I’ve known for quite some time that resolving complications as a midwife can look similar whether the baby is breech or vertex. With breech there are more external indications for baby’s well-being besides the heart rate as visually one can watch rotations and track baby’s well being recognizing, if necessary, the need to intervene. What midwives can learn from breech and apply to vertex births has to do with the fact that we are dealing with the same space inside the pelvis and baby’s rotations. It is also similar in that if we become aware of normal, physiological birth, whatever the position of the baby, we can identify when the baby is “talking to us” and needs our help.
For a head down baby, the shoulders are entering the brim of the pelvis at the same time the head is crowning. This is a time that we watch and wait for the head to be born. Once the head is born we are reassured by restitution and typically the birth of the baby follows with the next contraction. Of course there are variations of this pattern. In fact, I was at a birth recently and the baby skipped crowning and head altogether and just plopped out all at once onto the bed!
But sometimes the head down baby talks to us as they descend – not just a slow crown but a turtling sign retracting back onto and into the perineum. As midwives, we know this is a sign to act. Just like breech, we don’t have to hold onto the motto in that moment of, “hands off the vertex.” We do that. We know that in our bones. We know what normal looks like, feels like, and even if it takes us a second to see or accept the retraction or the turtling, we act.
I was recently lucky enough to hear feedback on the topic of breech with UK midwife Shawn Walker, RM and be exposed to her teachings on upright, physiological breech birth and the concept of “hands off the breech.” After seeing or hearing that providers missed the signs for a breech baby needing assistance, she created an alternative saying to “hands off the breech.” She uses “Respect the Mechanism” and then for when normal is no longer present, it is time to “Restore the Mechanism.” This is similar to Karen Strange discussing the resuscitation of babies and facilitating repair if the expected sequence of events have been ruptured. Amazing that as midwives we can help bring resiliency to such situations! How can we as midwives know when to act by recognizing when things aren’t normal and troubleshoot and restore the sequencing to release the baby? Understanding what Walker deems the “Complex Normality” for breech can also be a guideline to working with a head down baby in what we cannot see internally with a shoulder dystocia.
In breech and head down babies we are dealing with the same passage of the pelvis. Yes, everyone is anatomically unique. One mother might have a gynecoid pelvis, another an anthropoid or mixed variation. Some mothers are weightlifters or dancers or wear high heels or have previous injuries and these things affect the space inside of the pelvis as well. These variations can create surprises as we assist mothers when things move out of normal. For both situations, we can be thinking about what is normal to find at the different levels of the pelvis. Where is the baby in the pelvis? What part might be caught and where? Then we can think about how to help get a stuck baby on track if it is caught in the inlet, mid-pelvis or outlet whether it is caught on the bone or a ligament or if the baby has its arms behind its back.
Although I have never met midwife Mary Cronk, she has a famous kitchen drawer. Throughout the years, her story has trickled down the generations of midwives who now think about the stuck drawers in their kitchen in a different way for dealing with extended arms for breech or shoulder dystocia. You may have opened your drawer and a spoon or knife or other utensil has gotten caught in much the same way as a shoulder or extended arm can get caught on a pubic bone, sacral promontory, between the ischial tuberosities, or in the AP diameter in hollow of the sacrum. And what do you do? Do you push the kitchen drawer back in and cut through the counter (Zavenelli)? No, of course not. Do you open the drawer harder and harder until the utensil falls out or bends or breaks? If you pulled hard enough, you might come out with a damaged spoon (brachial plexus injury or broken collar bone or worse). As recommended by Frankfurt, Germany OB Frank Louwen for breech babies, push, don’t pull. Most midwives may shake or wiggle the drawer a little and jostle things around. Sometimes we will push the drawer just a little back in to reduce the pressure of the impaction and take our fingers to sweep the utensil to a different angle that removes the obstruction. Thanks to Mary Cronk, stuck kitchen drawers will never be the same for many of us midwives. We glance at the clock and are reminded of serious situations that we might face. We take the practice seriously. With a mother and baby, however, the mother is mobile so we actually have even more help. Of course, just like opening the kitchen drawer, with birth we all know what normal looks and feels like when it just slides right on out as usual. But when things don’t progress normally we must assess and troubleshoot in a timely manner so that we know how to “Restore the Mechanism.”
Turtling is not the only sign of shoulder dystocia. Turtling is tantamount to a breech not rotating into an anterior position. The shoulders (arms) are caught and baby needs help. Some babies do not have turtling, restitute, and yet can still be stuck in the mid pelvis or outlet. The head down baby that is not descending or being born after the next contraction might be a sign to have the mother change positions or have her simply lift a leg up into a running start to create more room in the pelvis. And if we need to go in and help a baby, knowing how to “Restore the Mechanism,” rather than remain “hands off” is essential. When we help that baby, we must think about creating more room by moving mom or moving baby. Opening the pelvic diameters can be useful using Gaskins or running start. We can reduce the diameters as well with removing the posterior arm. We can change the terrain by flattening the sacral promontory or nutating the pubic bone with McRoberts. We can also return to the mechanisms by moving the baby. Maneuvers like Wood’s Screw or Rubin’s not only reduce the diameter of the baby’s shoulders, but restore the spinning on the threads of the screw for the baby to spin out of the pelvis. Woods discussed restoring the path of the baby descending by comparing it to when a baby is caught on the crossed threads of a screw. By adducting the shoulders, the midwife can facilitate a smaller diameter and help the baby resume the path following the largest spinning diameters of the pelvis.
I wasn’t planning on addressing all of the maneuvers and variations here for shoulder dystocia, but I did want to highlight that those who are truly looking deeply in upright, physiological breech are providing important material that can be used for vertex babies too! The details of breech are the window into that line between knowing normal and recognizing when one needs help and just because we visualize less for shoulder dystocia, doesn’t mean that we cannot take these puzzle pieces and utilize them to help identify the need for help and to release the baby.
What is the take away? The breech movement for knowing upright, physiological breech birth is giving us opportunities to know how to help head down babies as well.
- Recognize normal, know normal rotations.
- Recognize how respecting the mechanisms (even for head down babies) can prevent complications.
- Know the levels of the pelvis and how to help to help a baby when baby is stuck.
- Watch maternal instincts solve issues yet be able to help utilize maternal positioning to open space and facilitate descent.
- Push, don’t pull (except posterior axillary crease pull or the final part of extracting the posterior arm).
Cronk, Mary. Word of mouth of the midwives and her kitchen drawer… http://rixarixa.blogspot.com/2012_12_01_archive.html
O’Leary, James A. Shoulder Dystocia and Birth Injury: Prevention and Treatment. McGraw Hill: 2000. 111.129-.
Strange, Karen. “Neonatal Resuscitations and Transitions.” San Diego, 2016.
Tully, Gail. “Resolving Shoulder Dystocia” https://www.youtube.com/watch?v=miBHAETbReg
Tully, Gail. “Shoulder Dystocia: The Basics.” Midwifery Today, Issue 66.
Walker, Shawn. “Assisting rotation of the fetal back to anterior in a breech birth.” Blog: The Midwife, the Mother and the Breech. January, 2015. http://breechbirth.org.uk/tag/mechanisms/
Woods, CE. A principle of physics as applicable to shoulder delivery. Am J Obstet Gynecology. 1943: 45: 796-812.