Taking "All Fours" a Little Further (Shoulder Dystocia)
Ina May Gaskin's suggestion to get a woman into an "all fours" position when faced with suspected shoulder dystocia made a lot of sense to me. I incorporated it into my practice and it is now the first thing I try when I see one of those fat little faces creeping out over mother's perineum.

Over time, I began to think more about what the baby was doing while the woman is turning over, and it occurred to me that we might give the baby an even better chance of freeing his anterior shoulder and coming out quickly if we get the mother to turn over onto all fours in a specific direction. The baby is rotating as it comes through the birth canal, and it is this rotation that is prevented when the baby's anterior shoulder gets stuck under the pubic arch. Can the direction in which the mother rotates assist the baby with its own rotation?

As the head is born, it will be facing toward the mother's back (I am using the examples of LOA and ROA babies, although the process can be worked out in the same way for any position). Once the head is born, it undergoes restitution in which it "untwists" to compensate for the twisting it did to come through the pelvis and external rotation. Following these movements the baby's head will be facing the same way as it was in utero. An LOA baby will look toward his mother's right leg, and an ROA baby toward his mother's left leg. By this time, the shoulders will be undergoing internal rotation and they will be in the anteroposterior diameter of the pelvic outlet.

The anterior shoulder of the LOA baby will want to rotate across the pubic arch from right to left (from the mother's perspective); as he is born he will continue to rotate in the same direction. Thus, if his shoulder sticks under the arch the mother may do better to turn over by keeping her left hip downward and taking her right arm and leg "up and over" the top of her left; she then helps the baby rotate by going with, rather than against, his direction of rotation. (If this makes no sense, you may want to demonstrate with a pelvis and a doll!)

Conversely, if the baby is ROA, his anterior shoulder will be moving across the pubic arch from left to right; you may want to get the mother to turn over by keeping her right hip downward and taking her left arm and leg over the right. The weight of the baby's back, in combination with the movement, might also help with the rotation and the birth of the shoulder.

A simpler way to remember this might be as follows: whichever side the baby's back is lying, keep that hip downward as the mother moves over onto all fours. You can just indicate with your hand the direction you want the woman to move in it is much simpler in practice than it sounds here!

I have no concrete evidence to suggest that this works any better than simply moving the woman onto all fours in a random direction, although since I have tried it I have had several babies whose anterior shoulders had delivered by the time the mother completely turned over. However, it takes no more time to move onto all fours in a particular direction, and it just might help free a few of those shoulders and maximize the chance of this maneuver working without recourse to further intervention. Let us know your experience.
-Sara Wickham, Midwifery Today Issue 49

Reprinted from Midwifery Today E-News (Vol 2 Issue 3, Jan 21, 2000)
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