R.A.F.S. Rectal Adjustment of the Fetal Shoulder [DRAFT]
Shoulder dystocia is one of the most concerning complications of birth where the shoulders do not follow the birth of the baby’s head. Many midwives fear it. It happens .5-1% of the time depending on the reference you read. Therefore, a true shoulder dystocia happens about once every 100 to 200 births. This is the rate I have experienced.
In 1994, I experienced my first true shoulder dystocia. It was a long active labor following 3 days of prodromal labor. All of us were very tired. After the baby’s head was born, it began to darken from the blood traveling to the brain, unable to return to the heart. I recognized the problem. I was attempting all the maneuvers I was taught. But you cannot accomplish them if you cannot reach the shoulder. Mom had been supine to begin with because she was so tired. Once we got her on hands and knees, I could reach a little farther, but not enough still. It is so scary to feel the seemingly endless neck! I was praying my brains out!
Thankfully, in the midst of my fumbling attempts, God gave the Motherwit, my fingers slid into her anus. Thank God! The posterior shoulder was right there within easy reach. I pushed it to the side with the flat of my two fingers and was able to reach the baby’s armpit with my other hand and wiggle her free. It had been about 3 minutes but it felt like much longer. She needed nothing more than a little stimulation and she was pink and happy.
Here is why it works. The anus and the rectum are between the baby and the spine.
[Insert graphic showing relationship of anus to spine]
The head is not in the way at all so there is no danger to the baby’s neck. In the diagram you see the location of the rectum. I had often wondered what was trapping the posterior shoulder. The tailbone could not do it and the sacral promontory is too high to be the problem. I hypothesize that because many Americans have stool filling the colon and rectum, the consistency of modeling clay, it fills the space that baby needs to turn its body. Of course, the head will push some out. But the stool that is higher remains, constraining the uterus from behind and limiting the baby’s spiraling movement.
I wonder if the dystocia rate was less back in the day when enemas were a routine procedure in childbirth. Not that I think any routines should be imposed. But I will recommend a warm water enema to a client who is short or short-waisted with a large baby.
All the cases of true shoulder dystocia in my practice that have happened since have been quickly resolved using what I now call RAFS; Rectal Adjustment of the Fetal Shoulder. I still try other maneuvers first. I have the mom shimmy and rotate her hips first. Runners stance and squatting may dislodge the baby, in which case, it wasn’t a true dystocia. But if baby’s head begins to darken much, I use RAFS. I am no longer afraid of Shoulder Dystocia. I hope you will add it to your arsenal.