It is not uncommon to be having a conversation with a friend about childbirth and be told a horror story. The main complication of each of these stories may differ from person to person, but the feelings of anxiety, dread, and sadness seem to be the same across the board. One of these complications that is routinely told as a horror story is that of shoulder dystocia. Though this complication can be scary, it occurs in about 0.4-1.6% of all births. OBGYNs and Midwives are typically trained on how to handle shoulder dystocia, which makes complications like fetal death and structural breaks very uncommon.
What Happens?
If you ever experience shoulder dystocia, you will find that your care provider has you moving your body a lot. They might start with you on your back, knees pulled up by your head, and the next minute, have you move into a lunge position, alternating legs while they work internally. It is a widespread tear with shoulder dystocia because of how much inside work has to be done on the baby. Shoulder dystocias also seem to come in somewhat of a trifecta, starting with the dystocia itself, next a full neonatal resuscitation, and following that, a parental postpartum hemorrhage. When I see shoulder dystocia, I prepare for these two other emergencies every time, whether they occur or not.
During childbirth, there are a few things that can give your care provider a heads up that they may be needing to manage a shoulder dystocia. The main thing that occurs in most shoulder dystocias is called "turtling" or "the turtle sign," which is basically when your baby's head is born, but instead of continuing to make its way out, the head suction cups onto the perineum, sort of like a turtle going back into its shell. Another sign that there might be shoulder dystocia is when the baby's head is born, and it takes more than a minute for the rest of the baby to be born.
In the incidence that your care provider calls it a shoulder dystocia, you may notice the room filling with more people in scrubs; this is because of what I mentioned above: the fact that most shoulder dystocias are grouped with the infant needing neonatal resuscitation and the birthing parent hemorrhaging. It is also because the best way to relieve shoulder dystocia is to move the birthing parent, and if they happen to have an epidural placed, this is no easy feat.
What Causes It?
Certain things can make the incidence of shoulder dystocia higher than in others. Some of these things include having a big baby or, in other words, fetal macrosomia. Sometimes, ultrasounds will try to diagnose this before the birth occurs, but ultrasounds are chronically inaccurate for dates and sizing after 12 weeks gestation. Another risk factor is having a previous shoulder dystocia. This is because of how the birthing parent's body is sometimes shaped. Specifically, the pelvis can be a cause of shoulder dystocia, and if this were the cause, it would likely occur again.
Malposition is another cause of shoulder dystocia; of course, it can be more difficult for a baby to get through the birth canal if they are not in an optimal position, and this can be the cause of shoulder dystocia. Diabetes or gestational diabetes is another factor that can increase the risk of shoulder dystocia, especially gestational diabetes, which goes untreated for long periods. Typically, when gestational diabetes is controlled either by diet or medication, shoulder dystocia will not become an issue. Another two conditions that can lead to shoulder dystocia are preterm labor and laboring with multiples. The cause of these things is that the baby is tiny and has a lot of room to get wedged into a weird position.
Finally, the parent's position while pushing can be a cause for shoulder dystocia. When left to their own devices, a parent will find the best pushing position for them and their baby. We lose sight of this when we have a hospital policy that enforces the rule that every birthing parent is to be on their back with their feet in the stirrups. Yes, for some, this position is the optimal way to birth a baby, but for the vast majority, there are better positions that encourage the pelvis to open more freely when it comes to birthing a baby.
After Birth
The good news about shoulder dystocia is that the prognosis is good. By three months, 50% of babies born with shoulder dystocia are at total capacity, and by eighteen months, 82% of babies are at total capacity. Less than 10% of babies born with shoulder dystocia maintain a permanent injury.
As much as I know how scary this topic can feel, I am a firm believer that the more we know, the less traumatic different birth outcomes and possibilities will be. This does not mean that there will be no trauma, but by having early conversations in prenatal care, we are lessening the incidence of trauma for everyone involved.
