Tight shoulders

So, my first week of clinicals ended last week, and I am only just now having an opportunity to sit down and write about it. Let me tell you a bit about my schedule: clinicals take up roughly 42 hours a week—2 labor and delivery shifts and 2 clinic shifts—plus one day a week in class, and every other spare moment devoted to either sleeping, eating or studying (well, and blogging…and watching the occassional episode of 24). Labor and delivery shifts start at 7:30 am for postpartum rounds and don’t finish until 9:00 pm. To get to the hospital on time, I need to leave my house around 6:30 am to account for the vagaries of the subway, which means waking up around 5:45 am (did I mention that this hospital has an absolute THOU SHALT NOT BE LATE policy? If I’m late once, we talk about it. If I’m late twice, I’m sent home. If I’m late three times, I need to find a new clinical site). It’s dark when I leave for the hospital, and dark when I come home. Not a very bright prospect for a certain student who really loves her sunlight. I thought I was going to be doing clinicals, but in fact, I think I’m in midwifery boot camp. I must have missed a memo somewhere along the way.

However, clinicals are going well. Much better than I had anticipated—in fact, most of the feedback has been very positive so far, and the preceptors I’ve encountered so far have been a lot of fun to work with. My second shift on labor and delivery involved working with one woman for most of the day. She was a multipara—first baby was 3500 gms, second baby was 4000 gms, and this one was feeling very large as well (we estimated 4000 gms), but she wasn’t diabetic, and she had a large, roomy pelvis, so we weren’t sweating (although we were watching closely, and we had a stool in the room just in case suprapubic pressure was needed in a hurry). She spent the first half of her labor out of bed and walking around (how about that! A hospital that actually has intermittent monitoring protocols that 1) work and 2) get utilized appropriately), but she wasn’t progressing quickly (about 1 cm every 2 hours), and certainly not as quickly as you would expect a multip to progress. We began to worry that if things didn’t continue to progress at a steady pace, the residents on the floor would begin to poke their heads into the room and want to start pitocin…and yes, I know! Progressing one centimeter in 2 hours is just fine, really, and not a problem if you’re at home or in a birthing center…but when you’re on labor and delivery, unfortunately there is a clock that is constantly ticking, and as a midwife on a hospital floor you have to take that into account. So we decided to rupture her membranes to see if that would help get things going. Not a benign measure, by any means, but preferable to pitocin. And sure enough, rupturing her membranes did the trick, and before we knew it, her labor was much more intense, and she was asking for an epidural, which she got.

Things slowed down a little bit after that, but she continued to make steady progress, and by 4:30 pm she was ready to push (we’d been laboring with her for the entire shift, since 8:30 am). We turned the epidural down so that she could better feel the contractions and the urge to push, and began the slow work of pushing that big baby down. Again, it took longer than we had anticipated, and she wasn’t the strongest pusher in the world, but finally, the baby began to crown. And crown. And crown. And we did, indeed, begin to sweat.

The woman had a very short perineum, and there was a little bit of scar tissue from what looked like a prior episiotomy, and her skin integrity was not that great. I gave perineal support as the head was coming out and we got the head over the perineum more or less intact. Once the head was out, my preceptor continued to apply perineal support while I worked on the shoulders. The head wasn’t rotating quickly…it definitley needed some gentle nudging to help it turn. We were concerned about a dystocia, but when I reached up I was able to feel the top of the anterior shoulder, so we knew for certain it wasn’t stuck. Nevertheless, this definitely wasn’t the type of baby that just slips out once the head is born. In fact, instead of holding the baby with both my hands gently supporting the head and neck, I actually had my hands on the shoulders, with one finger hooked under each armpit, and was gently tugging the baby out, bit by bit. I think I finally understand what is meant by “tight sholders” now. It’s not that they were stuck…but it wasn’t an easy fit.

When the baby finally came out, he looked HUGE! As it turns out, he weighed 4400 gms (not quite macrosomic)…but even so, a pretty hefty baby. Definitely took some muscle to lift him up onto his mother’s abdomen, where he proceeded to cry after about a minute of stimulation. Very adoreable baby; he looked like a 2 month old. Welcome to the world, fat and happy baby. There was terminal meconium, and when we had a chance to look at the perineum, there was a pretty nasty third degree laceration there, which baffled me since I was pretty sure the baby’s head had crowned without ripping. My preceptor told me that, given her short perineum, poor skin integrity, prior episiotomy, and just the sheer size of the kid, there was not much else we could have done to prevent it. Even so, I wonder if there was anything I could have done during the delivery of the posterior shoulder that could have prevented such a terrible tear.

In any case, the doctor came in to repair the sphincter, and we finished up the rest of the repair after that, and thus ended my 26th delivery. Tight shoulders. The largest baby I have caught to date.

This entry was posted in Birth Stories, Clinicals, Education, Hospitals, Labor and Birth, Vaginal Birth. Bookmark the permalink. Trackbacks are closed, but you can post a comment.


  1. Posted February 4, 2007 at 11:52 pm | Permalink

    Congratulations! Great story.

    I’ve read about the “ticking clock” in several hospital birth stories. I understand that in hospitals they often prefer if mom dialates about 1 cm an hour. What is the reason for this? Is it to get moms in and out quicker (a profit thing), or is it a supposed sign of an “abnormal” labor and they want to progress things along quicker for the sake of mom/baby? Or is it because they are afraid of being sued? Any other reasons? I truly believe that OBs, etc. who have the power in hospitals have the best interests of moms in mind…it is hard to understand the choices they sometimes make and I like to think (hope?) there is another side to the story that is just as compelling as the midwifery model.

    Sounds like you were able to get mom a vaginal delivery when many other providers would have went for the cesarean (or at the very least the pitocin)…great job!

  2. The Student
    Posted February 7, 2007 at 3:15 pm | Permalink

    I think the ticking clock stems from a lot of different pressures. For one thing, although many studies have demonstrated that the Friedman curve is obsolete (and even Friedman himself has stated that he never intended his study to be used as a guideline for management), the textbooks still define primary dysfunctional active labor as a failure to dilate at a rate of 1.2 cm per hour in primips and 1.5 cm/ hour in multips. And even if you’re not actually clocking a woman’s progress by the hour, I think that this concept is drilled pretty steadily into a doctor’s head during his/her residency, so it’s always there on some level, on a back burner. Plus there’s the ruptured membranes clock, which is sort of an unspoken rule that once a woman’s water is broken, she has roughly 24 hours to deliver, or else face a cesarean. This is supposedly to reduce the risk of chorioamnionitis (infection of the membranes, placenta and eventually baby) which can occur once the sterile membranes are ruptured and exposed to ascending bacteria from the vagina…but again, research has shown that the single greatest risk factor in chorio is repeat vaginal exams, which happen so frequently because impatient doctors are always sticking their fingers in to see if progress is being made.

    And while I do think many doctors have a woman’s best interest at heart, there are always a few (more than a few) who don’t. I have honestly seen cesareans performed becasue doctors didn’t want to wait around for a slow labor to prgress, or wanted to get to their clinic hours on time, or leave for the weekend. When a woman is admitted to labor and delivery in active labor, there’s the sense that something has to happen within about 12 hours. Either she is making progress, or she needs pitocin. If she has pitocin and is not making progress, she needs an intrauterine pressure catheter to make sure her contractions are adquate. If her contractions are adequate and she’s still not making progress, it’s either primary dysfunctional labor or secondary arrest of dilatation, and if it continues for 2-4 hours, she becomes a candidate for cesarean.

    The hospital just isn’t a very patient place. That’s why one of the best pieces of advice you can give to laboring women in low risk pregnancies is to STAY HOME for as long as possible. You have more opportunities to truly rest and relax at home, even with contractions, more oppotunities to walk or dance or jiggle or assume whatever position feels good, more opportunities to eat and drink…if you’ve planned a hospital birth, home is just a much better place to be during the early and early active stages of labor.

  3. nurse2
    Posted February 16, 2007 at 3:11 pm | Permalink

    I have a question . . . for big babies, do you ever try having mom get into the hands and knees position? Or would it have been impossible because she had the epidural? That is a big thing I am always thinking about . . . working as a doula, I have seen the OB or midwife in a hospital go nuts if a woman w/ an epidural got into the hands and knees position, even if the epidural was “turned down” at the beginning of the 2nd stage. I have seen HUGE babies (11lbs) born over intact perineums w/ mom in hands and knees, moms also LOVE this position, even moms who did have the epidural (if they can support their weight, they can assume the position). Sometimes lacerations are impossible to avoid but I think this position really helps . . . gives you some extra room and some extra time.

  4. The Student
    Posted February 16, 2007 at 5:56 pm | Permalink

    Hi, Nurse2:

    I have very rarely seen hands and knees used in the hospital, I think in part because 1) many of the women delivering have epidurals and it’s very difficult and cumbersome for them to move into hands and knees and then support that position and 2) many of the providers delivering women today have only done so from lithotomy, semi-fowlers or side-lying positions, and just don’t know how to use the hands and knees position, especially since all of the normal mechanisms of labor are upside down in that position. Hands and knees (the Gaskin Maneuver) is one of the BEST maneuvers for shoulder dystocia, and if the baby’s shoulders had actually been stuck, I think it would have been one of the first things we tried (but they weren’t stuck; the shoulders were fine, and no additional maneuvers were needed to deliver this baby). However, I haven’t heard of the Gaskin Maneuver being used to help prevent a laceration in a woman delivering a large baby, although I can see how that could work really really well. Next time we have a large baby (and maybe a woman without an epidural?), I will suggest using hands and knees and see how it goes. I have never yet caught a baby from hands and knees position, but I would love to!!

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