Long shoulder dystocia reply turned post

This post is submitted to the let labor begin on its own blog carnival at Lamaze’s Science and Sensibility.

I love the blog Rural Doctoring, especially for her birth stories. She is a wonderful writer, and from what she writes she seems like a thoughtful and conscientious physician. One of her most recent birth stories was about a repeat shoulder dystocia.

I started a reply, and after some researching and a lot of typing, I figured it was a lot better to post it as an original blog post rather than a rather long winded reply on her blog.

Here it is:

I almost wish you linked to the birth forum. (The original post complained that the birth story of this woman’s previous birth was torn apart on a natural birthing site.) I can understand why you didn’t, and I could probably guess where to look.

I have an interesting situation, since I delivered both my children with midwives and trained as a lay midwife for almost two years, but am now in medical school studying to be an ob gyn.

I hate it when I see zealots from either side. I shouldn’t judge the conversation on the site that I have not read. But, I am familiar enough with conversations in which the intention of the commenter is to prove their worldview is right, rather than listen, learn and communicate. And, I did read the comments on the post about Nola’s first birth. Some were wonderful, and I plan to read them again and learn from them. Some were reactionary.

I can think of several illustrative examples on both sides, both clinically and reactionary comment-wise. I know of an unassisted birth that ended up with a shoulder dystocia, and the child now has cerebral palsy and is severely developmentally disabled. I am fairly sure there was no pitocin involved.

Do I think the Gaskin maneuver could have helped? Yes, probably. Do I think EFM and IVs are generally a nuisance in a routine labor? Yes, and so does the WHO.

I actually question her being induced. It obviously didn’t prevent the dystocia. I suppose there is an argument that a larger fetus would have been even harder to extract, but how much would the baby have grown in the short amount of time it would have taken her to go into labor on her own?

She had the history of the large baby, a dubious 3rd trimester ultrasound with a weight estimate within normal limits, and a history of going postdate. That would have to be weighed with the risks of the induction. It was a successful one, and she was in her 39th week.

I thought it may be right that her problem is anatomical, as the physician at Rural Doctoring thought. It may be that any full term delivery of hers may involve a shoulder dystocia, regardless of induction or reasonable delivery date.

But, then I found this article:

Shoulder dystocia: are historic risk factors reliable predictors? By Ouzounian JG, Gherman RB, American Journal Of Obstetrics And Gynecology [Am J Obstet Gynecol], ISSN: 0002-9378, 2005 Jun; Vol. 192 (6), pp. 1933-5; discussion 1935-8; PMID: 15970854

which concludes:

“The triad of labor induction, oxytocin use, and birth weight greater than 4500 g yielded a cumulative odds ratio of 23.2 (95% CI 17.3-31.0) for shoulder dystocia.”

For those who don’t understand odds ratios, it says that with that triad (large baby, induction and pitocin), there was a shoulder dystocia 23 times more times than if this treatment triad did not exist. It seems to me that labor induction and use of pitocin actually increases the risk of a dystocia, instead of decreasing it, especially if it is likely that the baby is large.

So, interventions can cause dystocia? Sure. Lack of a skilled practitioner there can lead to birth injury due to shoulder dystocia? Sure. Can shoulder dystocias, some with fatal consequences, happen in hospitals and at birth centers and in homes? Unfortunately, yes.

I think we can talk to each other and learn without tearing each other apart. I am going to study everything everyone said on the first post and this one about the mechanics and anatomy of the interaction of the descending (and rotating, and flexing, etc) fetus and the bony pelvis. I am not a 3D person.

As much as I can research shoulder dystocia on the internet, I would be proud to have Theresa’s or the first post midwife’s ability to visualize and understand what is going on in there and what the woman can do with her body and what we can do with our hands to affect that.

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9 Comments

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9 responses to “Long shoulder dystocia reply turned post

  1. …and I found your blog through the Rural Doctors! I am really curious to read more of it. But I am curious about one piece: why do you think induction + Pitocin = greater likelihood of shoulder dystocia? I see those logically contributing to a whole host of ills, but shoulder dystocia has always seemed (to me) strictly anatomical – a combination of baby’s size, baby’s position, mom’s pelvis, and mom’s position. The only way I could think of induction/Pitocin affecting it is if some of the loosening/stretching of the pelvis that happens at the end of pregnancy did not get a chance to happen.

    It is refreshing to come across multiple blogs where I feel like I can ask real questions, and discuss the issues and learn, rather than just scrolling through a list of comments meant to bludgeon “the other side”!

  2. Those are interesting thoughts re: descent and rotation, and pitocin-induced contractions, and do make more logical sense. And of course the epidural makes sense too, I guess I had assumed they would control for that, but looking at the study I see they didn’t. Then again, I was really surprised to see only a third of the patients delivered with an epidural – could that figure really be accurate?

  3. MomTFH

    Thanks for the great comment!

    It’s not just that I think induction + pitocin can lead to dystocia, (I had actually not really heard of the proposed connection before reading this birth story). The study I link to says that there is a substantial (more than 20 times!) increased risk of shoulder dystocia with the triad of pitocin, induction and macrosomia.

    I can definitely see what may be the reasoning behind the pitocin influence. I think it must affect the ability of the fetus to properly rotate as it descends due to hypertonic contractions or other factors influencing the maternal and fetal readiness for the birth process. As for induction, as one point I would have agreed about the reduction of time for the pelvis to respond to relaxin, but I think relaxin starts its effects around 20 weeks, and I don’t know how much of a difference 39 weeks to 40 weeks would have made, relaxin wise.

    Maybe it’s due to the fact that induction + pitocin increases the likelihood that the mother will have an epidural, or at least be more likely to be in bed, on her back for an extended latent and then active stage. Prolonged labor in this position, especially with an epidural, can contribute to a persistently posterior fetus, which approaches the pelvic inlet in a much less favorable diameter.

    I am not sure if any of this has to do with a lack of full dilation before pushing, which may be more likely post induction with a poor Bishop’s score. I tend to think that would be more likely to contribute to failure to progress than shoulder dystocia.

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  6. MomTFH,
    I applaud your balanced viewpoint. I believe, doctors, midwives, home birth attendants can learn from each other. Women will have the best care with the various groups working together. I have spent many years in the hospital and also have experience attending home birth.
    In the hospital I have witnessed a shoulder dystocia that ended with death of the baby. The woman was in labor with her 5th pregnancy. She had gestational diabetes and a large baby was anticipated. Her labor was augmented with pitocin. She dilated suddenly from 5cm to complete dilatation. As she pushed the nurse in attendance put the emergency light on and I along with another nurse rushed to the room. We used McRoberts maneuver. The neonatologist was called to the room. More than 6 minutes elapsed between delivery of the baby’s head and delivery of the baby’s shoulders. Despite the attendance of doctors and nurses the baby died.
    Later I read a section in Sheila Kitzinger’s book, Home birth (1991).
    “Shoulder dystocia may occur because the woman has had oxytocin (pitocin) which has produced artificially strong contrations that have forced the pace, propelling a big baby along the birth canal before all the tissues have fanned out. The head shoots out and the shoulders are impacted.”
    I have also seen in both hospital and home births the situation where the water breaks
    when a woman is in the transition phase of labor and then the baby descends rapidly. The shoulder dystocia in these situations was relieved by getting the woman into a hands/knees position.
    I have also assisted at a home birth where the laboring woman preferred to remain in an upright standing position until the last 15 minutes of pushing. This woman delivered an eleven pound baby with no vaginal tears. She was following the cues that her body gave her. She was supported by her mom and sister. Her mom had also given birth at home.
    My experience with home birth allowed me to see how the body adapted to a large baby, a cord around the neck, a thin umbilical cord, etc. It was enlightening.

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  8. D

    Not sure what to do. My OBGYN told me he is going to induce me at the 39th week because the ultrasound says my baby is big. I told him the ultrasounds aren’t accurate (based on info on the net) and I don’t want to be induced early. He said I could be at risk for shoulder dystocia and since this is my third baby, if I’m dialated, I might as well be delivered. He is leaving town on my due date, Nov. 23rd. I’ve had two other natural pregnancies, one girl 5 years old, weighed 8 lb. 15 ounces, was induced 10 days late. One boy last year, died because of bladder blockage and no amniotic fluid, born 8 months, weighed 4 lb 10 ounces. Not sure what to do? Or who to ask for a second opinion? Very stressed. Email me at kollardk@aol.com please.

    • MomTFH

      I am really sorry about the loss of your boy. I am not sure what kind of advice to give you, since I can’t really contradict the decision of your physician. Based on the study I link to in this post, induction itself may increase the risk of a dystocia, as opposed to spontaneous labor.

      According to ACOG, macrosomia is defined as over 4500 g (9 lb 9 oz), and adverse events (e.g. shoulder dystocia) is not linked to weights under 4500 g. And yes, estimated fetal weight is notorious imprecise, and you don’t have a history of macrosomic babies, which is a better predictor.

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