Shoulder dystocia - BabyCentre Shoulder dystocia How can I recover after a birth with shoulder dystocia? What is shoulder dystocia? Shoulder dystocia can happen after your baby's head has been born. If one of her shoulders becomes stuck, and you need extra help for her body to be born, it’s called shoulder dystocia (RCOG 2012, 2013a, Simkin and Ancheta 2011). It is an unusual complication that can happen during the end of the second stage of labour (RCOG 2012, Simkin and Ancheta 2011). It's all to do with how your baby moves down through your pelvis and out into the world. Your baby's shoulder may get stuck if: Your baby is big (macrosomia) (Allen 2014, RCOG 2012). However, if you’re having a big baby, don’t panic as most big babies don’t get stuck at all. About half of cases of shoulder dystocia happen with babies that are not large (RCOG 2012, Rodis 2015).

Your baby hasn’t moved into the best position for her shoulders to be born (Simkin and Ancheta 2011). The position that you’re in restricts the room in your pelvis (Rodis 2015). Changing position may increase how much room your baby has to move through your pelvis (Reitter et al 2014). To understand shoulder dystocia, it helps to know how vaginal birth usually progresses . During birth your baby moves from your womb (uterus), down through the cradle of bones that make up your pelvis. At the front of your pelvis is your pubic bone. You can feel your pubic bone just behind the top of your pubic hair. At the back of your pelvis is the sacrum with the tailbone (coccyx) at the bottom. You can feel these bones between your buttocks. Normally when you start pushing , your baby is facing away from your pubic bone towards your sacrum. Usually, after your baby's head is born, her head and body will turn sideways. This allows her shoulders and body to pass comfortably through your pelvis on the next contraction.

With shoulder dystocia, one of her shoulders gets stuck, preventing her body being born (Tower 2011 ). It's usually the front (anterior) shoulder that gets stuck behind your pubic bone, although it is also possible for the back (posterior) shoulder to get stuck on the sacrum. The illustration below shows what happens with an anterior shoulder dystocia: If this happens, your baby needs to be born fairly quickly to make sure she continues to get enough oxygen (Allen 2014, RCOG 2012), particularly if there have already been signs of problems with her heart-rate (RCOG 2012). While your baby is stuck, the umbilical cord may be squashed, which means less oxygen is reaching her. Meanwhile, her lungs are still compressed, so she can't get oxygen by breathing yet. For this reason, shoulder dystocia is an emergency complication that needs resolving calmly but swiftly. This may all sound alarming, but be reassured that your doctor and midwife will be on hand to help your baby out in good time, while avoiding injury to you or your baby. What causes shoulder dystocia? Shoulder dystocia is unusual.

It happens in about one out of every 150 births (Ouzounian et al 2012, RCOG 2012, 2013a). It isn’t possible to predict shoulder dystocia (RCOG 2012, Revicky et al 2012, Rodis 2015). We do know that the risk is increased if: You experienced shoulder dystocia in a previous labour (Allen 2014, RCOG 2012). You’re having a big baby (Allen 2014, RCOG 2012, Revicky et al 2012). You have diabetes (Allen 2014, RCOG 2012). You are very overweight or you’ve gained a lot of weight during pregnancy (Allen 2014, RCOG 2012). Your baby's body is disproportionately larger than her head (Allen 2014, Larson and Mandelbaum 2013). Your labour is induced (RCOG 2012).

If you’re obese you’re more likely to develop gestational diabetes (NICE 2015, RCOG 2013b). Uncontrolled diabetes slightly increases the chance of your baby getting stuck because your baby is more likely to put weight on across her torso (NICE 2015, Rodis 2015). Interventions in your labour, once it’s underway, can also increase the risk of shoulder dystocia, such as the use of ventouse or forceps (Allen 2014, Revicky et al 2012). How your labour progresses can also be a factor. A very quick or very slow first stage of labour (Allen 2014, Revicky et al 2012), as well as a long second stage of labour (RCOG 2012), have both been associated with shoulder dystocia.

Shoulder dystocia often affects women with no risk factors at all (RCOG 2012, Rodis 2015), so you wouldn’t normally be offered a caesarean section to prevent shoulder dystocia unless you had a combination of strong risk factors, such as diabetes, an anticipated large baby and a history of shoulder dystocia (RCOG 2012, Rodis 2015). Can shoulder dystocia be prevented? There isn’t much that can be done to prevent shoulder dystocia, because it’s so unpredictable. However, if you have a risk factor like diabetes, good control of your condition can reduce your risk (Alwan et al 2009). If you’re having a big baby, some experts recommend lying on your side or kneeling on all fours to give birth (Simkin and Ancheta 2011). Whilst there’s no firm evidence that certain positions or manoeuvres help to prevent shoulder dystocia from happening (Athukorala et al 2006), there are other advantages to avoiding lying on your back for the pushing stage.

If you’re planning on giving birth at home or in a birth centre , your midwife will still be able to deal with shoulder dystocia by getting you into a position that helps to free the shoulder (RCOG 2013a, Kallilanidis et al 2016, Simkin and Ancheta 2011). If you want any reassurance before you give birth at home or in the hospital, talk to your midwife. She’ll be able to tell you what measures are in place to make sure your baby will be born safely. What will happen if my baby has shoulder dystocia? If the midwife or doctor helping you to give birth suspects your baby's shoulder is stuck, she has to act fast. She will tell you to stop pushing (RCOG 2012). She will immediately call for more help and the room may quickly fill up with a lot of people. More midwives, obstetricians, an anaesthetist and a paediatrician to look after your baby once she's born may be called upon (RCOG 2012).

It can be frightening for parents, especially if there is no time for the medical team to explain to you what is happening. Often, a different birth position can give your baby more room to be freed up (Crofts et al 2016, Draycott et al 2008, Tower 2011). You may be asked to lie flat on your back with your knees bent and your legs pulled up as far as they will go. This is known as the McRoberts manoeuvre. A midwife or midwifery assistant will usually stand on each side of you and help you to pull up your legs (RCOG 2012, 2013a). Another midwife or doctor will press on your tummy just above your pubic bone to help release your baby's stuck shoulder (RCOG 2012, 2013a). Most babies with shoulder dystocia are born with these simple measures. If your baby is still not born your doctor or midwife may need to ease a hand inside your vagina to help your baby out.

She may need to perform an episiotomy at this point to help get hold of your baby (Allen 2014, RCOG 2012, 2013). An alternative approach after McRoberts is for you to go on your hands and knees (RCOG 2012, 2013, Simkin and Ancheta 2011). Turning onto all fours may be enough to release your baby’s shoulder, or the doctor or midwife can try to free your baby in this position too (Tower 2011). On very rare occasions, the doctor may have to take a further emergency measure to help your baby, which involves breaking your baby's collar bone to free her stuck shoulder (RCOG 2012). Although this sounds alarming, your baby's bone should heal well afterwards (Allen 2014, RCOG 2013a). If needed, your baby can still be born by caesarean section . Your anaesthetist will give you a general anaesthetic to make you go to sleep. Then your baby will be eased back into your womb, from where she can be born by caesarean.

These last two procedures really are a last resort and are not followed unless absolutely necessary (RCOG 2012). How will my baby recover after having shoulder dystocia? Most babies born following shoulder dystocia are absolutely fine (RCOG 2012). However, your baby may need to be watched closely for a while. Sometimes, if the birth has been very difficult your baby might need to spend some time in the hospital's neonatal unit . Shoulder dystocia can cause damage to the bundle of nerves in your baby's shoulder and arm, which is called a brachial plexus injury (BPI). The damage happens when the nerves are stretched too much during birth and can affect about one in 10 babies after shoulder dystocia (RCOG 2012, 2013a). Your baby might have a condition called Erb's palsy, as a result of the injury, which means her arm is numb and paralysed. In most cases, the palsy gets better on its own within hours or days (RCOG 2013a, Semel-Concepcion 2014).

About one in ten babies with Erb’s palsy have lasting damage (RCOG 2012). If your child has Erb's palsy she may benefit from early physiotherapy and you should be given guidance on how to handle your baby to prevent further harm (Semel-Concepcion 2014). If she has lasting nerve damage, physiotherapy and other support will continue to help her, although it won't fix the problem. As your child grows, she'll have support with learning how to manage everyday activities. Although rare, a baby's collar bone or upper arm can break during birth (RCOG 2012). In most cases the bone heals well (Allen 2014, RCOG 2013a). If your baby has a bone fracture or nerve damage, you may need extra advice about breastfeeding positions or pain relief for your baby, so do ask your midwife for help. Being stuck during the birth can also interrupt your baby's supply of oxygen (Allen 2014). Babies are surprisingly resilient.

But if the oxygen supply is interrupted for a long time, or your baby was already showing heart rate problems before getting stuck, this can lead to brain damage (Allen 2014, RCOG 2013a). Your child and the whole family will need ongoing support if a difficult birth causes cerebral palsy or other disabilities. On extremely rare and very sad occasions, lack of oxygen can lead to a baby's death (Allen 2014, RCOG 2012). Although this is a very rare event, it's because of this remote risk that doctors and midwives are trained to react quickly and carefully. How can I recover after a birth with shoulder dystocia? Severe bleeding (postpartum haemorrhage) affects about one in 10 women who have this kind of birth (RCOG 2012). There's also a slightly higher risk of severe tears in your vagina or back passage (RCOG 2012). You’ll probably find there are a lot of emotions to deal with, too. There was all the anxiety about your baby during the birth. And if she has medical problems, you may have worries about her future, too.

On top of this, some women feel shocked, guilty, depressed or even angry after a difficult birth. These emotions can last a long time. Feelings of shock, guilt and anger can also affect your partner and your whole family. It's not always easy to talk about a difficult birth . People may feel embarrassed or find it hard to understand what you've been through. Do talk to your midwife, health visitor or doctors until all your questions have been answered. It may also help to talk to other mums who’ve had traumatic births in the BabyCentre community. Find out what to be aware of after a difficult birth . Last reviewed: April 2016 Management of Shoulder Dystocia Management of Shoulder Dystocia Written by Rachel Nall, RN, BSN, CCRN Medically Reviewed by Email addresses will not be shared with 3rd parties. See privacy policy Thank you. Your message has been sent. OK We're sorry, an error occurred. We are unable to collect your feedback at this time. However, your feedback is important to us. Please try again later. Close Read This Next What Is Shoulder Dystocia?

Shoulder dystocia occurs when a baby’s head passes through the birth canal and their shoulders become stuck during labor. This prevents the doctor from fully delivering the baby and can extend the length of time for delivery. If this occurs, your doctor will have to use extra interventions to help your baby’s shoulders move through so that your baby can be delivered. Shoulder dystocia is considered an emergency. Your doctor must work quickly to prevent complications related to shoulder dystocia. What Are the Symptoms of Shoulder Dystocia? Your doctor can identify shoulder dystocia when they see part of your baby’s head coming out of the birth canal but the rest of their body isn’t able to delivered. Doctors call shoulder dystocia symptoms “the turtle sign.” This means a fetal head will first come out of the body but will then seem to go back into the birth canal. This is said to be like a turtle that sticks its head out of its shell and puts it back in. What Are the Risk Factors for Shoulder Dystocia? Certain women may be more at risk for having babies with shoulder dystocia than others.

These include: having diabetes and gestational diabetes having a history of having a baby with large birth weight, or macrosomia having a history of shoulder dystocia having labor that’s induced being obese giving birth after the due date having an operative vaginal birth, which means your doctor uses forceps or a vacuum to guide your baby through the birth canal being pregnant with multiple babies However, many women can have a baby that has shoulder dystocia without ever having any risk factors. How Is Shoulder Dystocia Diagnosed? Doctors diagnose shoulder dystocia when they can visualize the baby’s head but the baby’s body can’t be delivered, even after some slight maneuvers. If your doctor sees your baby’s trunk isn’t coming out easily and they have to take certain actions as a result, they’ll diagnose shoulder dystocia. When the baby is coming out, events happen fast in the delivery room. If your doctor thinks shoulder dystocia is taking place, they’ll work quickly to correct the problem and deliver your baby. What Are the Complications of Shoulder Dystocia? Shoulder dystocia can increase risks for both you and baby. Most mothers and babies with shoulder dystocia don’t experience any significant or long-term complications.

However, it’s possible that complications, while rare, can occur. These include: excessive bleeding in the mother injuries to a baby’s shoulders, arms, or hands loss of oxygen to the baby’s brain, which can cause brain damage tearing of a mother’s tissues, such as the cervix, rectum, uterus, or vagina Your doctor can treat and minimize most of these complications to ensure they won’t be long-term concerns. Less than 10 percent of babies with injuries after shoulder dystocia have permanent complications. If you baby has shoulder dystocia while you’re giving birth, you could be at risk for the condition if you get pregnant again. Talk to your doctor about your risks prior to delivery. How Is Shoulder Dystocia Treated? Doctors use a mnemonic “HELPERR” as a guide for treating shoulder dystocia: “H” stands for help. Your doctor should ask for extra help, such as assistance from nurses or other doctors. “E” stands for evaluate for episiotomy. An episiotomy is an incision or cut in the perineum between your anus and the opening of your vagina.

This doesn’t usually solve the entire concern for shoulder dystocia because you baby still has to fit through your pelvis. “L” stands for legs. Your doctor may ask you to pull your legs toward your stomach. This is also known as the McRoberts maneuver. It helps to flatten and rotate your pelvis, which may help your baby pass through more easily. “P” stands for suprapubic pressure. Your doctor will place pressure on a certain area of your pelvis to encourage your baby’s shoulder to rotate. “E” stands for enter maneuvers. This means helping to rotate your baby’s shoulders to where they can pass through more easily. Another term for this is internal rotation. “R” stands for remove the posterior arm from the birth canal. If your doctor can free one of the baby’s arms from the birth canal, this makes it easier for your baby’s shoulders to pass through the birth canal. “R” stands for roll the patient. This means asking you to get on your hands and knees. This movement can help your baby to pass more easily through the birth canal. These don’t have to be performed in the order listed to be effective.

Also, there are other maneuvers a doctor can perform for either mom or baby to help the baby deliver. The techniques will likely depend on you and your baby’s position and your doctor’s experience. Can Shoulder Dystocia Be Prevented? Your doctor can determine if you’re at risk for having a baby with shoulder dystocia, but it isn’t likely they’ll recommend invasive methods. Examples of such methods include a cesarean delivery or inducing labor before a baby gets too large. Your doctor can anticipate that shoulder dystocia can happen. Talk with your doctor to learn about potential complications and how your doctor will manage shoulder dystocia if it does happen. Dystocia | Definition of Dystocia by Merriam-Webster : slow or difficult labor or delivery Origin and Etymology of dystocia New Latin, from Greek dystokia, from dys- + tokos childbirth; akin to Greek tiktein to give birth to — more at thane First Known Use: circa 1706 Medical Dictionary Dog Birth Difficulties - Dystocia in Dogs | petMD Dystocia in Dogs Dystocia is the medical term used to diagnose a difficult birthing experience.

This condition may occur as a result of maternal or fetal factors, and can occur during any stage of the labor. Abnormalities of presentation, posture, and the position of the fetus within the uterus can negatively affect the temporal relationship between the birthing offspring and the maternal birth canal. Uterine inertia (inactivity) may be primary or secondary. Primary inertia is symptomized by a failure of the body to commence synchronous uterine contractions, and secondary inertia is symptomized by a cessation of uterine contractions due to uterine fatigue. This latter condition sometimes occurs when labor has gone on longer than the uterine muscles are capable of meeting the demands for. There are three stages of labor. The first stage of labor entails the start of uterine contractions, relaxation of the cervix, and rupture of the chorioallantoic sac (water breaking). The female dog (bitch) may be restless, nervous and occupy herself in nesting activity. The second stage of labor is when the fetuses are pushed out by uterine contractions. In dogs the average length of parturition (delivery), from the beginning of stage two to delivery of the first offspring is usually less than four hours.

The time between deliveries of subsequent offspring is usually 20–60 minutes, but may be as long as 2–3 hours. It is important to consider this variability before intervening. The third stage is delivery of the fetal membranes. The female dog may alternate between stage two and three with multiple fetuses being delivered. She may deliver one or two fetuses followed by one or two fetal membranes, or she may deliver a fetus followed by its accompanying fetal membrane.

More than 30 minutes of persistent, strong, abdominal contractions without expulsion of offspring More than four hours from the onset of stage two to delivery of first offspring More than two hours between delivery of offspring Failure to commence labor within 24 hours of the drop in rectal temperature - below 99° F (37.2° C) Female cries, displays signs of pain, and constantly licks the vulvar area when contracting Prolonged gestation – more than 72 days from the day of first mating; more than 59 days from the first day of cytologic diestrus (the stage directly following the stage when conception would have occurred – can be determined by owner with vaginal swabs that are taken throughout pregnancy); more than 66 days from LH peak (luteinizing hormone, which peaks at the time of ovulation); (See Breeding, Timing) Discharge of uteroverdin from the vagina (a greenish-black pigment that is produced by the dog's placents), preceding the birth of the first offspring by more than two hours – indicative of premature placental separation Presence of bloody discharge prior to delivery of the first offspring or between fetuses vaginal wall to elicit abdominal straining [fe

athering]); the lack of this response indicates uterine inertia Diagnosis You will need to give a thorough history of your dog's health, including any information you have about your dog's lineage, and details of any past pregnancies or reproductive problems.

Your veterinarian will palpate (examine by touch) your dog's vaginal canal and cervix. Your veterinarian will take samples for testing; at the minimum, a packed cell volume (PCV), a total protein, a BUN (blood urea nitrogen), a blood glucose, and a calcium concentration measurement. Your dog's blood progesterone levels will also be measured. X-rays are crucial for determining the approximate number, size and location of the fetuses. X-rays may also show if the puppies are still alive, but an ultrasound can give even more subtle measurements, such as indications of fetal stress, assessing placental separation, and the character of the fetal fluids. Assisting the Beef Cow at Calving Time Jack C. Whittier James G. Thorne College of Veterinary Medicine Six to 10 percent of all calves born in beef cow herds in the U.S. die at or soon after birth. About half of those deaths are due to calving difficulty (dystocia). This multi-million dollar annual loss is second only to losses from failing to conceive. Calving difficulty has received much more attention in recent years, primarily because of the mating of larger European breeds of bulls to British breeds of cow.

Increased calving problems are also being encountered within purebred breeds, as genetically large bulls are often mated to cows of only average size. The purpose of this guide is to acquaint cattle producers with calving management principles that will help minimize calf loss in their herds. Factors causing calving difficulty About 80 percent of all calves lost at birth are anatomically normal. Most of them die because of injuries or suffocation resulting from difficult or delayed parturition (calving). Factors contributing to calving problems fall into three main categories — calf effects, cow effects and fetal position at birth. Calf effects Heavy birth weights account for most of the problems related to the calf. Birth weights are influenced by breed of the sire, bull within a breed, sex of the calf, age of the cow and, to a slight degree, nutrition of the cow. Shape of the calf may also have a small effect on calving problems. Cow effects Several factors associated with the cow influence dystocia, the major ones being her age and pelvic size. Age First-calf heifers require more assistance in calving than do cows, because they are usually structurally smaller. Pelvic area Pelvic area (birth canal) increases as the female develops to maturity.

Thus, a higher proportion of calving difficulty in 2- or 3-year-old cows is due to smaller pelvic openings. Heifers and cows with small pelvic areas are likely to require assistance at calving. However, even heifers with a large pelvic area may need help delivering large calves. The calf's birth weight and cow's pelvic area have a combined effect on dystocia. Many heifers giving birth to calves weighing more than 80 pounds will have difficulty, even if they have large pelvic areas. Two-year-old heifers tend to have either a pelvis too small or a calf too large to allow them to deliver without assistance. Therefore, calving problems could be reduced by decreasing birth weight through bull selection and/or increasing pelvic area by selecting the larger, more growthy heifers. Fetal position at birth About 5 percent of the calves at birth are in abnormal positions, such as forelegs or head turned back, breech, rear end position, sideways or rotated, etc. (Figure 1). This requires the assistance of a veterinarian or an experienced herdsman to position the fetus correctly prior to delivery. If fetal position cannot be corrected, the veterinarian may have to perform a caesarean section.

Figure 1 Abnormal positions of the calf for delivery Stages of calving (Parturition) Normal calving can be divided into three general stages — preparatory, fetal expulsion and expulsion of the placenta or afterbirth. The time interval of each stage varies among types and breeds of cattle and among individuals of the same breed. Although the exact stimulus that initiates parturition is unknown, it does involve hormonal changes in both the cow and fetus as well as mechanical and neural stimulation in the uterus. A general understanding of the birth process is important to proper calving assistance and, therefore, is presented here and summarized in Table 1. Table 1 Cleaning (2 to 8 hours) 1. Cotyledon-caruncle (button) attachments relax 2. Uterine contractions expel membranes Stage 1 Preparatory (2 to 6 hours). During pregnancy, the fetal calf is normally on its back. Just prior to labor, it rotates to an upright position with its forelegs and head pointed toward the birth canal (Figure 2). This position provides the least resistance during birth. Toward the end of gestation, the muscular lining of the dam's uterus increases in size, which aids in delivery.

Figure 2 Normal positions of the calf just prior to delivery In the preparatory stage, the cervix dilates and rhythmic contractions of the uterus begin. Initially, contractions occur at about 15-minute intervals. As labor progresses, they become more frequent until they occur every few minutes. These contractions begin at the back of the uterine horn and continue toward the cervix, forcing the fetus outward. Any unusual disturbance or stress during this period, such as excitement, may inhibit the contractions and delay calving. At the end of the preparatory stage the cervix expands, allowing the uterus and vagina to become a continuous canal. A portion of the placenta (water sac) is forced into the pelvis and aids in the dilation of the cervix. This water sac usually ruptures and the membranes hang from the vulva until Stage 2. Stage 2 Delivery (1 to 2 hours, may be longer in heifer). This stage begins when the fetus enters the birth canal and usually occurs while the cow is lying down. Uterine contractions are now about every 2 minutes and are accompanied by voluntary contractions of the diaphragm and abdominal muscles.

Surrounded by membranes, the calf's forelegs and nose now protrude from the vulva. After the nose is exposed, the dam exerts maximum straining to push the shoulders and chest through the pelvic girdle. Once the shoulders have passed, the abdominal muscles of the calf relax and its hips and hind legs extend back to permit easier passage of the hip region. The calf is normally born free of fetal membranes (placenta), because they remain attached to the cotyledons or "buttons" of the uterus. This ensures an oxygen supply for the calf during birth. Upon passage through the vulva, the umbilical cord generally breaks, respiration begins, filling the lungs with air and causing the lungs to become functional. Delivery normally is completed in one hour or less in mature cows. Special assistance is warranted if this stage goes beyond 2 to 3 hours. First-calf heifers can take 1 to 2 hours, or longer. Proper judgement should be used so that assistance is neither too hasty, nor too slow. Stage 3 Cleaning (2 to 8 hours). The caruncleocotyledon, or button attachment between the uterus and placenta, relaxes and separates after parturition.

The placenta is then expelled by continued uterine contractions. Cows normally expel the placenta within 2 to 8 hours. Preparing for calving assistance Normal delivery in cattle should be completed within 2 hours after the water sac appears. If prolonged, the calf may be born dead or in a weakened condition. Since timing is vital to providing proper assistance, frequent observations are a must. Assisted deliveries should not be attempted without proper preparation of facilities and equipment. A clean, well-lighted maternity pen and clean pulling chains and equipment are desirable to reduce bacterial contamination. Check with your veterinarian for advice on when to assist the cow alone and when to call him. Since cervical dilation is completed in Stage 2, assistance can be given too early. However, since final dilation is quite rapid, assistance is often given too late, which is much more serious. Cleanliness cannot be overemphasized. Introduction of bacteria by equipment or arms of the person assisting with the calving may reduce fertility of the cow by delaying return to estrus and lowering conception. Equipment needs are two clean buckets, soap (for cleaning the cow), disinfectant, obstetrical lubricant, paper towels, calving chains and handles and plastic sleeves.

Have water in both buckets — disinfectant is added to the second bucket. Place the calving chains and handles in the disinfectant solution. Restrain the cow with head catch or halter. Tie the tail with light twine to the neck of the cow. Scrub the perineal area (around the anus and vulva) and the tail with soapy water. Pour water from the bucket to rinse the area. Do not dip dirty towels back into the bucket. When the area is clean, dry with paper towels. Use the remainder of the water in the first bucket to wash your hands and arms. If possible use plastic sleeves on initial examination. This may prevent contact with abortion-causing organisms that can infect humans. Apply an obstetrical lubricant to the sleeves. If extensive manipulation of the fetus is needed, the gloves may be removed since they tear easily. Steps in calving assistance After observing a delay in delivery, a pelvic examination should be done to determine the extent of cervical dilation. It should be dilated enough to allow easy passage of the fetus. Determine the position of the fetus (Figures 1 and 2).

If it is in an abnormal position, experience and judgement must be used to determine if a correction can be made or if professional help should be summoned. Examine the size of the calf relative to the birth canal. A large calf forced through a small pelvic opening may result in death of the calf and injury (including paralysis) to the cow. If this examination is made when the head and front feet are still in the birth canal, the opportunity for a successful caesarean section exists. If the examination indicates a dry fetus and birth canal, additional lubrication is needed. Use a commercial obstetrical lubricant (methyl-cellulose product) or petrolatum (Vaseline®). Do not use soap as it is irritating to the vaginal membranes, causes inflammation and swelling of the reproductive tract and can result in delayed return to estrus and lower conception rates. Attach the obstetrical (pulling) chains to the front legs of the calf, placing the loop of each chain around each leg. Placement of the chains should be around the pastern (below the dewclaw and above the hooves) with the looped chain on top of the hooves.

Careful attention to this placement when pulling on the chains will generally result in the least amount of damage to the calf. If the chains are allowed to become slack and/or excessive force is applied, the chain may damage the hooves. Placing the chains above the fetlocks (above the dewclaws) with a half-hitch around the pastern can result in broken front leg(s). Attach the obstetrical handles and pull gently, making sure the chains have not slipped. Although some calves can be delivered by pulling both legs evenly, it's usually best to alternately pull on one leg and then the other a few inches at a time (Figure 3). Once the legs are "walked out" in this manner, the shoulders are allowed to pass through the pelvic opening one at a time. If the shoulders should happen to "lock" at the opening, apply traction to the calf's head by attaching a chain around the poll and through the mouth. This traction will reduce compaction of the head against the sacrum (top of the birth canal) and reduce the dimensions of the shoulder and chest region.

Figure 3 Applying traction at delivery by "walking-out" the shoulders The chance of uterine or cervical lacerations and tears is greatest when the calf's head and shoulders come through the birth canal. Such damage may lead to infections and future reproductive problems. Since pressure dilates the birth canal, damage can usually be prevented if traction is applied gradually. Gradual application of traction also helps prevent damage to the cow if assistance happens to be given too early, because very slow traction will not interfere with normal dilation of the cervix. Once the head and shoulders are exposed, rotate the calf a quarter of a turn to aid in the hips entering the pelvic canal. If this does not allow delivery, pull the calf downward at a 45-degree angle, or nearly parallel with the rear legs of the cow. "Hip lock" can be a problem serious enough to cause loss of the calf. If it happens in a cow lying down, push the fetus back a short distance and rotate the calf a quarter turn, then apply traction to the front legs in a direction toward the cow's flank or side. This rotates the calf enough so one hip bone goes through the pelvic opening ahead of the other.

If you are unable to repel or rotate the calf, place the calf's legs between the cow's hind legs and pull forward. If delivery is delayed, make sure the calf begins breathing normally as the umbilical cord will be pinched closed. All posterior (rear feet first) presentations should be considered an emergency, because the umbilical cord is pinched between the fetus and pelvis early in the delivery. This means blood circulation is slowed, and the fetus may die or sustain brain damage unless delivery is rapid. Attach the obstetrical chains above the fetlock joint and be sure the birth canal is adequately lubricated, since extraction is against the normal direction of hair growth. A posterior delivery is usually eased by alternating traction on the rear legs and by rotating the fetus about a quarter of a turn to take advantage of the greatest diameter of the cow's pelvis. If delivery proves extremely difficult, a caesarean section is probably necessary and should not be delayed. Only an experienced herdsman or veterinarian should use mechanical calf pullers. If used incorrectly, permanent damage can occur to both calf and cow. Correcting abnormal presentations other than a leg or head turned back usually requires professional help.

For instance, a fetus that is upside down may be in that position because the uterus or fetus is rotated. Starting the calf Once delivered, clear any mucus from the calf's mouth and throat with your hand. Then, if necessary, stimulate the calf to breathe by either rubbing it briskly, tickling the inside of the nostril with a straw or slapping it with the flat of the hand. Artificial respiration can be applied to the calf as follows: place a short section of garden hose into one nostril, hold mouth and nostrils shut so air enters and leaves only through the hose, then alternately blow into the hose and allow expiration of air. Repeat at 5- to 7-second intervals until the calf begins to breathe. Another method is to alternate pressure and release on the rib cage. Commercial respirators are also available and may be a wise investment in larger herds. Potential post-delivery problems Uterine prolapse This is an inversion of the uterus that can occur when a partial vacuum is formed in the uterus. It is sometimes caused by pulling the calf too rapidly and may result in death of the cow if not treated promptly and correctly.

Encouraging the cow to stand soon after delivery will reduce the chances of a prolapse. Always contact a veterinarian for treatment and necessary drugs. Cull heifers or cows that prolapse because of the probability of it happening again. Retained placenta The placental membranes are normally expelled within 2 to 8 hours after birth. Occasionally, however, they fail to separate from the uterine attachment. This condition may pose a health threat to the cow and cause problems in rebreeding. Not all reasons for retained placentas are known, but high incidence may indicate a disease problem. They commonly accompany difficult births, multiple births and short gestations. There are differing opinions as to the best treatment for retained placentas. Research has shown that manual removal can cause complications that would not have happened otherwise. For cows with no signs of abnormal vaginal discharges, good appetite and good milk production, no treatment may be best of all. If antibiotics are to be placed in the uterus, care must be taken to prevent introduction of bacteria through contaminated instruments or equipment. Boluses may reduce fertility of the cow. Antibiotics by injection or intrauterine application requires attention to residue avoidance in the sale of the milk or animal for food.

Summary of calving management recommendations Observe the herd closely during calving season, especially first-calf heifers because they will require the most assistance. Have the proper equipment and facilities available prior to calving and in clean, working order. Give assistance during delivery or call a veterinarian when needed. Do not wait more than a few hours after labor begins to act. Correct any abnormal fetal positions in the early stages of delivery. When pulling a calf, loop the chain or rope around the pastern. Apply gentle traction on one leg at a time to facilitate passage of the shoulders through the birth canal. Remove mucus from the calf's nose and mouth immediately after birth. If the calf does not start to breathe normally, tickle the nostrils, hold it up by the hind legs and shake it, or apply artificial respiration with a piece of hose or by alternating pressure and release on the rib cage. Disinfect the navel cord with iodine to prevent infection. Make sure the calf nurses within an hour after birth or give colostrum to weak calves. Keep birth weight and ease-of-calving records to identify those sires and dams responsible for calving problems. This information is especially important for selecting sires to breed yearling heifers.

When possible, cull those females with a history of calving problems and avoid selecting replacement heifers from such cows. Table 2 shows a simple calving-ease scoring system. Table 2

Question: In medicine, dystocia is difficulty in doing what?
Answer: Giving birth