The explanation for the success of the all-fours [Gaskin] maneuver probably lies in movement at the sacroiliac joints at term, which can result in a l-cm to 2-cm increase in the sagittal diameter of the pelvic outlet. The lithotomy position restricts posterior movement of the sacrum, while placing the mother on her hands and knees with weight evenly distributed over all four extremities allows rotational movement around a transverse axis through the sacroiliac joints. Additional benefit is probably obtained from the movement involved in the actual change of position, which may help disimpact the shoulders, and the addition of gravity to the forces tending to push the posterior shoulder anteriorly, allowing it to slide over the sacral promontory. This would make it particularly useful in severe bilateral shoulder impactions.
Critics of the all-fours position will claim such a change in position is time-consuming and difficult to accomplish, precluding the use of other maneuvers. In the unlikely event that this maneuver is not successful, several other suggested maneuvers can be performed in this position, including attempting to rotate either shoulder toward the fetal back or chest, and attempting to deliver the posterior arm. Although delivery of the posterior arm in the lithotomy position has been reported to be difficult in some cases because of inability to insert a hand into the vagina, the all-fours position offers the potential for increased space between the shoulder and the vaginal wall because of the mobility of the sacrum and the fact that the weight of the maternal abdomen and fetus are not resting directly on the posterior arm. Though fundal pressure and suprapubic pressure would be difficult if not impossible in this position, they are not likely to be necessary or useful in attempts to deliver the posterior shoulder. Deliberate fracture of the clavicle would be no more difficult in this position, and as a last resort even the Zavanelli maneuver can be performed in this position.
It takes as little as 30 seconds to get a patient to her hands and knees even in the event of an unexpected shoulder dystocia.
- Encourage the mother to assume the all-fours position at intervals during labor. It is a very comfortable position, especially when the baby is occiput posterior, and it is useful for facilitating rotation and descent. Admittedly, not all mothers will be comfortable in this position, or it may be one of many different positions assumed by the patient during the course of her labor, but it will help if she becomes familiar with this position in advance of the birth. Advise her that it may become necessary to assume this position again for delivery of the shoulders.
- Avoid intravenous lines. A heparin lock can provide emergency venous access without the restrictions of dangling IV lines.
- For the same reason, avoid continuous electronic fetal monitoring equipment, or remove the belts as the vertex is delivered.
- Along the same lines, avoid stirrups and extensive sterile drapes, and for obvious reasons, avoid epidural anesthesia.
- Have at least two assistants present at the birth. Labor coaches can help facilitate rapid changes in position if necessary.
- Deliver the baby in a bed, not on a narrow delivery table. Consider using the lateral decubitus position, or better yet, complete the entire delivery in the all-fours position in those patients at high risk for a shoulder dystocia.
- The Farm
Differentiating "sticky shoulders" from true shoulder dystocia isn't easy, but I define true shoulder dystocia as one that takes multiple maneuvers to release, results in a depressed baby, and leaves the midwife with sore arms, wrists and fingers...
McRoberts doesn't always work. Standing doesn't always work. Suprapublic pressure doesn't always work. Trying to deliver the posterior arm doesn't always work. Breaking the baby's clavicle isn't always possible. Even cutting a big episiotomy, a favorite technique of the medical profession, probably won't do a thing to help release most babies.
The key to delivering a baby with shoulder dystocia is to keep one's mind clear enough from panic and fear so that you can direct the woman into various positions, try multiple techniques, and never quit until the baby comes out. If you don't know the techniques, you must learn them and review them often. A severe shoulder dystocia may not happen until a practitioner has delivered hundreds of babies. You can never get cocky and think you have the right technique or position to prevent shoulders from getting stuck. Sticky shoulders aren't all that uncommon -- they'll come with just a trick or two. Real shoulder dystocia is different and deadly, and every midwife who delivers enough babies will have this experience some day. I know of midwives who stopped practicing after experiencing true shoulder dystocia. The fear and sense of helplessness became unshakable and polluted their ability to see birth as a normal process. The accountability became too much to cope with.
I cope with the aftermath by trying to keep my boundaries clear. I didn't cause it to happen -- I just happened to be the one there who had to deal with it. I do the best I can at any moment, which is all any of us can do. I know the various techniques and I use them all until the baby comes, and then I make sure I know how to resuscitate the baby. It's the birth that woman got; it's the birth that I got. Bad things happen sometimes and we have to live with them and move on, knowing that we do not have supernatural powers, that we're only human with limited ability to control life and death.
- Gretchn Brauer-Rieke, CNM,
Midwifery Today Issue 55 - Second Stage
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Question of the Week: Herbs for Hemorrhage
Q: What are your favorite herbs (and amounts) for postpartum hemorrhage? What has not worked? Have you ever felt that you could not keep a hemorrhage under control with herbs and bimanual compression until a mother could be transported to a hospital?
- Amy Kieffer, student midwife
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Question of the Week Responses: VBAC with Extended Uterine Scarring
Q: Does anyone have information about or experience with successful VBACs with an extended uterine scar (8 in. vs. 4 in.)? A woman is interested in homebirth who was attempting an unassisted homebirth with her last baby. Upon SROM she found a foot presenting. She and her husband went to the hospital and the doctor on call did a c-section but had to extend the incision to get the baby out. He assured and reassured her that she had a perfectly good chance of delivering vaginally next time, given she has a care provider.
A: I would want to know if a single or double closure was used to sew up the uterus. Check the medical record. If it was a single -- well, think twice.
-Sally Ann Miller, BSN, RNC, IBCLC
St. Louis Park, MN
A: The risk assessed to VBACs because of previous surgery and scarring has always interested me. In April 1991, during my 7th month of my first pregnancy, I had an intestinal blockage. Exploratory surgery was performed. From what I understand, my uterus was removed (or moved far to the side) to allow for the blockage to be found and the repair done. I was stitched and taped and left the hospital 3 days later with an incision about 5-6 inches long. Because of IV fluids and hydration my abdomen was 2 times larger than when I entered the hospital. At no point was the incision or scar tissue mentioned following the surgery or during labor. I went on to have an unmedicated vaginal birth of a 7 lb 14 oz baby girl. I have to wonder, although a c-section includes the uterus in the incision, how can a previous c-section years before be any more of a risk than major abdominal surgery 2 months before birth?
On that note, a woman I know has had 7 c-sections and plans to have 1-2 more children. How is carrying so many babies and having so many c-sections approved of by a doctor? The reasoning just doesn't seem to make any sense in our current medical policies.
- Chantel Haynes, pregnancy & birth assistant
Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
I am a student midwife in South Australia. We are now unable to qualify as a registered midwife due to lack of insurance coverage. Two universities train midwives (direct entry training has started this year). However, now no company will insure student midwives to attend the required number of births to be able to register. One university has no insurance and the other does not have insurance coverage after June 2002. Independent midwives also are having huge problems with professional indemnity insurance as well, and a large number are no longer practicing because of it.
At a time when midwives are finally being trained to be respectful and maintain a woman's rights throughout her pregnancy/birth and postnatal period, it has all come to a grinding halt. Something must be done -- why will it stop at midwifery students? This will surely affect general nursing, medical students, etc. and therefore all areas of peoples' lives.
- Wendy Scott
It is noteworthy to add that permanent immunity to hepatitis B is not absolute after receiving the standard series of three injections. It is appropriate to have a follow-up blood test to check for the post vaccination titer level. The older the recipient is, the more likely the titer is not high enough, leading to the need for another injection. Titer levels may also diminish with time. Makers of the vaccine have literature available.
The APGAR score [Issue 4:15] is calculated from five fundamental physical signs: the infant's heart rate, respiratory effort, muscular tone, reflex irritability and peripheral perfusion. Any birth attendant who did not make these, and more, routine observations of the neonate would be incompetent. If any or all of these assessments were abnormal then you would use your clinical judgment to determine appropriate management, from outright need to resuscitate to simply continuing observation. For Marsden Wagner to suggest that we should rethink the assessment of these physical signs because they do not predict the later neurological development of the child is as flawed as to suggest that we should stop taking temperatures because no study has ever proven that it predicts the future occurrence of infectious disease.
It is manipulative of BirthPsychology.com to suggest that the birth attendant's assessment of these physical signs are part of some social conspiracy to undermine a mother's confidence in her ability as a parent. Until recently, the APGAR was used in quite the reverse: to prove the incompetence of the birth attendant, and sue.
I'm 39 years old and had my first child 11 months ago. For the past 3 months I have had abdominal (ovaries area) pain and mood swings for 1-2 wks at the end of each menstrual cycle. I am nursing, which may account for some of my tiredness. I have had an ultrasound and it is not cysts on my ovaries. Small fibroids were identified around the ovaries. About 1997 I had a good-sized fibroid and endometriosis removed from outside my uterus. I spent several years in various infertility treatments and this baby was conceived with IVF. I have changed my diet to organic. I tried (one week) dong qui, which seemed to make my milk dry up. Suggestions?
I am an obstetrician/gynecologist seeking info on collaborative practice/midwifery. Our goal is to work on establishing this in our area. However, upon reading the article by Dr. Wagner [What Every Midwife Should Know About ACOG and VBAC] I am appalled at the tone of the content. It is very antagonistic and inflammatory. As a physician who is actively seeking info I feel turned off by the message given by your publication. There has to be a moderating influence in your editorial board. How can you expect to breech the divide between the disciplines if you publish extremist material? To imply that rising maternal death rates are due to rising c-sections and epidural rates undermines your credibility. It makes you seem as dogmatic as old-style MDs who say you must have an episiotomy WITHOUT any evidence to support the claim. I will look elsewhere for a source that is supportive of a true collaborative and truly progressive style of medicine.
- Parke Hedges, MD
San Antonio, TX
Marsden Wagner responds:
This obstetrician has labeled me antagonistic and an extremist -- another example of shooting the messenger if you don't like the message. I fear that obstetricians have been in a position of power for so long that some are unable to take criticism -- a dangerous attitude to say the least.
My credibility is challenged because I suggest that the rising maternal mortality rate in the US the past 15 years (a fact) may be related to the rising rates of c-section and epidural. In fact, good data in the literature shows c-section has a rate of maternal mortality 6 times higher than vaginal birth. Even if you eliminate emergency c-section and consider only elective c-sections, the maternal mortality rate is just under 3 times higher than vaginal birth (Hall M, Lancet, 354, 776, 1999).
Good scientific data in the literature reveals that the maternal mortality rate is higher if epidural block is used for the pain of normal labor -- ask any anesthesiologist. Since the rate of c-section and the rate of epidural block for normal labor pain both have been shown to be increasing in the US, it is not extremist but logical to suggest the rising maternal mortality is likely related to the increasing rates of c-section and epidural block.
The tone in the message from this obstetrician is a familiar one -- it represents what I call "tribal loyalty." Since I am a member of the tribe -- a medical doctor -- I must never say anything that might be considered critical of the practice of other doctors. But tribal loyalty is a self-defeating strategy because it eliminates the possibility for doctors to admit they make mistakes and therefore improve their practice. An example: Between 1990 and 1999 many women having VBAC in the US were given Cytotec induction. Finally in 1999 published papers proved that Cytotec induction with VBAC markedly increases the risk of uterine rupture, and ACOG finally said don't do it. So we now know that during these years many women had uterine rupture because obstetricians were making a mistake. But I have never heard a single obstetrician admit to making this mistake, much less express remorse.
Obstetricians and midwives will collaborate well together only when there is mutual respect in an egalitarian professional relationship.
- Marsden Wagner, MD, MSPH
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