I was sitting at the nurses’ station, getting ready to order dinner, when the nurse appeared. She looked worried. “I want you guys in here to help — this baby’s head is taking too long to come out.”
My senior resident and I strolled into the room, all smiles, trying not to alarm the patient. She was a mother of two, on her third baby. I did not expect any problems — after the first couple of births, the babies tend to practically fall out. However, this very experienced nurse had sensed that something was not right.
We stood in the room as the head finally emerged fully from the birth canal. The doctor in attendance attempted to deliver the baby’s shoulders. But instead of the usual gradual sliding out of the top shoulder, nothing came out. The doctor tried again. No luck.
It’s called a shoulder dystocia (“dystocia” means “difficult childbirth” in Greek). It is one of the most feared complications in obstetrics.
It was too late to perform a caesarean section, but we had to deliver the baby in the next 10 minutes, before the infant’s oxygen levels dropped too low. After that, brain damage or even death would be likely. I asked the nurse to start a timer. In a situation this tense, everyone’s sense of time becomes distorted, and so having a designated time-keeper is critical.
Shoulder dystocia used to be extremely uncommon. But while many dystocia cases have no clear explanation, it is much more common in diabetic women, who tend to have children with larger shoulders and torsos in relation to their head size. Until recently, there weren’t that many diabetic women having children — Type 1 diabetes, which manifests at a young age, is very rare, and type Type 2, which is brought on by lifestyle, didn’t manifest until women were past the age where they were likely to have children.
It’s true no longer. Today, people begin to show the signs of Type 2 diabetes at younger and younger ages, which has meant that we’ve had to learn a lot more about how to handle the complications in diabetic pregnancies.
The chief resident stepped forward and pressed, hard, above the mother’s pubic bone. With luck, that would dislodge the baby’s shoulder. No luck. She then tried to pull the baby’s arm out of the birth canal, but it was wedged in too tightly. We tried to rotate the baby’s shoulders but this also failed. Five minutes had passed. The infant was turning blue.
We tried to stay calm. I repeated the rotation maneuver. Given the situation, there wasn’t much we could do. There’s something called the Zavanelli maneuver, where the baby’s head is pushed back in and a c-section attempted, but that would be even more risky than our current situation. We had heard of doctors intentionally breaking the mother’s pubic bone, but that would be extraordinarily painful. Even trying to rotate the shoulder and pull the arm was risky — eventually, the baby’s arm bones would break under the strain.
But we were lucky. This time it worked, and the baby’s enormous shoulders finally emerged. I handed the large (10-pound), limp, blue infant to the waiting pediatric team. As the baby lost oxygen, he had also become progressively more limp, which may have been the breakthrough that allowed his shoulder to finally rotate and slip through. We watched nervously as the team began to resuscitate the infant.
The baby began to cry and we all breathed a sign of relief. Not all shoulder dystocias have such a happy ending. He hadn’t been without oxygen long enough to suffer from it, and our attempts to rotate his shoulder didn’t look as if they had caused permanent damage to the nerves controlling the arm. Most important, he was alive. Our hearts pounding, sweat running down our faces, my resident and I sat down at the nurses’ station to breathe and regroup.
I thought again about the advice I give my diabetic patients: exercise. Avoid processed foods like white rice and flour tortillas. Try to keep your weight gain during pregnancy down to a minimum. It’s not easy for them. Often they live with extended family and are under pressure to eat grandma’s lovingly prepared (but high-carb) meals, or work in settings like restaurants that require them to eat whatever is available, whenever.
Incidents like this baby’s stuck shoulder are the reason that I focus my research on discovering ways to help my patients manage obesity and diabetes in pregnancy. I’ve just begun, and I don’t have all the answers yet. If you have thoughts and suggestions for how to help women follow a diabetic diet during pregnancy, or how you made healthful dietary changes during pregnancy, please share your comments below!