“Shoulder Dystocia” – with Dr. Caroline Friedman

Dr. Caroline Friedman, or @drfriedmanobgyn on Instagram, returns to Healthful Woman to discuss shoulder dystocia. Shoulder dystocia occurs when the baby’s shoulders don’t come out within about 60 seconds of their head during delivery. Dr. Friedman and Dr. Fox explain why this happens and what obstetricians do to overcome it.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Doctor Nathan Fox, an OB/GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. Doctor Carolyn Friedman, welcome back to the “Healthful Woman Podcast.” 


Dr. Friedman: Hi, thanks for having me again. 


Dr. Fox: Doctor Friedman is a podcast sensation. The last time we were together and we recorded the podcast on pre-menstrual symptoms, that podcast jumped to the top of the charts very quickly. And you are currently second place in the most downloaded “Healthful Woman Podcast” of all time, just passing Melka‘s “Exercise in Pregnancy” by one download. 


Dr. Friedman: Well, both very important topics, so I’m not surprised. 


Dr. Fox: Why do you think you’re such a sensation? What is it? You think it’s the topic or you think you’re just way cooler than Melka? 


Dr. Friedman: No. I’d like to think it’s the topic. 


Dr. Fox: Excellent. Well, I’m sure this is going to be a great one also on shoulder dystocia, which is an important topic, an obstetrical topic, but I also wanted to discuss with you a little bit about your new Instagram account. 


Dr. Friedman: Yeah. Awesome. 


Dr. Fox: Yeah. It’s called a handle. Is that the right word? 


Dr. Friedman: I guess so. I don’t really know the term. 


Dr. Fox: What is it? 


Dr. Friedman: @drfriedmanobgyn. 


Dr. Fox: Doctor’s Dr, or spelled out? 


Dr. Friedman: D-R-F-R-I-E-D-M-A-N-O-B-G-Y-N. 


Dr. Fox: What types of things are you putting on your Instagram? 


Dr. Friedman: Honestly, just little blurbs a few times a week about some of the most common topics I’m asked about in the office from patients coming in to see me, both for OB care and GYN care, a lot of things that I read about that are wrong in the lay literature that’s out there, the news, things like that that I just want to kind of clarify for the population that’s on Instagram, and then whatever else people ask about. 


Dr. Fox: I do look. There’s great stuff there, a lot of information. I give you the heart, the like on Instagram. 


Dr. Friedman: Thank you. 


Dr. Fox: So, that’s awesome. And I highly recommend it. So, you can get to see Dr. Friedman on the Instagram. 


Dr. Friedman: Thank you. I appreciate it a lot. 


Dr. Fox: Like I always say, the Instagram. 


Dr. Friedman: Yes. The Instagram. 


Dr. Fox: That dates me, very nice. We’re going to talk about shoulder dystocia. And just so our listeners understand, what is shoulder dystocia? What are we talking about here? 


Dr. Friedman: We’re talking, first of all, about something that happens at the time of a vaginal delivery. When a baby is born, first, the head comes out since we don’t do breech deliveries, which is feet-first anymore. Generally, that’s the hardest part of a delivery. And if a baby has gone through all the appropriate maneuvers in the part of labor that is required in order for a vaginal delivery to happen, generally, the shoulders and the rest of the body kind of just fall right out so to speak after the baby’s head is born. 


If the shoulders and the rest of the body don’t come on their own after the head is born, we usually diagnose that as something called a shoulder dystocia. It’s not like it has to happen immediately, but usually, after a certain period of time, whether it be 60 seconds or so, or if we have to do additional maneuvers to help deliver the shoulders and the body, that’s usually when we call something a shoulder dystocia. 


Dr. Fox: Yeah, the word dystocia is a word that we have in obstetrics a lot, and it’s really not used anywhere else in my life that I know of. And it basically just means like stopping or slowing down. We talk about labor dystocia. It’s another fancy term we, you know, teach the medical students and residents about. But basically, if you’re in that situation, all the time someone’s pushing in labor, they’re pushing, they’re pushing and pushing, it’s really to get the head out. 


You know, they’re just trying to fit this head because the head’s typically the biggest part of the baby, and it’s also, there’s bones, not as malleable, let’s say, as the rest of the body. And so, they’re pushing, they’re pushing and pushing, and then suddenly when the head comes out, everyone’s like, “Yay.” But the baby isn’t out yet. And like you said, most of the time after the head comes out, babies are shaped sort of like lollipops and the body just comes right out. So, if the head fits, the body’s going to fit, but occasionally, it doesn’t. 


And when that shoulder gets stuck, it’s usually stuck behind the mom’s pubic bone, which is that bone very low down on the belly, upper part of the pelvis that goes across from left to right. If the shoulder gets stuck behind there, for the obstetrician, that’s like, “All right, now more has to happen.” And it’s not an issue usually with her pushing, it’s sort of more geometry at that point that it’s just trying to come out where it’s stuck. So, that’s what it is. How do you determine if it’s, like you said, a normal delay versus an abnormal delay? Where do we draw the line between normal and abnormal so to speak? 


Dr. Friedman: Right. It’s not 100% black or white. Not every provider does this exactly the same. But personally, you know, after the head is delivered, I will sort of just wait hands-off and see what happens next. I may ask the mom to push one or two more times to see if the body follows. And usually at that point, if it’s been about 45 or 60 seconds and the body is not following on its own, that’s generally when I’ll notify the nurses that we have a shoulder dystocia and start to move on to some other techniques we have to try to relieve the issue. 


Dr. Fox: Right. There isn’t a set definition some people use like after X amount of time like you said. Some people could stop, like, “Hey, I know what’s normal, and this is not normal.” And a lot of things in medicine are like that, which is fine. Once you’ve done hundreds and thousands of deliveries, you sort of get a sense of where things are happening as they should or not. And, okay, so the shoulder’s not coming as it should, there’s a delay, why do we care? Like, what’s the big deal? Women push for 4 hours when they’re delivering the head, why is 60 seconds or 2 minutes such a big deal for the shoulder? 


Dr. Friedman: Well, the biggest concern is that if we can’t get the baby delivered in a certain amount of time, that maybe the baby’s not getting enough blood flow, because you’re sort of in this in-between period where it’s still getting blood through the umbilical cord from the placenta, but this is often compressed or being squeezed a little bit when the baby’s in this, you know, in-between position, and it’s not yet breathing and getting oxygen on its own because it’s not born yet. 


So, we need to figure out a way to get the baby delivered before that time happens, which generally is, you know, five-ish or more minutes, but we want to make sure that we’re resolving the issue in a safe way. Because if you’re not, then there can be other issues, specifically like nerve damage or broken bones to the baby, which is obviously not ideal. 


Dr. Fox: When the babies are there and they’re coming out, it’s not always, but when they’re in that sort of position you said where the head is out and the body is sitting basically in her vagina, right, the head is out already, you can see the head, the nose, the ears, the face, they’re not yet breathing. They haven’t had an opportunity to take that big gasp and start breathing through their mouth, their nose, their lungs. But like you said, the cord is frequently compressed at that point, so they’re not really getting oxygen into their belly. 


And so, think of it like the baby’s holding his or her breath, let’s say, 15 seconds, 30 seconds, a minute, nothing bad is going to happen in that time. But once it starts getting to two minutes, three minutes, four minutes, five minutes, it really can be a big issue at that time. And that’s the worst complication that could happen from a shoulder dystocia, and that’s one of the things we’re worried about. But what ends up happening is just from the geometry of it, in order to dislodge the baby’s shoulder from behind that pubic bone, there’s a lot of things that either we need to do or sort of happens on its own, and that can be musculoskeletal issues like you said. 


Like, sometimes when the babies come out, they can end up getting a broken arm like their humerus, which is the upper arm bone, or a broken collarbone, or clavicle. And that sounds pretty bad when a baby breaks a bone, but, in fact, it turns out that’s not such a big deal for babies, fortunately, because they heal so quickly. They don’t need a cast. They basically do nothing and it just heals. So, we don’t want it to happen, but it’s not sort of critical in that sense. But there could be nerve damage. 


And there’s these nerves that travel down sort of the side of the neck into the arms, the fancy term is the brachial plexus, someone ever Googled that, and that’s one of the things that tortures medical students in anatomy to learn all the branches of the brachial plexus. But if that gets injured because the neck is getting stretched, there could be temporary or even permanent nerve damage, and the baby, then child could have diminished function in that arm. So, it’s an issue. How common is this? How often does it happen in births? 


Dr. Friedman: Luckily, it doesn’t happen that often, but it happens. Especially, you know, if we’re doing thousands of deliveries a year, we see it pretty commonly, which is good because we have a lot of experience with it. But for all intents and purposes, it happens probably less than 3% of the time. 


Dr. Fox: Yeah. It’s a couple of percent of births. It’s not that much. And what hard with this particular situation is everyone…you know, all the obstetricians know about it. We train for this. This is one of the obstetrical emergencies, and everyone knows that it could be a problem for the baby. But number one, it’s rare. Okay. But like you said, most of us are doing a lot of births, so even thougit’s rare, we see it enough that we can train it and know what to do, nurses and everybody. 


But having a shoulder dystocia does not mean the baby’s going to get injured, right? Probably only 10% of babies who are involved in a shoulder dystocia have any injury, and most of those injuries resolve and they’re not permanent. And so, one, if the baby has a temporary injury at birth, yeah, it’s stressful, and you don’t want it to happen, and, you know, there’s no reason that you would want parents or baby to go through that. 


But again, if it’s something that’s “an injury,” but it’s temporary, okay, like, you know, we can sort of handle that. But, so if you think about the total number of babies who will be harmed permanently by shoulder dystocia, it’s pretty unusual. And so, what do you do about that? Like how do you sort of talk about that and council these very rare, bad outcomes, and you freak everyone out about it, or do you not? And that’s a tough balance. 


Dr. Friedman: Right, exactly. It’s a hard question. And, you know, it depends on certain risk factors, but most of the time these things happen is when we’re not expecting it, when the patient doesn’t have any specific risk factors. And so, you don’t necessarily, like you said, you don’t want to freak everybody out and tell everybody that this is a potential that can happen, but you can kind of see how things go and just have open communication with the patient during the labor process. 


Dr. Fox: As the obstetrician, every single one of us at every single delivery are thinking about it. 


Dr. Friedman: A hundred percent. 


Dr. Fox: One hundred percent of the time when, you know, we’re super-duper excited and say, “Hey, the head’s coming out,” and we’re, you know, smiling and this and that, and the parents are so excited and taking pictures. And, you know, we are always, always like, “Where’s that shoulder? Is it coming out? Do we have a problem or not?” And people don’t realize that is literally the one thing on our mind in every single birth at that point. 


Dr. Friedman: Exactly. 


Dr. Fox: And sometimes, you start to sweat a little bit. If it’s, you know, you’re like, it’s 10 seconds, 20 seconds, and you start thinking more and more. And that‘s sometimes why at that point, you may see your obstetrician get a little bit quiet and start concentrating a little bit more and maybe ask for a couple of friends to come over and, you know, help out just in case, and it’s really just for that reason. We‘ve all been there. So, who is at risk for getting a shoulder dystocia? Like, who would be someone who we’d be thinking, “All right, this woman is at high risk to have it.” 


Dr. Friedman: Well, definitely for women who have had this happen before, so they had a shoulder dystocia in a prior pregnancy, then we know that they are at increased risk relative to the general population. It’s hard to say exactly how many times it will happen again as it depends on a lot of factors like we keep saying, but it’s probably somewhere around 10%. 


Dr. Fox: Right. It’ll happen again. Yeah. Something like that. Again, it’s hard to know because a lot of them end up… They had it the first time, and it was a bad experience. They’ll have a C-section the next time, so you don’t always know. But yeah, some are 10%, 20%, somewhere like there. It’s common. That’s the biggest risk factor. 


Dr. Friedman: Right. We also know that if the baby ends up being on the larger side, that baby will have an increased risk for having the shoulders get stuck. 


Dr. Fox: Right. And that makes a lot of sense, right, bigger babies are harder to fit. 


Dr. Friedman: Right. 


Dr. Fox: They’re also harder to deliver the head. It’s the same concept. But once the head comes out, they tend to be bigger and geometrically slightly more complicated to deliver. 


Dr. Friedman: Right. Then women who have gestational diabetes also are at risk just because of the way the abdomen and shoulders are relative to the head in those patients and those babies. 


Dr. Fox: Right. So, that’s a really interesting concept. So, women who have diabetes, the thought is that the babies get more sugar. And babies who are big because they’re like genetically big tend to be big everywhere, big heads, long legs. They’re just big. And so, if the head fits, the body is usually going to fit again, proportionally. It may be harder to deliver them because the head’s big, but once the head comes out proportionally. 


But when you take a baby that’s supposed to be a certain size and give them extra sugar, their head doesn’t get bigger, their legs don’t get longer, they just get sort of bigger. And so, their shoulders are wider, their bellies are bigger. And so, proportionally, once the head comes out, they’re more likely to have a disproportionate shoulder and trunk size. For any baby weight, if the mother was a diabetic or gestational diabetic, the chance of a shoulder dystocia is a little bit higher. 


The mother’s weight, the heavier she is, there’s a higher risk, but it’s not as great a risk factor as those. Same thing like a long labor is a risk, but those are sort of softer risk factors because they’re also so common. So many women will gain a lot of weight in pregnancy and, okay, it’s not the biggest risk. Really, you know, prior shoulder dystocia, big baby, diabetes. Now, the hardest part I find is the big baby risk factor because as you know, and as I know, but not everyone realizes, we don’t know the baby’s weight before the baby’s born. We only guess the weight, and we’re frequently wrong. 


We’re always wrong actually, but the question is how wrong are we? Are we a lot wrong or a little wrong? And so, that’s a tough situation because babies can be born and they’re much bigger than we thought they would be, which can put us in a situation of a shoulder dystocia where we weren’t expecting one. Or the opposite, we’re totally freaking her out that her baby’s so big, so big, so big, and then the baby’s not so big. And then we scared her or maybe done things that we didn’t need to do ultimately. How do you address that with patients at the end of pregnancy? 


Dr. Friedman: It’s tough. I mean, you know, not everybody in pregnancy is getting an ultrasound or a growth ultrasound. Like we say, that gives us, you know, an estimation in pounds and ounces of how big we think the baby is. So, a lot of times we’re measuring the uterus, which is equivalent in low-risk patients and estimating the size of the baby, And for anybody that’s kind of in the “average range,” I don’t usually bring it up again because it’s so rare. 


It’s not something that we want to scare everybody about. If we’re expecting maybe a bigger baby based on the ultrasound or how much the patient has gained during the pregnancy and things like that, then it may be a discussion I have either in the office towards the end of the pregnancy or in the hospital as we start the labor process, depending on when I’m seeing the patient. 


It’s something that I sort of bring up in the beginning of the process as a possibility and its spectrum. So depending on, you know, if we’re expecting it to be a 12-pound baby, I’m going to talk about the risks in a much more objective way and maybe recommend various different options, either early induction or C-section instead. Whereas if it’s kind of on the borderline, you know, we mentioned that we talk about the risks and then answer any questions the patients have, but we don’t usually change our management protocol so to speak based on that. 


Dr. Fox: It’s usually hard, and there’s so many variables that go into this, you know, what are her risk factors otherwise? How does the baby look on ultrasound? What is her history? What is her pelvis like? Has she had other births? I mean, what is her comfort with risk? You know, some people are much more uncomfortable with any risk of this and would rather have a C-section, and other people are much, much more comfortable with a low chance, you know, risk compared to having a C-section, all that goes into it. 


And because of that, it’s hard to get very precise and helpful recommendations on what to do. Because I can pull up a table and say, “All right, if your baby is this weight, you have this percent risk of a shoulder dystocia. And if it’s this weight and you’re diabetic, it’s this.” And you can pull that up, but again, that‘s for weights after the baby’s born. We don’t know the weight before. So, you have some variability on the likelihood of the shoulders dystocia based on the real weight and the variability that we don’t actually know what the weight is and we could be over or underestimating it. 


So, those are two big variables. And number three, no matter what the situation, predicting a shoulder dystocia doesn’t mean predicting an injury, because again, the vast majority of babies who are in a shoulders dystocia will come through it okay. And so, these conversations are… they’re really hard to have and they have to be long. It’s hard to say, “Okay, you know, because of A, you need to B, and because of this, this.” You just really have to have a long conversation about it and to go over all the various things we do know and don’t know and see where it goes from there. 


Dr. Friedman: Exactly. It’s very individualized. 


Dr. Fox: Yeah. There are recommendations out there, and they’re pretty lenient for the vaginal delivery. Like if you look up the mirror culture of OB/GYN, it basically says, “You shouldn’t discuss C-section for a woman unless the estimated weight is like over 11-plus pounds, like 5,000 grams.” And all of us are like, “Oh my God, that’s huge.” And they say that because under which…who knows, there’s so much variability and for a diabetic are like 10 pounds, but that’s a really wide bracket of people you’re going to be laboring with big babies. 


You know, I use those recommendations, I’ll tell people what the national recommendations are. That’s not always how we conclude what we’re going to do in that situation. So, let’s say you have someone who is at risk for shoulder dystocia because of either that history, diabetic, baby’s measuring a little big, and you’re having this conversation. What could you possibly do to avoid it or to avoid injury? 


Dr. Friedman: There is not a ton to try to avoid injury other than proceeding with a C-section. You, in theory, can get a shoulder dystocia during a cesarean delivery, but that’s very rare. Or you can talk about inducing at, you know, 39 weeks or so, rather than waiting until spontaneous labor happens at 40, 41 weeks knowing that the baby is going to continue to grow the longer you wait. 


There’s not great evidence that this reduces risk of shoulder dystocia, but sort of, logically thinking, seems like it should. There are risks and benefits to both options. There are some risks associated with induction, although overall, it’s very, very, very safe. So, I think that’s, you know, where the individual discussion with each patient really comes in. 


Dr. Fox: It’s so interesting, part of this is dating me compared to you. So, when I was training, same problem was there. We knew that people are at risk for shoulder dystocia, we knew that we couldn’t predict it, all the same things were true then. We don’t know much now than we did then. But what’s so interesting about the question of, should you induce someone who the baby seems to be big, right? Again, we don’t know the baby’s big, but baby seems to be big. And so, at the time, there was two problems. 


Problem number one was we weren’t sure if it would improve outcomes, and number two, we were pretty sure it was going to increase the risk of the cesarean for the mother by inducing. And so, when we were training, we were like, “Listen, you know, we’re going to increase your risk of a cesarean because we’re inducing. We may or may not be decreasing the risk.” And that was sort of the conversation. What’s happened since are two things, which is really interesting. 


Number one, there’s really, really, really, really good evidence now that we’re not increasing the risk of a C-section by inducing at 39 weeks, as long as you do it right, like you do it properly. So, that’s good. That’s good news. So, we don’t think it’s quite as harmful to induce labor. It may be annoying, right? Because it’s longer and there’s, you know… We had a podcast on induction. There’s things that happen in induction that a lot of people don’t want. Okay. Like that makes sense, but it does not seem to be harmful from a medical perspective in that sense. 


And there was a big study at Europe where they induce people, but they were doing it at like 37 weeks and it did help. But in the U.S., we rarely are going to induce people sort of “electively” 37 weeks. So, at 39 weeks, whether that helps you or not is unsure. So, I think the discussion has become a little more lower intention because we’re not so worried about the induction, but we’re not certain it’s going to help. But who do you recommend a cesarean to? Meaning, “Don’t labor, don’t try to labor. This baby’s too big, you’re a too higher risk.” Who do you recommend it to? 


Dr. Friedman: So, usually, for patients who have had a prior shoulder dystocia, and especially if that was a severe shoulder dystocia or the baby who had permanent damage, or it was really traumatic for mom, or if we’re expecting a bigger baby or we’re thinking that there’s going to be a bigger baby this time around than was involved with a shoulder dystocia in the past. That’s probably the scenario in which I would most firmly recommend not trying again absolutely. 


Dr. Fox: Yeah. I’m pretty similar in that. And I’d say most women are on board with that plan, but there are a few that aren’t. And again, the numbers are in her favor no matter what she does. Even if she has a 30% chance of a shoulder dystocia, again, only 10% of those are going to have an injury and only 10% of those are gonna have a permanent injury. So, it’s still under 1% of the babies will be “harmed” in the long-term. And, again, different people feel differently about those numbers. Some women are like, “Listen, you’re talking about a less than 1% chance of a risk to my baby. But for me, I have to undergo a C-section. That sucks. I don’t want to do that.” 


And it’s not a horrible decision, like fine. And other people are like, “You mean there’s like any chance of my baby getting injured? I don’t want any part of that. I’d rather have a C-section.” And people feel differently. You know, ultimately, we’re just going to tell them what we think is safe. And, unless they’re making some insane decision, you know, we’re going to go with it. What about in terms of the estimated weight? Do you have like cutoffs that you use or that you’re comfortable with, or is it a lot of gray zone? 


Dr. Friedman: It’s a lot of gray zone. I mean, I certainly try to abide by the ACOG rules or the suggestions with the estimated fetal weight of 5,000 grams without diabetes and 4,500 with. And then, you know, in that sort of gray zone underneath that, but still seeming big, we’ll kind of have a discussion. 


Dr. Fox: I tend to be more concerned with the diabetics. Those babies really do have a different proportion than the others. And also what she’s done before if it’s a first baby versus their fifth baby. Someone who’s delivered four 9.5 pound babies before, you’re not quite as worried, obviously. Even though it could happen, it’s just not as likely. It’s also difficult because different doctors counsel people differently. 


So, patients hear different messages sometime. And I think, you know, some of that’s on us that we’re not doing a great job being consistent, but some of that’s just the inherent uncertainty of this. And I think, you know, people need to understand that there’s a lot of things that happen with obstetrics and medicine, where there isn‘t a right answer because we don’t know all the data, and we don’t know the exact risk, and we don’t know exactly what’s going to happen. So, a lot of it is personality, just how people view these things. 


Dr. Friedman: Exactly. 


Dr. Fox: I mean, I have people who are very adamant that if there’s any risk whatsoever, boom, “Let’s schedule a C-section,” happy. And others are like, you know, “Unless you’re telling me that you’re certain my baby’s going to be harmed, I am not doing a C-section.” And both those women are perfectly reasonable, they’re just different. And there’s everybody in between, and some people are asking you, like, “What should I do?” And other people are saying, “I really want to do this.” And again, everyone is so different. That makes medicine interesting actually that humans are quite different from one another. 


Dr. Friedman: Yeah. Exactly. 


Dr. Fox: Okay. So, let’s say someone’s laboring, right, and they’re either at risk for a shoulder dystocia or something is happening that maybe we think now they’re at risk for shoulder dystocia. What might you do differently during the labor? Like, do you ever stop a labor and say, “We’re going to do a C-section” in the middle of labor because of that, or is it just stuff that you prepare for the delivery itself? 


Dr. Friedman: Usually just for preparation for the delivery. I mean, if we’re expecting a larger baby and mom has been pushing for three hours and I’m a little worried that something may happen, I may be a little less willing to do “heroic measures” to get a vaginal delivery. We may say, “Yeah, this may be dangerous, let’s try for a C-section.” But it’s more about making sure that, you know, you have all hands on deck, that your nurses are aware of the potential for a shoulder dystocia, that other doctors on the labor floor are aware that you might call for help, kind of be thinking about, like you said earlier, which way the head is coming down and which shoulder will be potentially the problem shoulder, and just kind of mentally preparing for the need to do more than what a typical delivery would involve. 


Dr. Fox: That makes a lot of sense. And for people for whom it doesn’t make sense, it will soon because we discussed sort of the maneuvers we need to do to sometimes dislodge that shoulder. It frequently involves other people. And so, when we think there might be a shoulder dystocia, like we said before, it’s one of those scenarios where I’ll tell a woman, “Listen, your baby’s really big. We may be worried about A, B, and C. 


When the baby’s coming out, I’m going to have, you know, one or two other people in the room. I’m going to do this. And just as you understand that, you know, they’re not just there as spectators, but we may need their help.” And also if it happens, a lot of people might run in the room emergently, like sometimes we don’t expect it and it just happens. And so, if we’re in a situation where the head comes out and the shoulder is stuck and we think there’s a shoulder dystocia, so what are the maneuvers that we do or that we try to do to dislodge it? How does that work? 


Dr. Friedman: First, we ask for help, we call for help. We make sure everything…you know, we have what we need to do this. There are usually two maneuvers that we try first. And one is called the McRoberts maneuver. And essentially, we lay mom all the way back, and we pull her knees towards her chest so her pelvis is really flexed hoping to try to change the diameter of the pelvic opening so that it makes a little bit more room for the shoulder to come through. 


Dr. Fox: Right. A lot of women push in that position anyways, especially if it’s the first baby. You know, those are usually harder to push out generally, and so a lot of women will find themselves in that position to open the pelvis as much as possible to help the head come out. But a lot of women don’t need that or are comfortable in other positions or, you know, they have a much easier time pushing, but then we’ll usually put them in that position. Like you said, it just opens the pelvis even just a few millimeters more, and that’s sometimes all you need to do. Okay, so that’s typically the first maneuver. 


Dr. Friedman: Yap. And then we’ll usually do something if that doesn’t work called suprapubic pressure, where we figure out which shoulder’s the one that’s the problem stuck underneath the pubic bone. And then, typically, someone standing to mom’s side will apply pressure kind of coming from the back of the shoulder, moving it forward to try to move it just a little bit so that it can squeeze under the bone. 


Dr. Fox: Right. And just for those of us who are not quite figuring out the anatomy of that, they’re basically taking a fist and pushing it where your bladder is. You know, they’re pushing down on your belly because that’s where that shoulder is because it’s right behind the bone, and the thought is from outside her body, you can push that shoulder either straight down or just angle it so it rotates a little bit, it’ll now come under the bone. 


And so, that’s one reason you need someone else in the room, and you’ll frequently ask us call for a stool in the room because that person may not be tall enough to do that, and so he or she may need to get on a stool in order to push down on the shoulder. So, those two usually relieve I would say most shoulders dystocias, particularly the mild ones. And after that, it starts getting…all the maneuvers are basically internal. These are things we do with our hands inside that she wouldn’t notice we’re doing, for example. So, what are the kinds of things we try to do sometimes to dislodge the shoulder? 


Dr. Friedman: Yeah. So, sometimes we’ll try, if we can’t get the front shoulder to come through the bone, or come under the bone, we’ll try to deliver the posterior arm or the other arms since that’s not being inhibited by a bone. And if we can get that out, then, again, it will change the diameter of the shoulders and the way the baby is, and usually allow for the front shoulder to then come through. 


Dr. Fox: Yeah. I mean, if you think about it, basically like geometrically, the baby’s trying to come out of like a hula hoop, right? So, it’s a circle. And if you think like you’re trying to get a baseball bat through hula hoop and it’s just not fitting, you’re pulling it, there’s really only a couple of options. You can either, if the hula hoop isn’t perfectly circular, you can maybe rotate the bat instead of up-down to maybe 45 degrees, and that’s one of the maneuvers we do. Because again, the pelvis, isn’t actually a circle, it’s an oval. 


So, that’s one thing we can do. Or there’s maneuvers where it’s actually not a baseball bat because you can bend it, so you can actually sort of fold the baby a little bit shoulder to shoulder to get it in. And the other thing is you can, you know, which is interesting, what you said about the other arm is if you take the bat and sort of pull it from the bottom up through the hoop, you can just do one shoulder by one shoulder. And all those are maneuvers that we do, they tend to be successful. Those are the maneuvers that sometimes a baby can get injured during those maneuvers. 


The thing that gets a lot of discussion is how much we put traction on the baby’s head and neck, meaning sort of in layman’s terms, how much do we pull on the head. And during deliveries, we actually don’t really pull on the head. And, certainly, people think we do, but what ends up happening is we have our hands on the head, and as the mom is pushing, we just sort of guide the head down so that their shoulder comes out. And it’s one of the ways that we know there’s a shoulder dystocia. Just by doing that, it’s not coming out, we’re all trained like don’t pull because it’s not gonna work. That’s not what you need to do. 


And I think a lot of people believe that any time there’s an injury to a baby during a delivery, it’s cause one of us pulled too hard or we did some improper maneuver and we could do that. I mean, obviously, we have the capacity to injure a baby or harm a baby if we don’t know what we’re doing, but it ends up happening that we don’t really understand why some babies have a shoulder dystocia with the exact same maneuvers, exact same forces will have an injury and other babies won’t. 


We don’t understand exactly why some babies who have an injury will recover like a nerve injury and others won’t. There are definitely a lot of cases of moms who push and push and then she has a C-section, and the baby comes out and they have the same type of injury. So, there’s thought that some of it is related to the stresses or the forces on the baby’s nerves during labor and not so much delivery, and there‘s a lot of disagreement about this. 


I can say that in my own experience, plaintiff attorneys tend to think it’s all the obstetrician fault, and obstetricians say it’s never the obstetrician’s fault. But you know, we’ve all done enough of these to know that you can literally do the exact same maneuvers and the exact same thing for some two different babies, one has a broken clavicle and one doesn’t, and you’re like, “How did that happen?” And there’s just so much we don’t understand about this, and yeah, it’s hard. 


Dr. Friedman: It is. But it’s all okay. 


Dr. Fox: I’m definitely giving Friedman some sort of flashback of a shoulder dystocia she had, and we’ve all had those situations where every maneuver you’re trying, it’s not working. You call on other people, it’s not working. And it feels like it’s been 45 minutes, but it’s been like 1.5 because, you know, it’s always in our mind, it’s always in our mind. But I’ve fortunately never been in a situation where baby didn’t come out. 


They all come out at some point. But, yeah. Again, it’s one of these things I think it’s nice for women to know exists and not to scare them because, again, it’s not likely to happen to anybody who’s listening. And even if it does, your baby’s almost certainly going to be okay. Even if there’s an injury, it’s almost certainly going to be temporary and will go away. But it’s one of these things to sort of get a sense of, you know, why it is we do what we do at delivery. 


Why we might do one thing versus something else. Why we make it suddenly pretty serious at the time of delivery when we were, you know, happy-go-lucky before. Why people might run in the room, you know, “Why is people running in my room?” And it’s just to understand sort of what goes through our heads, and it’s part of the training to deliver babies. There’s actual, you know, hand maneuvers we need to learn in order to do this. And it’s unfortunately common enough that we have to learn how to do this, but fortunately, common enough that we know how to do that. 


Dr. Friedman: Right. We have a lot of experience. 


Dr. Fox: Excellent. Wow. Friedman, good work. 


Dr. Friedman: Always fun. 


Dr. Fox: Shoulder dystocia, it’s a really interesting topic. Again, I find the most fascinating part about what to do when they’re pregnant and they’re at risk for it and how to make those decisions about having a cesarean or having an induction or none of the above. And, there isn’t a right or wrong answer. You can read about cutoffs, but they’re all sort of gray and they’re not based on perfect data. But it is something to discuss and sort of to get a sense of why one woman might choose one thing or why one obstetrician might recommend something. 


Dr. Friedman: Exactly. 


Dr. Fox: Fantastic. Well, we’re going to see how this podcast does compared to all the other ones on the top 10 charts. 


Dr. Friedman: All right. Sounds good. 


Dr. Fox: And I highly recommend everyone check out your Instagram account. I am a loyal follower. 


Dr. Friedman: Thank you. 


Dr. Fox: And if anyone who knows me in Instagram knows I don’t follow a lot of people. So, that’s a good recommendation, and we’re looking forward to having you on again. 


Dr. Friedman: Thanks. Can’t wait. 


Dr. Fox: Thank you for listening to the “Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. 


The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.