Waiting Can Be So Hard

by Jan Tritten

© 2011 Midwifery Today, Inc. All rights reserved.

[Editor’s Note: This editorial originally appeared in Midwifery Today, Issue 98, Summer 2011.]

Though we possibly shouldn’t break birth up into stages, doing so helps us to analyze what we do and how birth is progressing. It is a modern delineation that helps us all know what we are talking about. So what are the main issues regarding second stage? One of the most important issues is the fear it seems to provoke in midwives, often leading them to try to “deliver” the baby as soon as the head emerges instead of waiting for the next contraction and letting the mother deliver her baby on her own time. Fear can lead to some horrendous circumstances.

A lovely young woman came to a Eugene conference several years ago with birth footage of “shoulder dystocia” that caused severe brachial palsy in her daughter, who had already had several operations to try to fix the problem. When she showed a group of us midwives the footage of the birth, we let out gasps of horror because it was not shoulder dystocia. The nurse-midwife attending this mother did not wait for the next contraction and instead started pulling on the baby’s head, first in one direction, and then another, then up, down and to the side, then the other side, repeatedly. It was horrible to watch. This was a midwife-caused disaster. The baby lived but the sequelae the little girl and the family are living with were totally unnecessary and tragic. It was this film that led me to have our staff work on a video about shoulder dystocia and what it is and isn’t. It should be ready by the end of the year. We also have a clinical booklet, The Shoulder Dystocia Handbook, available for purchase on our Web site.

Gail Hart mentioned on my Facebook page that she once waited many minutes for shoulders after the head was out and that it can sometimes take five minutes or more. The babies Gail attended with long waits were communicating, grimacing and making faces, and their scalp color was good. However, there are cases of true shoulder dystocia and it is important to recognize those and act fast. You do not want to be waiting for the shoulders when the head does not restitute, turns black and pulls back on the perineum. Fast action saves lives. If you see the signs of shoulder dystocia, acting now can save a baby’s life. Do not wait to act.

Shoulder dystocia is quite rare when the fetal ejection response is allowed to come into play. Some very experienced midwives report rarely having seen it, but they are the ones who go with the mother’s urges and inclinations in birth. If mom needs a “rest and be thankful phase” when complete, they know this and let the birth evolve. Poor positioning can easily contribute to sticky shoulders. Semi-sitting and lying down positions do not give the largest diameter to the pelvis. It seems there are many more cases of shoulder dystocia in these positions. (When we receive photos for the back page of the magazine, the moms are usually in a semi-sitting position.)

I would also like to ponder for a moment what the midwife’s role is in second stage. I hear from many moms, and some think the midwife should just wait in another room. Yet, there is an ethical aspect to midwifery. If a midwife is hired to attend a birth, she bears a level of responsibility for what happens at that birth. The time where the most severe problems can arise are in second and third stage. At these times conditions can change fast. Watchfulness is a necessity. As the baby is moving down, a wrapped or short cord can tighten; shoulder dystocia can occur; fetal heart tones can become ominous. Maybe only a position change is all that’s needed, but these are the times when a midwife is needed to monitor, sit quietly or provide more active help.

Since the midwife does bear a level of responsibility, it seems if a mom wants her to leave the room in second stage, it would be better not to invite her at all. Many midwives have tried this and will never do it again because they ended up playing the role of “rescuer” and were held responsible; one recounted being called into a birthing room where a severe case of shoulder dystocia was ensuing and then a hemorrhage followed. The baby also needed resuscitation. Moms, please don’t put your midwife in that situation. Make sure she is the right one for you. Develop a relationship based on trust in the prenatal course and work with her for the best outcome for you and your baby. Trust is the key, mutual trust.

I recently saw some of the most amazing birth photos I’ve ever seen on Lisa Barrett’s blog (www.homebirth.net.au). On it you will find breech photos obviously taken in second stage. They are pictures of patience, that important trait that all midwives need to possess. Fear not, but have patience and discernment of when, and how, to act!

Jan Tritten Jan Tritten is the founder and editor-in-chief of Midwifery Today magazine and a midwife who was in active practice from 1977–1989. She became a midwife in 1977 after the powerful homebirth of one of her daughters. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world! [ PHOTO BY ANDREA NOLL ]   >  Editorials  Click here to read some of Jan’s Midwifery Today editorials.   >  Curriculum Vitae  1947 Born in Los Angeles, California. 1965 Graduated from Placer High School in Auburn, California. 1966 Trained for one year as a psychiatric technician. Courses included basic nursing, pharmacology, microbiology, anatomy and physiology, psychology. 1966–1971 Worked at DeWitt State Hospital in Auburn, California as a psychiatric technician. 1968 Graduated from Sierra College with an Associate of Arts degree. 1970 Graduated with honors from Sacramento State College with a Bachelor of Arts degree in Social Science. 1971 Earned Lifetime California teaching credential with fifth-year program from Sacramento State College. 1972 First daughter born in a hospital. It changed my life forever. It was an unsatisfactory birth experience, but I had a wonderful postpartum experience with 2-1/2 years of breastfeeding. 1976 Second daughter born. She was born at home with a doctor who talked me into a homebirth. The difference between the two births sent me on a path to do something to help women have positive birth experiences. 1976 Began training as a midwife. Because I was raising young children and running a business, and because there were no CNM schools in my area, becoming a CNM was not within my reach. 1977 Began attending births with the Birth Co-op in Eugene while organizing courses in our community taught by CNMs, physicians, nutritionists, etc. 1978 Began a midwifery practice, New Life Care, with a partner, Chris Howard, and apprentice Monika Dunsmore. 1979 Son born at home. 1980 Did a one-year program with Marion Toepke McLean, CNM. Four of us completed the program, which was modeled after CNM curriculum at that time. She took a year off from her practice to teach us and to go to our births with us. 1982 First group of midwives certified by the Oregon Midwives Council. Our board was composed of CNMs and physicians. 1986 Slowed down practice and started Midwifery Today magazine.

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