FlipFLOP: Four Steps to Remember

by Gail Tully | September 1, 2012

Midwifery Today, Issue 104, Winter 2012.
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FlipFLOP is a memory tool listing four successful techniques to free a baby from shoulder dystocia, an emergency caused by one or both shoulders caught by the pelvis after the birth of baby’s head. In FlipFLOP, two well-known midwifery techniques combine with two effective obstetrical techniques for a step-by-step solution suited to helping an active birthing woman. In FlipFLOP, the four steps spell out the word flop like this:

1. Flip the mom over with the GaskinManeuver
2. Lift the Leg
3. Rotate baby to the Oblique
4. Bring out the Posterior arm

The F in FLOP

From Central American midwives, Ina May Gaskin learned that with shoulder dystocia, it is best to turn the mother over onto hands and knees. The success of this maneuver (and our love for the messenger) is revealed by the fact that this technique was named after Ina May and is now commonly called the Gaskin Maneuver. It is often the turning over onto hands and knees that frees the baby.

When a woman has been on hands and knees for the birth of the head, she has made the largest diameter for the pelvis, but a baby may still get stuck. Hands and knees won’t prevent every shoulder dystocia. The midwife needs to know that flipping the mother over to hands and knees, whether independently or with help, is the point of doing Gaskin’s—not being in that position already. If the mother is already on hands and knees with a shoulder dystocia, she can simply go on to the next technique in FlipFLOP: lifting her leg.

The L in FLOP

Lifting the leg puts the knee to the mother’s armpit and the foot flat on the floor (or mattress). This posture pulls Tullyopen half the pelvis on the same side as the lifted leg. The mother looks like she may be in the starting position to run a race, so we call it Running Start.

The O in FLOP

Rotating the shoulder girdle of the baby into the oblique diameter of the pelvis was popularized by the insight of Woods in 1943. Later, Rubin reversed the direction of the dial, so to speak, to adduct the shoulders, thus reducing the diameter of the baby. I’ll discuss a hand placement that protects the baby’s bones from breakage.

The P in FLOP

Bringing out the posterior arm is an old technique that has recently gained much praise. With one arm out, the baby’s diameter is 20% smaller, and if the baby is still tightly impacted in the pelvic outlet, the baby’s anterior shoulder can be rotated 180 degrees and the other arm can then be brought out safely by the same technique.

Each of these techniques may succeed independently. But in this order, the least invasive actions, the Gaskin Maneuver and Running Start, put the mother in the most optimal position for steps 3 and 4, should they be needed.

A FlipFLOP Scenario

Let’s talk through a situation in which FlipFLOP brings a baby out. Imagine this situation: The baby’s head is out; the midwives may or may not see the head retract deep into the mother’s flank, but the next contraction hasn’t brought the baby out. In fact, if the baby looks dusky or limp or obviously “turtles,” the midwife is justified to begin resolutions for shoulder dystocia before the next contraction.

Let’s say this midwife chooses to have the mother flip over to hands and knees and get into Running Start because she noticed the baby’s head turning dark.

With the mother on hands and knees, she sees that the cheeks are pressed up and crowding baby’s eyes. The chin is not visible—the classic turtle sign. The midwife accepts this as a call for help from the baby.

Most US training recommends either head traction or head displacement by lateral pressure; either one makes the uterus have to exert more force to bring the baby, increasing the risk of brachial plexus damage. This is followed by the McRoberts Maneuver to bring both knees into the supine woman’s abdomen. Too often the knees are splayed outward, not up. Suprapubic pressure is then rightly applied to push the anterior shoulder off the brim and into the pelvic canal so it can come down with uterine pressure. The McRoberts Maneuver works 42% of the time without harm to the baby, and suprapubic pressure improves that outcome somewhat.

Our heroine, however, chooses to ask her mother to flip over immediately upon recognizing the holdup. She hasn’t reached in yet to discover whether this is a “true” shoulder dystocia or something else, perhaps a compound presentation with the elbow held back in a rather flattened sacral curve. (Definitions of shoulder dystocia vary widely.)

Our midwife initiates the first two steps of FlipFLOP immediately because she knows by doing this she has accomplished two things: she has helped the mother open her pelvis more, and the mother is now in a position in which the midwife has most success in rotating the shoulders to the oblique and removing the posterior arm, should that prove necessary. Our midwife had hoped that flipping the mom would rotate the baby via the motion of the mother, but alas, due to the plot of this article, it has not.

She chooses now to identify the shoulder’s location inside the mother. She knows that not checking the lie of the shoulders will limit her to doing techniques by rote. She prefers matching the technique to the type of shoulder dystocia she finds. She could have, before asking the mother to flip, reached in to find the lie of the shoulders and then asked the mother to reposition herself to an appropriate position. This might be the choice of a midwife who prefers to start with the McRoberts Maneuver.

Since our heroine finds the extra room achieved in Running Start position beneficial, she has the birthing mama get into this position first. Our midwife slips four fingers of her dominant hand in alongside baby’s head between baby and mother’s thigh.

Her fingers search for the shoulder by rotating her four fingers and palm upwards towards the mother’s tailbone. In this way, she avoids “poking” the mother in the anus and dragging feces internally on her glove. She may find the posterior shoulder in one of five places:

1. Posteriorly in the sacral curve, with or without space between it and the sacrum
2. Pressed tightly into the tailbone
3. In the oblique diameter in the mid-pelvis
4. Transverse, at the outlet
5. She may not find the shoulder at all, but only the neck. This posterior shoulder is high above the sacrum and stuck on the sacral promontory.

The most common location will be in the AP diameter (the shoulder in the sacral curve). When she finds one shoulder easily, it indicates the (missing) anterior shoulder is stuck on the pubis above the inlet. The next most common location is just behind the tailbone.

Knowing the side that baby’s back is on allows the midwife to cup her hand to baby’s scapula. She uses her right hand as the lead hand when baby’s back is on the mother’s right side and her left hand to the left-sided back. Let’s say our midwife finds this shoulder midway up the sacral curve with the baby’s back on the mother’s right. Using her right hand, she flows right into the 3rd step, which is rotating the shoulder into the oblique diameter.

This is how you rotate the shoulder girdle to the oblique diameter:

1. Slip your hand in along the mother’s thigh to the depth of your palm or further.
2. Place your palm (cup your palm) on the baby’s posterior scapula.
3. Brace your index and middle fingers along baby’s humerus.
4. Pressing outward (distally) with your index finger, rotate the posterior shoulder with pressure from your palm and fingers in the direction of the baby’s chest until it is in the oblique diameter on the side of the pelvis that the chest is on.

If the posterior arm is behind the back even somewhat, you will have to bring it over the side of the baby so that the elbow is on the chest side of the baby’s ribs. This brings the elbow and arm to the chest side of mother’s tailbone where the arm can bend. Now rotation to the oblique is easier and breaking bones becomes unlikely.

Hands and knees position angles the provider’s arm for maximum upper body strength. The midwife can continue to be gentle, but use great strength should it be required to rotate a large baby in a tight space. This is how a female provider can succeed by safely “pushing” with her palm down to rotate with female upper body strength in techniques that a man can typically achieve by scooping with his palm upward when a woman is lying on her back. A hands and knees maternal position allows us to use much less force to achieve rotation.

Most babies will be out by now, but if you are navigating a tight android outlet, you may have to bring the baby’s posterior arm out.

This is how you bring out the posterior arm:

1. After you’ve already rotated the baby to the oblique, brace and arc the humerus over baby’s chest. Make sure the elbow isn’t caught under the sacrum so you can succeed.
2. Fold the arm so the wrist comes up by the neck.
   1. Tease the forearm up by poking your middle finger into the anticubital fossa (inside the elbow). When the elbow is nearer the baby’s chest than the side, poking the anticubital fossa will bend the arm.
   2. To help more, stretch your index finger to the far side of the forearm to pull it up over baby’s chest by bending the elbow.
3. Finger-scissor the wrist with the index and middle fingers. This allows you to grab the wrist in the small amount of room you have in a way that the hand won’t slip out of your fingers. (You may have to pull your right hand out now and reach inside with your left fingers.)
4. Now, lift the wrist out by sweeping the arm over baby’s face (The Vanna White Maneuver).

The arm is now out. If your baby still doesn’t come out, rotate the chest with a hand on either side of the chest. Stop half way and reposition your hands until the once anterior shoulder is now posterior. Repeat the steps above.

Bringing out the posterior arm is getting renewed attention due to Dr. Michael Hoffman and Dr. Tak-yeung Leung’s recent studies. In Hoffman’s research, delivery of the posterior shoulder had the highest overall rate of success when compared with all other maneuvers. Dr. Sarah Poggi showed why—bringing out the posterior arm reduces the girth of the baby by 20%. Leung found the McRoberts technique succeeded as a first technique only 25% of the time and bringing out the posterior arm often worked best, with rotational techniques working second best, such as Woods’ or Rubin’s. I find the shoulder will rotate as you bring the posterior arm over the chest, so I see rotation as the first step in bringing out the posterior arm. Though I write rotating the shoulders into the oblique and bringing out the posterior arm as two separate steps, one leads right into the next. It’s just that most babies come out once they are in the oblique.

Flipping the mother onto hands and knees, the Gaskin Maneuver, is now a recognized method in obstetrics, as well as a treasured first step for many midwives. The success of Gaskin’s is either in freeing many a baby or, if not, then helping the midwife to rotate the baby using the best advantage of her upper body strength with the mother in this position. Having one of the mother’s knees by the ribs with the foot flat on the floor opens one half of the pelvis while the mother’s overall pelvis is opened more than if she was on her back.

FlipFLOP organizes well-loved and successful methods of bringing baby out safely. I invite you to use it and report back on ResolvingShoulderDystocia.com or by writing to me at gail@SpinningBabies.com.

Sources:

• Bruner, J, et al. 1998. “All-fours Maneuver for Reducing Shoulder Dystocia Labor.” J Reprod Med 43 (5): 439–43.
• Frye, A. 1995. Holistic Midwifery: a Comprehensive Textbook for Midwives in Homebirth Practice, Vol. II. Portland, OR: Labrys Press.
• Grimm, M, R Costello and B Gonik. 2010. “Effect of Clinician-Applied Maneuvers on Brachial Plexus Stretch During a Shoulder Dystocia Event: Investigation Using a Computer Simulation Model.” Am J Obstet Gynecol 203 (4): 339.e1–5.
• Hoffman, MK, et al. 2011. “A Comparison of Obstetric Maneuvers for the Acute Management of Shoulder Dystocia.” Obstet Gynecol 117 (6): 1272–78.
• Leung, T, et al. 2011. “Comparison of Perinatal Outcomes of Shoulder Dystocia Alleviated by Different Type and Sequence of Manoeuvres: a Retrospective Review.” BJOG 118 (8): 985–90.
• Poggi, SH, CY Spong and RH Allen. 2003. “Prioritizing Posterior Arm Delivery During Severe Shoulder Dystocia.” Obstet Gynecol 101 (5 part 2): 1068–72.
• Rubin, A. 1964. “Management of Shoulder Dystocia.” JAMA 189 (11): 835–37.

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