In this episode, Sister Julienne is haunted by the specter of a traumatic birth from decades earlier. Shoulder dystocia is top of the list of harrowing complications of labor. The techniques used to manage this complication more often result in success than not, but facing it is no less terrifying. Unlike Sister Julienne's isolated birth environment, modern midwives often have a team to call on for pediatric resuscitation and surgical rescue with emergency cesarean birth. I offer the story below from my memoirs.

It was the eighth birth I had attended as a student midwife, nearly thirty years ago. The obstetrical unit was newly built and decorated with all rooms set up for labor, birth, and recovery in one space. Within the walls of the small hospital proper, the unit supported a non-interventive patient-centered birth philosophy and was primarily run by the midwifery practice. Linda, the patient I was caring for, was having her first baby and it was going to be a big one. My midwife preceptor and I discussed the risks of large babies and how I should mentally prepare myself for the possibility of managing a baby who might get stuck. Shoulder dystocia is a dreaded obstetrical emergency. Linda pushed slowly and steadily until the head reached its largest circumference, stretching her perineum to its thinnest. Supporting both her and the baby, I felt the skin tear under my lower hand as the head emerged and then receded.

Colloquially referred to as the “turtle sign,” the receding head is caused by the baby’s anterior shoulder becoming trapped behind the mother’s symphysis. I looked pleadingly over my shoulder to my preceptor who was standing behind me. Looking me squarely in the eye and not moving a muscle, she said, “You are the midwife. You know what to do”.

Heart pounding, hands trembling, I found my voice and commanded the assisting nurse to prepare for the McRoberts maneuver and suprapubic pressure. The least interventive, this maneuver has a success rate of forty-two percent. Managing a calm and decisive tone, I briefly reassured and instructed the mother what was to ensue and what I needed from her. With all players positioned, I called for the mother to push and the nurse to apply pressure over the symphysis pubis. That being unsuccessful, I attempted an internal rotation to free the shoulder, talking the mother through the pain of my intervention. As my hands are narrow with long fingers, I had suitable tools to reach through the birth canal to coax the baby into a position to release the shoulder. When that was unsuccessful, I continued my reach toward the baby’s posterior arm and linked my finger around it to sweep it across the chest toward the head. I had an eighty-six percent chance of success.

That move successfully relieved the impacted shoulder and with heroic maternal strength, the new mom delivered her new son into the world, while I caught the toddler-sized newborn. He wailed a welcome and peed. Resisting a matching wail, I took a deep breath, let it go, relaxed my shoulders, and then set the squirming newborn on his mother’s chest. The assisting nurse covered the pair with a warm blanket. "One minute APGAR nine,” she said.

I looked back again to my preceptor who smiled and said” See?” I did see that I could do this, but we were not done yet. This ten-pound baby left the mother vulnerable to uterine atony and hemorrhage. Holding my breath, willing my heart to slow, I waited for the placenta and silently reviewed steps to manage third-stage emergencies. Fortunately, there was no more drama. The new family humbled me with thankfulness and praise for my skills. That day’s midwifery lesson concluded with direction in suturing to repair a second-degree perineal laceration. After examining the newborn and ruling out clavicle fracture and Erb's palsy, my preceptor and I considered it a reasonable outcome.

I went home exhausted and dreamt of being in labor and delivering my own baby. A dream theme repeated often throughout my entire midwifery career. Yes, some births stay with us and change us forever, for better or worse.