Shoulder Dystocia






The phenomenon of shoulder dystocia has long been recognized. Smellie, one of the earliest physicians specializing in obstetrics, described a situation he encountered in 1730 as follows:

Called to a gentlewoman in labor. The child's head delivered for a long time -- but even with horrid pulling from the midwife, the remarkably large shoulder prevented delivery. I have been called by midwives to many cases of this kind, in which the child was frequently lost.

Morris in 1955 gave what is now a classic description of shoulder dystocia:

The delivery of the head with or without forceps may have been quite easy, but more commonly there has been a little difficulty in completing the extension of the head. The hairy scalp slides out with reluctance. When the forehead has appeared it is necessary to press back the perineum to deliver the face. Fat cheeks eventually emerge. A double chin has to be hooked over the posterior vulvar commisure, to which it remains tightly opposed . . .

Time passes. The child's face becomes suffused. It endeavors unsuccessfully to breathe. Abdominal efforts by the mother and by her attendants produce no advance. Gentle head traction is equally unavailing. Usually equanimity forsakes the attendants -- they push, they pull. Alarm increases. Eventually, "by greater strength of muscle or by some infernal juggle," the difficulty appears to be overcome, and the shoulder and trunk of a goodly child are delivered. The pallor of its body contrasts with the plum-colored cyanosis of the face, and the small quantity of freshly expelled meconium about the buttocks. It dawns upon the attendants that their anxiety was not ill founded, the baby lies limp and voiceless, and only too often remains so despite all efforts at resuscitation.

Perhaps the most famous case of brachial plexus injury was that involving Prince William of Germany who subsequently became Kaiser Wilhelm II in 1888. It seems that William was in breech position at birth and was manipulated by several physicians and a midwife during delivery. Apparently the baby was not breathing when it emerged, but by "continuous rubbing . . . dousing in a hot bath, and a series of short, sharp slaps on his buttocks" the doctors managed to get the child to breathe.

The third day after delivery the midwife noticed that William's left arm was slack. It was thought that the arm had been "wrenched out of the socket" and some of the muscle tissue torn. Most likely, William suffered a brachial plexus injury. In addition it is suspected that there were several moments of asphyxia which might have caused slight brain damage. It has been postulated that this was the cause of William's later hyperactivity and emotional instability. He may also have suffered slight cerebral palsy. For the rest of his life, William's "withered" left arm was concealed from the public by careful posing for photographs.

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Copyright © 2017 Henry Lerner

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