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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Literature Search on Hands-Off Births and Waiting for Shoulders

I'll share a literature search re "waiting for shoulders" -- Can we wait for the shoulders (assuming all else looks well)? -- These authors certainly thought so! (NOTE: my remarks are preceded by *** and are in parentheses).

Practical Obstetrics (1932) "When the head of the baby is born, the mucus and amniotic fluid are wiped away from the nose and mouth and the neck is freed from the encircling coils of the umbilical cord....Haste should not be employed in the delivery of the shoulders; the latter are generally expelled by spontaneous mechanism."

Delees' Obstetrics for Nurses (1904) "After the perineum is stretched so that it seems as if the head may come through, in the interval between pains the patient is asked to bear down a little and the head will come. After a few moments the pains force the shoulders out and then the trunk follows." ***(after a few moments "the pains force" -- contractions resume))

Bensons (1983) "In vertex presentations, the forehead appears first (after the vertex), then the face and chin, and then the neck..... Wipe fluid from the nose and mouth, and then aspirate the oral passages with a soft rubber suction bulb or with a small catheter attached to a DeLee suction trap" ****(that's another issue of course[Very Big Grin] GH) Before external rotation (restitution), which occurs next the head is usually drawn back toward the perineum. This movement precedes engagement of the shoulders, which are now entering the pelvic inlet. From the time on, support the infant manually and facilitate the mechanism of labor.

DO NOT HURRY****(the author puts this in italics). If the strength of the contractions seems to wane, be patient, labor will resume. Once the airway is clear, the infant can breath and is not in immediate jeopardy! Delivery of the shoulders should be slow and deliberate. The shoulders must rotate (or be rotated) to the anteroposterior diameter of the outlet for delivery."

Synopsis of Obstetrics (1940) -- after delivery of the head --- "Delivery of the shoulders: a: Do not yield to the urge to hasten delivery as soon as the head is born. b; There is usually a lull in the pains at this time. ****("lull" is normal) c: Wait until the head rotates externally, which is an indication that the shoulders have rotated internally. There is no hurry as long as fetal color is good. d: When sure that the shoulders lie directly antero-posterior and pains have recurred, delivery may be assisted.

Even books for the "lay public" talk of 'waiting for the shoulders'

Childbirth at Home (Sousa 1976) "When the head is born, the attendant can suck mucus from the baby's throat, if the baby is not already crying. With the next contraction, the mother can push gently to rotate the baby's body. Usually the rest of the baby will then slide out smoothly. If not, wait until the next contraction pushes out the baby's top shoulder."

The New Childbirth (Erna Wright 1967) -- "The next contraction will deliver the baby's to below the chin.... After this there is usually a pause of about a minute or two... You may have to give a little help..with the next contraction. This will deliver the shoulders, first the front shoulder and then the other one."

Many of my books are out on loan at present, so I think I'll stop with this last reference[Grin].

From Guide To Effective Care (1995) -- "After delivery of the head, the shoulders rotate internally.... Once rotation is complete, the shoulders are delivered one at a time to reduce the risk of perineal trauma... Difficulty with delivery of the shoulders is rare following spontaneous birth of the head ***(This means if vacuum extractors and forceps are "not" used, then shoulder dystocia "is rare"... hmmmm). Delivery of the shoulders should not be attempted until they have rotated into the anteroposterior axis." ****(I read this to mean that since rotation often doesn’t' occur until the "next" contraction after the birth of the head; we need to wait for that "next" contraction).

This "lull" can be a very special moment for mom.. Help her relax, take a breath; her work is almost over, in just a moment she can see the rest of her baby --- encourage her to touch or talk to her baby, stroke his/her hair etc. etc. As long as baby's color is good, then why hurry? The next contraction will come within a minute or two (or three....), if external rotation has occurred, there should be no problem with the rest of the birth. (Of course a purple, wedged in baby needs help... but we seldom see this -- even with big babies).

Other note. Any position where mom is on a bed may impede shoulders -- if we encourage moms to deliver side lying or squatting or standing or kneeling or etc , then we should see a lot less slow shoulders. WE GET BIG BABIES UP HERE TOO! [Grin] Sometimes I look at a baby under nine pounds and wonder what happened to it -- it's so small compared to our "usual" baby.