Save the Date:  June 11, 2022 Resolving Shoulder Dystocia full day and June 12, 2022 Breech Basics Full Day. San Diego, CA 2022. After Tema Mercado’s 1 Day Spinning Babies Course on June 10th.

If we look at the whole instead of the hole, we begin to see the whole baby in relationship to the pregnant body.  For head down babies, the head is the first thing that one sees with the emerging baby.  But that baby has a whole body, and that is why we look towards the interior landscape as well.  How might we recognize this need to act or intervene?

If someone is pushing and pushing and pushing (and we have maybe even suggested positions that create more room at the outlet and that doesn’t help) we can step back and observe with all of our senses.  The baby and the person laboring both have inside information and this may be the time of observational patience. Sometimes we can use these observations to avoid a shoulder dystocia.

I will add here that Freeing the Sacrum is always a good liberatory effort in that it can affect all levels of the pelvis.  

1. We can watch the instinctual positions for labor and birth. Even if someone is in their head they may try to squat or go into certain positions assumed to bring a baby.  However, you may see that they begin to externally rotate their femur or lengthen their body and tuck their pelvis (inlet opening positions).  Both a low head and a shoulder higher up means that inlet opening positions can be for a low baby. 
2. We can listen to reports of pain above the pubic bone (we also rule out a full bladder or for some discomfort from a scar or general contraction pain/instnsity). Do we feel part of the baby on top of the pubic bone externally?  In this scenario, the head is not high or on top of the pubic bone as in a -3 station.  Can we palpate a shoulder above the brim?
3. We can also look to the sacrum.  Kristen Hosaka DC and others report that the sacrum for a nuchal arm/hand will raise only on one side as the baby descends.  Do we need to disengage (or back up baby) just a  so that the baby can pull its arm down or flex its head or reposition?

As I teach Resolving Shoulder Dystocia and Breech Basics we are looking at an extension of Spinning Babies Solutions for the Levels of the Pelvis from a larger view.  Why keep pushing harder and harder if there is an impaction further up in the pelvis?  It may not be there but we can consider the possibility. 

If we feel a shoulder above the pubic bone, can we disimpact and/or use an inlet position to release the baby to be born? If we visually see a pendulous belly, we can tie up the belly to give some support to angle of the baby into the pelvis while providing support for the soft tissues that may not be able to be supportive or naturally engage with a tuck of the pelvis (posterior tilt)? By tying up the belly we can change the angle of the baby entering the pelvis and thus the shoulder may clear the pubic bone.

I hear that Walchers, another inlet opening position, is used by some European in-hospital midwives preceding McRoberts for shoulder dystocia.  For out-of-hospital birth, that is not a timely or convenient position, but for a hospital bed that is already broken down, it may be a way to open the inlet of the pelvis by dropping the legs.  As a Spinning Babies Trainer, I hear stories of people using Watchers with success for more than the inlet (regarding the location of the head including station).  As Walchers is usually used as the last resort due to the discomfort or strain on the body, we don’t want Walchers to be the answer for all stalls. Yet, as it is increasing in use, we can hear that inlet positions can work to free something caught up higher thus releasing the baby’s head below.  The importance of this aside is in the understanding of how it works so that we can minimize interventions especially at the last minute.

As we look up above the brim for vertex and breech shoulder dystocias we find that there is also a time to utilize emergency and life-saving resources.  Here is a shortlist of ways we can assist in freeing a baby.  Not all will work on their own, but each of these can be part of our tools box:

1. Utilizing movement, gravity, and positions that allow for more space in the inlet or shifting of that space (running start, movement from McRoberts to hands and knees and back again), wiggling is included for this movement
2. Opening the inlet and disimpacting a shoulder with abdominal lift and tuck (thank you Lindsey) 
3. Suprapubic pressure to release the shoulder (or rare overlapping breech head)
4. Disimpaction or lifting of baby along with rotational maneuvers
5. Providing support for a pendulous belly 
6. Fundal pressure for an already manually flexed breech head that has been freed from bony obstructions and difficult to move (Breech only! This is rare.) 

I look forward to more contributions to this of-the-top-of-my-head list.

Anyway, reserve the dates of June 10th-11th, 2022 here in San Diego for a full day of shoulder dystocia and a full day of  the fundamentals of normal breech and beginning complications.  For those who took the class in March, contact me if you are interested in taking it again. I am still learning to hold this space not just with the information, but through the time and space for all to process difficult shoulder dystocias and find more confidence alongside humility with simulations. 

Resources :

Calais-Germain, Blandine and Núria Vives Parés, Preparing for a Gentle Birth : The Pelvis in Pregnancy .  Healing Arts Press 2012.

Eccleston, C., & Morales, N. (2022). [A story of twins on two continents]. Actualités Sage-femme, 104, 20-23.

Hodge, Hugh L.   The Principles and Practices of Obstetrics.  Philadelphia:  Blanchard and Lea, 1864. 148-149. http://resource.nlm.nih.gov/67240830R(on anterior obliquity of the uterus for descent).

Kiapour A, Joukar A, Elgafy H, Erbulut DU, Agarwal AK, Goel VK. Biomechanics of the Sacroiliac Joint: Anatomy, Function, Biomechanics, Sexual Dimorphism, and Causes of Pain. Int J Spine Surg. 2020;14(Suppl 1):3-13. Published 2020 Feb 10. doi:10.14444/6077

King, Janie McCoy.  Back Labor No More!! What Every Woman Should Know Before Labor. Elmo: Plenary Systems. 1993.  

Poggi, SH, et al. Intrapartum risk factors for permanent brachial plexus injury. Am J Obstet Gynecol. 2003; 189: 725-729

Seeras K, Qasawa RN, Ju R, et al. Anatomy, Abdomen and Pelvis, Anterolateral Abdominal Wall. [Updated 2020 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525975/

Siccardi MA, Imonugo O, Valle C. Anatomy, Abdomen and Pelvis, Pelvic Inlet. 2021 Mar 16. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 30085610.

Takaki S Ms Pt, Kaneoka K PhD Md, Okubo Y PhD Pt, et al. Analysis of muscle activity during active pelvic tilting in the sagittal plane. Phys Ther Res. 2016;19(1):50-57. Published 2016 Nov 29. doi:10.1298/ptr.e9900