Shoulder Dystocia Maneuvers: The One Medicine Leaves Out

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 backgounds, 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 is 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 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 (ACOG and AJOG probably rejected it) 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, and with the patient positioned in an all-fours position, the fetal shoulders were able to be rotated to the oblique position, and two patients were delivered with the posterior arm. In addition, none of the patients had received anesthesia or were delivered by vacuum extraction.3

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 that 4500g, there were no cases of brachial plexus injury. All maternal and infant injury 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 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, providing relief from 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 how the maneuver facilitates delivery as the position favors gravity and the posterior arm and/or shoulder could deliver first, following the curve of the pelvic axis. Therefore, traction with the supine or McRoberts position would apply to the anterior shoulder, countering the natural curve of the pelvis and decreasing the possibility of success.6

Since no brachial plexis 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 liklihood 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.

This physician-author admitted that he had no experience with the Gaskin maneuver (surpise !), but stated that the "advantages and results outlined by Bruner warrant its incorporation into general clinical practice". 8 This provokes the question of whether he ever used it, or taught it to his students. So, 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 managment. In 1991, Dr. David B. Acker wrote a paper in Obstetrics and Gynecology, encouraging physicians to be more precise writing their delivery notes when shoulder dystocia has occured during delivery. 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 manuevers used, and an estimation of traction forces exerted, has made it hard for providers to defend themselves in legal cases where catastrophic injuries occurred.

Eventually, hospital corporate quality and safety departments created "Shoulder Dystocia Delivery Note Addenda" to help physicians and other delivering providers, create a record of 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 that they were utilized. 11 There are seven specific maneuvers listed. Unfortunately, the Gaskin manuever, or all-fours, is not on the list. This is hardly a suprise, but I must assume that a maneuver, created and utilized by midwives, is not going to be on a list created by a hospital corporation. Hopefully, if any nurse-midwives are called upon to fill out "the addendum", they will "write in" the Gaskin manuever as the very first intervention attempted.

At the present time, I don't know how frequently these forms are being utilized as evidence in litigation settings. I can't imagine that any provider is going to admit that they didn't use gentle traction. But more than that, it concerns me that the Gaskin maneuver, a highly effective technique, is absent from hospital risk management delivery forms. Attorneys should take notice, especially since there is literature supporting its effectiveness. Any maneuver touted in publications, and by accomplished medical authors, should pass the test for 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 forced 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.

10.Acker, David B. A Shoulder Dystocia Intervention Form. Obstet Gynecol 78:150, 1991.

11. Hospital Shoulder Dystocia Delivery Note addendum. et al.

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Shoulder Dystocia Maneuvers: The One Medicine Leaves Out

Mid-level Mortification