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Hello everyone,
I have been watching this thread with
interest......my understanding about shoulder dystocia is that it only becomes
evident once the head has birthed and the shoulders fail to appear - hence its
never truly 'diagnosed' until no shoulder presents despite the woman's
efforts to push her baby out, assistance given by the midwife with downward
traction on the head with no further advances being made.....surely
only then can a diagnosis of shoulder dystocia be truly made?? Yes as the
midwife you may have that 'feeling' and you're on alert, given those soft signs
we all know that may present throughout labour/birth....mainly a delay with
second stage and difficulties with the birth of the face and chin. However,
sometimes you get no warning at all until the actual time of birth where,
restitution and the external rotation of the head may take place
slowly, or interruptedly or not at all....(where you get that 'turtle'
sign as the head burrows back hard against the perineum) However, what I
want to raise here is that.....in remembering the 'mechanisms' of physiological
childbirth, I think its important for us to recognise that
'restitution' and 'external rotation of the head' are two very
distinct mechanisms - NOT one and the same thing!!
Internal rotation of the head as the baby comes
into contact with the pelvic floor musculature causes a twist in the baby's
neck.....'restitution' is the process whereby the twist in the neck which
resulted from internal rotation is now corrected....'external rotation of the
head' is the separate and distinct process that heralds that the shoulders are
rotating into the antero-posterior diameter of the pelvic outlet, hence in the
haste to facilitate birth we see many 'man-made' shoulder dystocia's (and/or)
perineal trauma......with pulling on the head before external rotation of the
head and thus the internal rotation of the shoulders is complete!
As for Sue's question as to why exactly do babies
die with shoulder dystocia......my understanding was that it has to do with the
compression of the chest in the birth canal preventing venous return from the
baby's head (you never forget that deep deep purple of a stuck babies head)
which if not corrected quickly....leads to intercranial bleeding/haemorrhage,
brain damage and ultimately death.
Just my two bobs worth!
Tina Pettigrew
Midwife
Sent: Friday, November 18, 2005 1:16
PM
Subject: Re: [ozmidwifery] question
Remember the placenta is beginning to separate at
the point of the head being born so the baby is dying of hypoxia and acidosis.
ALSO are probably correct on not waiting for restitution. The signs of
shoulder dystocia are evident before the head is crowned and then the 'turtle'
sign appears and clinches the diagnosis so it is full steam ahead and get that
baby born. You could wait all day for restitution and end up with a dead baby.
Jenny
Jennifer Cameron FRCNA FACM
President NT branch ACMI
PO Box
1465
Howard Springs NT 0835
08 8983 1926
0419 528 717
----- Original Message -----
Sent: Thursday, November 17, 2005 2:32
PM
Subject: Re: [ozmidwifery]
question
Good point Anne!
I did quite a thorough search last night and
have printed off some good articles which I will pass on. However I
could not find the answer to why EXACTLY babies die in shoulder
dystocia. If it is asphyxia, then (obs point of view) this proves that
the cord is not sustaining them. The ob said to me that if the cord
WERE sustaining them there would be no urgency to deliver the body, also
quoted from the ALSO course that the fetal Ph drops 0.04 (?) per
minute after delivery of head therefor we should not be waiting for
restitution but delivering body ASAP. (I didn't even go
there!!)
My feeling is that it is more to do with
probable cord compression, (although I cannot picture why this should
necessarily be so as the body and hence, presumably, the cord, would
still be above the pelvic brim) and trauma to the neck usually caused by
mis-management (panic) in trying to deliver the shoulders than asphyxia, but
it is true that they become asphyxiated within a short time if truly
stuck. Any answers on that one?
Thanks
Sue
"The only thing necessary for the triumph of evil is for good men to do
nothing"
Edmund Burke
----- Original Message -----
Sent: Thursday, November 17, 2005
5:54 AM
Subject: Re: [ozmidwifery]
question
Dear Susan,
You could say to them if this is so why do
they rely so much on cord ph's ? One would think when the baby
was born and the pulsating cord was still not supplying the baby
effectively the cord blood (venous and arterial) was null and void to
provide an estimation of oxygenation for the babe.
Regards
Anne Clarke
Queensland
----- Original Message -----
Sent: Wednesday, November 16, 2005
9:30 PM
Subject: [ozmidwifery]
question
I have a question for you wise
ozmidders.
I was having a discussion today with one of
our obstetricians regarding cord clamping, and the benefits to the baby
of delaying this until pulsations cease. When I mentioned the
benefit of the baby recieving oxygenated blood via the pulsating cord
which could assist it's transition to independent respiration
particularly if it was compromised (etc etc) the obs was of the
view that the pulsations could NOT be providing oxygenated blood because
the uterus would have contracted down and the placenta could no longer
be getting oxygen from mother's circulation.
Now I know that I have read reams on this
and this is stated to be one of the benefits, but I could not answer
that particular question physiologically and convincingly.
The point was also raised that in shoulder
dystocia, babies die of asphyxiation, which (obs opinion) would not
happen if they were recieving oxygen via the cord.
I did print off George Morley's excellent
papers for this Dr to read but would very much welcome anything that can
show that the baby would still be receiving oxygenated blood post
birth.
TIA
Sue
"The only thing necessary for the triumph
of evil is for good men to do nothing"
Edmund
Burke
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