Running Start Position for Shoulder Dystocia (Vertex and Breech)

I learned to use this for shoulder dystocia and breech from Gail Tully of Spinning Babies®  fame who teaches Flip FLOP.  Flip FLOP is an acronym that leads a midwife step by step to remember various ways to help release a stuck baby.  

Flip onto hands and knees 

Leg up into a running start position

Oblique: Turn the baby to the oblique to free the shoulders

Posterior arm can be swept creating 2 cm extra space

Of course there are variations of what we might need to do to free a baby as the baby may be stuck in different ways and in different places. However, for those of us familiar with this acronym, we also can apply it similarly to freeing breech shoulders. 

Today I am just addressing the running start position and how it helps in addressing shoulder dystocia. This position might even be used by the person giving birth instinctively to make room for a baby descending. It can also be used in an emergent moment. Small shifts can sometimes free stuck babies in of itself.

What is a running start?

 You can see that this particular drawing shows a knee up to the ribs in a forward lunge on one side and a knee on the floor with the other leg. A forward lunge is different than a diagonal lunge or a side lunge in that it affects the outlet of the pelvis on the side where the leg is raised. With the 90 degree flexion of that hip it opens up the outlet making space for a providers hands to help the baby. When the leg is in front it opens the anterior-posterior diameter of the outlet of the pelvis even more. 

With the other leg, the knee is on the ground, the stretch at the anterior top of the leg opens the other side of the pelvis at the inlet. Although it is stretching the psoas a bit similar but not quite as extreme as a one-sided Walchers, it is also shifting the front part of the ilium on that side away from the sacrum. When both are used together it creates asymmetry in the pelvis.

Sometimes entering any different position or using movement (like getting out of a birth tub) can shift the space enough that a stuck baby is released. Sometimes raising a knee creates that change. If we find more space is needed on the other side of the pelvis, we can shift which leg we raise. We usually lift the leg that is on the back side of the baby. 

However, when this doesn’t work, this position still allows a provider to have more access to put their hand inside and manually free the baby internally from where it is stuck. This is usually the bones but can sometimes include soft tissues like the sacrotuberous ligament or a bigger baby or baby with the arm/s behind it caught in the mid-pelvis. This asymmetrical space of the running start can be used for resolving entrapped arms, shoulders, or even possibly a head.

If one is needing to access maneuvers from above the pelvis itself, an assistant will have to reach around to access the inlet of the pelvis with either supra-pubic pressure, an abdominal lift and tuck, or for a freed breech head that is flexed and not caught on the bones, fundal pressure.

On the side of the knee that is raised, one will find more space for their hand to go internally to feel where one might find a shoulder or help locate and/or rotate the shoulder diameter. The other side is opening space above.

The Flip FLOP acronym must be adjusted for breech shoulder dystocia but can still be used as a familiar guide by those who have practiced it for vertex shoulder dystocia.

Flip into hands and knees

Leg up for room to help get one’s hands in to help the baby

Oblique, yes rotate the baby to the oblique and beyond  (some may disimpact and rotate back and forth as well)

Posterior arm can be swept out to create more space (don’t stop here)

But then you must rotate the baby to free and sweep down the other arm if needed (for a double shoulder dystocia). You must after freeing these arms bring the baby to face you (if in hands and knees ) to sacral anterior.  Then you will move on to assist the head by making sure it is in the outlet and utilizing your tools to help it flex. 

I will post another blog comparing the turtling sign for vertex shoulder dystocia to Frank Louwen’s Open Access photo for normal and stuck signs for a breech shoulder dystocia. 

#positionsaffectthespaceinthepelvis #runningstart #parkersposition #resolvingshoulderdystocia #breechbasics #flipflop #shoulderdystocia #birthanatomy #birthpositions #midwifeskills #spinningbabies

Calais-Germain, Blandine. Preparing for a Gentle Birth.

Frye, Ann. Holistic Midwifery Volume 2. 

Mossay, Jamie. Sketches for future publications. 

Tully, Gail. Resolving Shoulder Dystocia.

Looking for information on Parker’s position and its use.  Let me know if you have a link to that source.