Midwifery vs. Obstetrics in Shoulder Dystocia
I found this article on Ina May Gaskin's website, and I find it fascinating. The OBs were all pulling their hair out on how to deliver babies with shoulder dystocia, and look at their solutions in the report. Pushing baby back in, and c-sectioning. Or, cutting the pubic ligament. :o (OUCH!!!) Babies died, or were permanently handicapped. Mothers were damaged for life.
Ina May learned a maneuver from midwives in Belize, who learned it from midwives in Guatemala. Wonder how long they went to med school? It involved no cutting, tearing, pushing, etc. It's an "all-fours" maneuver. Every baby lived. Every mother lived. No paralysis. No damage. 60% intact perineums, even. Unbelievable! :clap:
I took the article from Ina May Gaskin's website.
The Gaskin Maneuver
The All-Fours Maneuver for Reducing Shoulder Dystocia During Labor
By Joseph P. Bruner, MD, Susan Drummond, RN, MSN, Anna L. Meenan, MD, and Ina May Gaskin, MA, CPM
Journal of Reproductive Medicine, Volume 43, 439-443, May 1998
The objective of this study was to report the clinical results of eighty-two cases of shoulder dystocia managed primarily with the “All-Fours Maneuver” — which, as the name suggests, involves moving a laboring woman to her hands and knees.
I introduced the all-fours maneuver in the United States in 1976, after learning about it from a Belizean midwife who had, in turn, learned it from Mayan midwives in the highlands of Guatemala. I became aware of the frustrations obstetricians were feeling with regard to shoulder dystocia when I read in 1985 about a case report that was published in the American Journal of Obstetrics and Gynecology (1985;152:479-84). Dr. William Zavanelli, the obstetrician who attended the case, tried suprapubic pressure, rotational maneuvers, and attempted to deliver the posterior arm — all without success. He then resorted to the desperate measure of rotating the head to its prerestitution position, flexing it, pushing the baby back into the uterus, and performing an emergency cesarean a little more than an hour after the fetal head was reinserted. The baby weighed 12 pounds, 2 ounces and did well. Eugene Sandberg, MD, who authored the article about the maneuver, was impressed by Zavanelli’s inventiveness: “The Zavanelli maneuver has particular appeal because of its simplicity, its ease of performance, and its unique divergence from the traditional vaginal delivery-oriented thinking behind all previously suggested maneuvers. It offers not only the potential of an additional therapeutic maneuver for a difficult problem but also a window into a new realm of obstetric thought,” he wrote.
Of himself, Dr. Sandberg wrote: “I consider myself to be merely the assembler and chronicler of the feats of these obstetricians whom we watch with fascination and a degree of hero worship — a sort of modern-day Dr. Watson.”
Three years later, a second article by Sandberg about the Zavanelli maneuver appeared (“The Zavanelli Maneuver Extended: Progression of a Revolutionary Concept,” American Journal of Obstetrics and Gynecology; 1988;158:1347-53). This time the focus was on a registry of nine additional cases in which obstetricians used the maneuver to resolve shoulder dystocia. In one of these cases, the fetal head “remained outside the vulva for twenty to twenty-five minutes before it was reinserted” and the baby was delivered by cesarean. There was one stillbirth among these nine cases, one mother suffered from sepsis and subsequent hysterectomy, one baby was born with an Apgar score of 1/4 but was reported normal at age seven, and one baby currently has some degree of mental retardation.
In 1993 still another article appeared on the use of the Zavanelli maneuver: James O’Leary’s “Cephalic Replacement for Shoulder Dystocia: Present Status and Future Role of the Zavanelli Maneuver,” Obstetrics and Gynecology, 1993;82:847-50. O’Leary’s registry included fifty-nine cases in which the Zavanelli maneuver was among those attempted. In six cases, it was not possible to push the baby back into the uterus. Three of these women underwent symphysiotomy (surgical cut through the ligament which hold the front of the mother’s pelvic bones together), and one had a low transverse hysterotomy. The additional measures used to deliver the other two babies were not reported in this article.
“After resuscitation, only sixteen infants demonstrated a clinical state that placed them in the Apgar score range of 0-3.” Four babies with complications had seizures while in the nursery, and two of them “may have had a permanent neurologic injury or cerebral palsy.” Two large babies died, one from gastric hemorrhage and the other from severe hypoxic-ischemic encephalopathy. Twelve babies suffered Erb palsy, which turned out to be permanent in the case of five.
Maternal complications included two ruptured uteruses, three lacerations of lower uterine segments, six transfusions, and eight morbid postoperative courses.
Aware of this literature since the mid-1980s, I began a registry of shoulder dystocia births resolved primarily by the use of the hands-and- knees technique. Midwives from different areas of the country added their cases to the registry, as did a family practice physician, who used the maneuver several times in her hospital practice. “The All-Fours Maneuver for Reducing Shoulder Dystocia during Labor” is a report on the results of that registry.
The eighty-two cases in the All-Fours Maneuver Registry came out of a pool of 4452 births. Shoulder dystocia, in this study, was defined as inability to deliver the fetal shoulders after delivery of the head, without the aid of specific maneuvers. Thirty-two of the cases of shoulder dystocia that occurred at the Farm Midwifery Center were previously reported in the Journal of Family Practice (1991;32:625-629).
Half of the eighty-two babies weighed more than 4000 grams (about 8.5 pounds); 17 or 21 percent weighed more than 4500 grams (about 8 pounds, 10 ounces); thirty of the 1-minute Apgar scores were less than or equal to 6, and two were less than or equal to 3; only one of the 5-minute Apgar scores was less than or equal to 6, which is 1.2 percent; forty-nine of the women or 60 percent delivered over an intact perineum, and there were no third- or fourth-degree lacerations; one woman had postpartum hemorrhage not requiring transfusion; and one infant had a fractured humerus.
“The most significant observations of the study were the negative findings. No still births or neonatal deaths were reported. Not a single infant suffered Erb palsy, either transient or permanent, and no newborns experienced seizures, hemorrhage, hypoxic-ischemic encephalopathy, cerebral palsy, or fractured clavicle. No patients required any tocolytic medication during labor. No vaginal, cervical, or uterine lacerations occurred. No women required transfusions. And no cases of postpartum, ileus or pulmonary embolus were reported. Overall, the maternal complication associated with the use of the “Gaskin Maneuver” was 1.2 percent (one case of postpartum hemorrhage, transfusion not required), and the neonatal complication rate was 4.9 percent. . . None of these patients required any additional maneuvers. . . Not only was the Gaskin Maneuver instrumental in relieving shoulder impact in every instance, it is also a non-invasive procedure requiring only a change of maternal position.” The average time needed to assume the position and complete the delivery was 2-3 minutes, with the longest reported interval being 6 minutes.
What about moving a woman with regional anesthesia from the dorsal lithotomy position to the all-fours position on a standard delivery table? Bruner reports that at Vanderbilt University Hospital, laboring women with epidural anesthesia are routinely moved from the labor bed to the delivery table in less than a minute. With practice it’s possible that an experienced delivery room-team can also assist pregnant women into the all-fours position within a few minutes. Another advantage of the all-fours position is that it does not preclude the performance of other established procedures, such as McRoberts, suprapublic pressure, shoulder rotation, delivery of the posterior arm and even the Zavanelli maneuver.
The conclusion of the study is that the all-fours maneuver appears to be a rapid, safe, and effective technique that is applicable in a delivery room or other birth setting, for attendants with a range of levels of training. “Future studies should focus on ways to incorporate this technique into the practice of all midwives and physicians.”
