A shoulder dystocia and neonatal resuscitation

Last night, I was caring for a laboring woman who had been laboring all day. I labored with her throughout the night until she started pushing. The baby's head was making a slow decent but we didn't think too much about it because that can be normal. The head crowned, slowly was born, and turned. With the next contraction, I expected the rest of the body to slip out, but it didn't so I attempted to lightly move the shoulders to assist the baby to be born. However, the shoulders didn't budge at all. I decided to try one more time with the next contraction but they didn't budge. At all. I've never had a true shoulder dystocia, but knew it was an emergency so I had the more experienced midwives take over. We moved mom to the hands and knees position which is the best position for birthing a shoulder dystocia, but the baby still didn't budge.

While the midwives attempted to deliver the baby, I jumped up and began to gather supplies for an emergency. I cleared an area for resuscitating the baby, set up the equipment, prayed, and watched. Next to me, the midwives were also praying out loud and trying every trick to get the baby out. However, the baby had an entry dystocia so was stuck at the entrance to the pelvis instead of the pubic bone in a way we couldn't easily deliver. They took turns trying to reach the baby's shoulder and arm to try and pull the arm above the head, decreasing the diameter of the shoulders. However, the baby was wedged so tightly, it took ten minutes of the midwives pulling and the mom pushing before finally the midwives got a grip on the baby. Those ten minutes felt like years. At first, the baby's head was a normal color and she moved her mouth and made faces. However, as time went on and she didn't receive oxygenation because she was so stuck, her face turned a deep, dark plum purple and she went very still. 

The moment the baby was born, the midwives laid her floppy body on the floor and began "bagging" the baby (using a resuscitation bag to breathe for the baby) and rubbing her briskly with a towel. Her head was a deep, dark purple but her body was completely white. Because we were resuscitating her on the floor right next to the mom, we were able to keep the cord intact which probably made the difference between life and death as the baby received oxygenation via the ventilations and the blood. While the midwives bagged, I grabbed a stethoscope and listened to the baby's heart rate. Counting for six seconds, I heard eight beats (a heart rate of 80) and told the midwives. For a newborn heart rate less than 100, the next step on the resuscitation protocol is to begin chest compressions. I helped bag the baby while we began chest compressions. The baby was still limp, pale, and unconscious. 

After a minute or so, I listened to the heart again and heard twelve beats (a heart rate of 120) so we were able to stop chest compressions. The baby was still limp and unresponsive but her body was starting to pink up. It felt like an eternity before she gained muscle tone and began to cry. Never have I been so happy to hear a newborn scream and cry! When she began to cry, i clamped and cut the cord and one midwife took the baby to one bed to continue giving oxygen while the other midwife took the mom to the other bed to make sure she wasn't hemorrhaging. As soon as the placenta was out, I gave the mom oxytocin (pitocin) and methergine to make sure she didn't hemorrhage.

Once everyone was stable, we all stepped back and took a deep breath. What a Ride! It felt like an eternity, but the dystocia lasted about ten minutes and the resuscitation lasted another ten minutes. My hands started shaking so bad and I wanted to cry, realizing we almost had a baby die on us. However, after discussing what happened with the director of the birth center, she said, "don't think of it as 'I almost had a baby die!', think of it as, 'I helped save a baby's life!'

Thankfully, mom and baby are both healthy and suffering no ill effects from this morning's scare. The baby is chunky and cute and has a very boisterous cry. Each time I hear it ring throughout the birth center, I smile and praise Jesus for that cry.