In the midst of a profusion of shoulder dystocia papers and publications, there is a notable absence of discussions regarding what is, arguably, the most effective and least damaging maneuver to relieve shoulder dystocia. When searching the medical literature, it is rare to find a decent discussion on what midwives, of all designations and backgrounds, know as the "Gaskin" Maneuver. When it is mentioned, it is mostly referred to as The All-Fours Maneuver, not referring to its source, Ina May Gaskin. The medically christened maneuvers are: "Woods", "Rubin", and "McRoberts". (There is a HELPERR mnemonic from The American Academy of Family Physicians ALSO Course, which includes "roll the patient to her hands and knees" as the last maneuver to attempt). 1
Ina May Gaskin is a famous midwife, and traditional medicine has been reluctant to give her credit, even though doctors readily admit that her maneuver works and also facilitates all the medical maneuvers. I suspect many physicians fail to put their patients on their hands and knees because someone taught them not to trust a "midwife" maneuver.
Thanks to James A. O'Leary, MD, a study of the Gaskin maneuver was featured in his publication: Shoulder Dystocia and Birth Injury.2 In 1998, four authors, including Ina May Gaskin, published an article in the Journal of Reproductive Medicine outlining the all-fours maneuver for reducing shoulder dystocia during vaginal delivery. Eighty-two consecutive cases of shoulder dystocia were reported in 4,452 births (1.8% incidence) over a twenty-year period. Midwives did most of the deliveries. In 68 out of 82 deliveries, the baby's body was delivered with the next contraction following delivery of the head, and without any maneuvers required. In 12 cases, with the patient in an all-fours position, the fetal shoulders were rotated into the oblique position, and two patients were delivered with the posterior arm. In addition, none of the patients had received anesthesia or undergone vacuum extraction.3
Ina May Gaskin
Dr. Michael Krietzer authored the Gaskin article in Dr. O'Leary's book, commenting that the most significant observations of the Gaskin study were its negative findings. Although 50% of newborns weighed more than 4000g and 21% weighed more than 4500g, there were no cases of brachial plexus injury. All maternal and infant injuries occurred in cases with birthweights of more than 4500g.4
In spite of the results of this study, the precise mechanism by which the Gaskin maneuver relieved shoulder impaction was never studied. But doctors, upon learning of the maneuver, decided that the "mere act" of turning the woman from her back to hands and knees relieved the "weight-bearing forces" on the sacrum, thereby relieving the obstruction. "Because nurse-midwives did most of the deliveries, it is likely that shoulder dystocia was recognized when the shoulders failed to deliver during the contraction following birth of the baby's head."5
Actually, I am willing to bet that the midwives did immediately recognize signs of shoulder impaction, especially in macrosomic infants. Thus, hands and knees as a favored midwifery delivery posture. Dr. Kreitzer goes on to explain that the maneuver facilitates delivery, as the position favors gravity and the posterior arm and/or shoulder can deliver first, following the curve of the pelvic axis. Therefore, traction in the supine or McRoberts position would be applied to the anterior shoulder, counteracting the natural pelvic curve and increasing the likelihood of failure.6
Since no brachial plexus injury occurred in the study, "it is reasonable to assume that the amount of traction applied along the pelvic axis, to effect delivery, was less than would be required with the patient in a supine position, and reduced the likelihood of injury." 7
It is so incredibly helpful to have the mechanism finally explained. Heaven knows, those midwives must have happened upon this position by accident, and now a physician can finally explain why it works! He also goes on to explain that other established shoulder dystocia maneuvers were, apparently, facilitated by the all-fours position.
The physician-author admitted that he had no experience with the Gaskin maneuver (surprise!), but stated that the "advantages and results outlined by Bruner warrant its incorporation into general clinical practice. 8 This statement raises the question of whether he ever used it or taught it to his students. Even though all-fours was sanctioned in the Bruner study, after 16 years, it has hardly been a frequently accepted part of mainstream obstetrical literature or practice.9 Why? Not because it doesn't work, but because it was probably known and utilized by midwives long before obstetrics even existed.
Shoulder Dystocia Intervention Forms are now required by Hospital Corporations' risk management. In 1991, Dr. David B. Acker wrote a paper in Obstetrics and Gynecology, encouraging physicians to be more precise in their delivery notes when shoulder dystocia occurs. He stated that, "Medical notes describing complications must be clear and precise, yet the busy clinician often does not take the time to write an appropriate narrative describing the means and methods necessary to resolve shoulder dystocia.10 He developed a detailed form to help physicians describe the maneuvers used to resolve shoulder dystocia. Since shoulder dystocia litigation has been ongoing and many providers have been sued, the lack of detailed delivery notes describing the maneuvers used, and the traction forces exerted has made it hard for providers to defend themselves in cases involving catastrophic injuries.
Eventually, hospital corporate quality and safety departments created "Shoulder Dystocia Delivery Note Addenda" to help physicians and other delivering providers document events and actions taken during a delivery complicated by shoulder dystocia. Usually, the first item on the form requires the delivering provider to mark a box admitting that a "gentle attempt at traction was assisted by maternal expulsive forces". The next section requires that "any and all maneuvers" be listed in the order in which they were utilized. 11 There are 7 specific maneuvers listed. As most midwives would expect, the Gaskin maneuver, or all-fours, is not on the list. I can assume that a maneuver created and utilized by midwives is not going to be on a list compiled by individuals representing a hospital corporation. Hopefully, if any nurse-midwives are called upon to fill out "the addendum, they will "write in" the Gaskin maneuver as the very first intervention attempted.
At present, I do not know how frequently these forms are presented as evidence in litigation. And what provider, completing a risk management document, is going to admit that they didn't use gentle traction? More than that, however, it concerns me that the Gaskin maneuver, a highly effective technique, is absent from hospital risk management delivery forms. Attorneys should take notice, especially given the literature supporting its effectiveness. Any maneuver touted in publications and by accomplished medical authors should meet the standard of care. I also hope that hospital midwives will take a hard look at the forms from their respective hospitals. Familiarity with what midwives may be coerced to document in shoulder dystocia situations may be helpful someday, practically and legally.
1. HELPERR for Shoulder Dystocia. www.aafp.org/also
2. J.A. O'Leary (ed.) Shoulder Dystocia and Birth Injury. M.S. Kreitzer: Recognition, Classification,and Management of Shoulder Dystocia. Chpt. 14. Page p.179-207.
3. O'Leary/Kreitzer p. 199.
4. O'Leary/Kreitzer. Table 14.2. pp 199-200.
5. O'Leary/Kreitzer p.199.
6. Ibid. 199
7. Ibid. 199
8. Bruner JP, Drummond SB, Meenan AL, Gaskin IM. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1988;43:439-443.
9. O'Lary/Kreitzer p. 199.
Acker, David B. A Shoulder Dystocia Intervention Form. Obstet Gynecol 78:150, 1991.
11. Hospital Shoulder Dystocia Delivery Note addendum. et al.
*Thanks and appreciation to Heather Webster, CNM, PMHNP-BC, for clarification regarding the “Gaskin Maneuver”, currently known, correctly, as “All Fours”. Upon information and belief, Ina May Gaskin learned the hands-and-knees positioning from indigenous Guatemalan midwives and has declined to take credit for inventing the maneuver.
www.midwivesontrial.com
© 2024 Martha Merrill-Hall