyone having this done for shoulder dystocia and suspect it is done incredibly rarely because mortality is almost certain)

note: I know that some women come and ask me why their doctor pulled on their baby's head so hard. When asked if there was a lot of activity in the room, the answer is usually yes, and then I guess what might have happened is this: when a baby is looking like s/he might be a shoulder dystocia... verrrrrry slow descent of the head... very, very long crowning (or crowning, retreating, crowning, retreating)... as the baby's head begins to be born (one eek at a time... oh! there's the top of the ear! oh, there's the earlobe... oh, look, an eyebrow! [I have heard families saying these things - to a care provider, these ever-so-slow presentations are horrifying]... the eyes, the cheeks, the upper lip, the bottom lip... and finally the chin... sometimes, this can take several minutes all on its own), the doctor tries HARD to not allow rotation occur (where the head goes from looking down/up to the side) because when the baby rotates, the shoulder also turns and that is the absolute impingement point (hypothetically, and to me, probably). So, as the head is being born, the doctor "assists" the head by pressing (often seen as pulling) downward to try and get the shoulder down under the pubic bone before rotation begins or completes. (I could show you so much better in person.) It is probably a combination of both pressing down and pulling, but when I have had to do this, I focus hard to make sure it is more pressure than pulling.

Midwives, who wouldn't typically have to contend with narcotics or epidurals in the mom (unless she is a CNM and if she is a CNM in the hospital, she is required to call an OB or ten), can add a couple of other maneuvers including the Gaskin Maneuver - getting the mom onto hands and knees - or something akin to the Gaskin Maneuver, having a woman lunge... and lunge... and lunge... squatting, lunging... flipping from hands and knees to lunge... a variety of movements that sound much easier than it really is with a baby's head between the legs. (I am one who had the thought that the Gaskin Maneuver actually works because the movement of getting a woman from her back to her hands and knees was the mechanism, not the hands and knees itself, that dislodged the shoulders - this came after seeing stuck shoulders [not dystocia] become un-stuck as women in pools stepped out and over the side... that swirling-opening the hip motion.

No matter who is doing it, the drill includes tending to rescusitation of the baby and tending to hemorrhage of the mom - both distinct possibilities, if not probabilities.

Baby: many true sd babies come out needing serious rescusitation (docs cut the cord, midwives typically would not do that)

Mom: unsure until recently why a mom tends to hemorrhage after a sd, Michel Odent reveals the after-effects of surges of adrenalin (which certainly occurs when a dozen or more people converge into the room and onto your body)... it causes the blood vessels to swing wide open and blood to pour out of open "wounds" such as the placental site.

So, with all of that information, it can probably be understood why they call so many people into the room, but folks are also called to watch and learn what to do (or NOT to do) during a sd they might be in charge of. Also as witnesses for court. (not kidding)

Sticky shoulders is not the same thing as a true shoulder dystocia. I personally know two people who had their baby die in a shoulder dystocia (one at home, the other in the hospital).

The midwife under investigation... I cannot imagine her agony as she tried to free that baby. I cannot imagine it was 20 minutes before calling 911 (time goes FREAKY during sd... it is a VITAL part of the practice we do, too... one person assigned to call out times as every 15 seconds passes)... I believe the press totally screwed what was said up... an episiotomy 6 times over several hours? No way. 6 times to get her hands in the vagina to break the clavicle to try and get the baby out? That I can imagine (although incredibly extreme, but in a panic, I could see someone trying ANYTHING).

I know this was long, but do hope it explains sd a little better.

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Reader Comments (8)

There's also www.shoulderdystociainfo.com, written by an MD. My photo of the shoulder dystocia I attended is on that site too. ;)

December 12, 2005 | Unregistered CommenterKristina

doh! try this one:

http://tinyurl.com/buaz8" REL="nofollow">Click here.

December 12, 2005 | Unregistered CommenterKristina

so our 13# baby with sd- mom is semi-standing in front of bed- had her lay back and tried to put legs into mcRoberts- person on the other side of mom drops leg down instead of up-- and we ask her to move on to hands and knees- roll toward the side with the leg already down on her side before she gets to hands and knees another attempt to get either shoulder to come- on over-- mw cannot get a finger in and really there is little room to no room to even cut an epis-- while mom is in hands and knees - I felt for shoulder from the top and rotated it to the oblique gently on mom but firmly like rolling a baby covered in blankets-roll so the shoulders collapse toward the front of the chest rather than to the back which would make for a more expanded chest- baby spins but no contraction- I lightly rub up a contraction and mom pushes- baby inches out chest, hips and even legs-- this is almost a full body dystocia- if trying to rotate in hands and knees didn't work we would have had her stand -lunge turn around squat, mc roberts... the key thing is to remember to keep trying and moving --
in hospitals not all these babies make it regardless -- they may do a few less movements but then again we usually will not be pushing a baby back in to be delivered via-c section, but babies still may not make it.
something to avoid is fundal pressure, and I am a bit biased against pulling on the head/neck I think it has a similar impaction potential as the fundal pressure - heads are not "handles"
if we could have gotten a finger or hand in again fingers putting pressure on the back side of the shoulder- collapsing/folding baby to bring shoulders closer together - possibly a hook but not with a pointed finger more with the pad so you are not digging in to the nerves

December 12, 2005 | Unregistered CommenterAnonymous

Just read that this baby died of sepsis - not due to shoulder dystocia.

December 13, 2005 | Unregistered CommenterAnonymous

I saw my first shoulder dystocia a few weeks ago. I was stressin! The doc was fabulous! My first thought was "Is that shoulder coming??" nope. then next thought..."I hope you don't cut my mom all to shit" & she didn't! a little suprapubic pressure from the nurse and it popped out. So now i'm wondering if it was just a sticky shoulder and not a dystocia? how to tell? Probably have to have your hands in there to tell huh?

May 13, 2006 | Unregistered CommenterAnonymous

I would consider what you describe as a sticky shoulder and not because there were hands in there, but because the shoulders came with minimal intervention.

It does not take hands being inside to feel or know if there is a true shoulder dystocia. If the head begins suffusing is one of the best ways for one to know. It is accompanied by a horrible sinking feeling inside the attendant and those "in the know" around the room.

When movement of mom isn't assisting the birth, then physical actions need to begin. Oh, how we pray the baby comes without physical manipulations!

Hope that helps.

May 19, 2006 | Unregistered CommenterNavelgazing Midwife

While my aunt was delivering her second child, the clavicle was broken to get the baby out.

She told me afterwards that my new cousin was SCUH-REAMING after he finally made it out.

She has four children total now...none were born without complications in some form. :-(

May 19, 2006 | Unregistered CommenterSara

Barb, can you explain the difference between stuck shoulders and shoulder dystocia?

August 29, 2010 | Unregistered CommenterJen C.

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