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Re: Shoulder Dystocia From: Anna Meenan, MD (annam@uic.edu) Wed Jan 12 21:15:58 2005 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Elrod Darryl G MAJ 48 MDOS/SGOBO: "Re: Coding question" Previous message: Anna Meenan, MD: "Re: WSJ - Dentists Out-Earning Primary Care Docs" In reply to: Anna Meenan, MD: "Re: Shoulder Dystocia" Next in thread: Kaycnm@aol.com: "Re: Shoulder Dystocia" I e-mailed Ina May Gaskin the other day, figuring this thread would interest her. She got back to me today, but isn't currently registered to post, and wanted me to post the following for her: "I agree with Anna that putting the woman on hands and knees does not always mean that the baby simply slides out (although this does sometimes happen). In three or four cases, I've had to reach the posterior armpit (splinting my first two fingers across it and then applying traction). I've never had a brachial plexus injury to a baby nor have my partners. In two cases, I wasn't able to reach the posterior armpit, so I decided to reach into the vagina to deliver the arm. I grasped the hand in order to pull out the arm. A midwife who tried to follow the same strategy told me that she was surprised when she couldn't find either hand, so she extracted her hand and inserted it behind the baby's back. The baby had its hands in a "handcuffed" position. Anyway, she managed to push one of the hands forward, re-extracted her hand, and re-inserted it to deliver the hand she had pushed forward. The rest was easy. Two Florida ob-gyns have told me that the hands and knees maneuver worked when nothing else. In one case, the maneuver was accomplished quickly enough that the baby was born in good condition. In the second, the physician had tried all of the other methods listed in the ALSO mnemonic for shoulder dystocia and only tried hands and knees last. By this time, the baby was too far gone to resuscitate, but the doc said the baby came easily once the mother had got to her hands and knees. She told me that she wished that hands and knees had appeared higher on the ALSO list. I haven't checked lately to see how ALSO presents it now, but I do know that more people are including hands and knees as a reasonable maneuver to try for a difficult shoulder dystocia. Of course, it's easier to accomplish quickly if the mother has been told previously that it might be necessary (I do this sometimes if I anticipate a shoulder dystocia.) I believe that the mother's movement itself can help to free the impacted shoulder. I also think that the maternal antero-posterior diameter increases when the woman is on her hands and knees (compared to its diameter when she's seated or on her back). I would welcome any data from instances in which any of you used the hands and knees maneuver to deal with a shoulder dystocia for the Shoulder Dystocia Registry. I need the following: Baby's weight Gestational age Parity Condition of baby ( including Apgars, need to resuscitate) Time elapsed between delivery of head and shoulders Condition of perineum (episiotomy? Laceration? Degree of either") Number of maneuvers tried Maternal morbidity Ina May Gaskin midwifeim@earthlink.net In answer to Ina May's concern about the placement of the All-Four's maneuver in the ALSO mnemonic, I can tell you that it was moved up from the last maneuver to the second-to-last one acouple of years ago, I think. It used to be that the last two entries were: R--Remove the posterior arm R--Roll the mother to all-fours Now it is Roll to all-fours, then Remove the post. arm I am an ALSO instructor and I will say that we do clarify in each workshop that we do that the order the maneuvers are done in is not critical, and that they can be done in any order, as long as excessive lateral traction on the head or neck is not employed. As I mentioned previously, I generally skip the step that comes before the last 2 R's. (E--Enter the vagina with one hand to perform rotational maneuvers) -- Anna L. Meenan, MD At Fri, 7 Jan 2005, Anna Meenan, MD wrote: > >Baby doesn't always just slide out. I fact, in the times I've used it, >I can only recall once (the first time, actually), where the baby came >very easily. In that case, the baby pretty much came shooting out when >I inserted my hand into the vagina posterior to the baby (between the >posterior shoulder and the sacrum). I suspect that I therefore released >the posterior shoulder by lifting the sacrum up off of it. I've had a >couple of times where steady gentle traction ultimately delivered the >posterior shoulder (though I would not say that the baby "slid right >out", and a couple of times where I had to deliver the posterior arm. to >get the rest of the baby. What I find when I use the Gaskin Maneuver is >that it gives me much more space to work posteriorly. The most recent >shoulder dystocia that I had was in a lady with an extremely dense >epidural. When we didn't get the anterior shoulder with gentle >traction, McRoberts, and suprapubic pressure, I had her roll on her side >and delivered the posterior arm ( I can't do any maneuvering posteriorly >with mom sitting on her butt.). Unfortunately, baby ended up with an >Erb's Palsey of the ANTERIOR arm. > >It would be interesting to measure forces involved in delivering the >posterior arm, or in delivering the posterior shoulder with the Gaskin >Maneuver, as Art suggested. I have never had much success with >rotational maneuvers, and I find it difficult to do much of anything >with the anterior shoulder, as you need to get up under the pubic >symphysis to get at it in order to push it in either direction, and with >the baby's cheeks plastered against the introitus, I find that difficult >to do. > >-- > Anna Meenan, MD > >At Fri, 7 Jan 2005, GIN11153@aol.com wrote: >> >>>From what I've heard from midwives, the Gaskin maneuver works almost all the >>time-baby just slides out! >> >>Gail Neuman RNC CPHW SNP LNC >>listowner of LegalNurseConsulting@yahoogroups.com >>certified high risk OB/legal nurse consultant >>Notary Public/Certified Loan Signing Agent >>Tustin, CA > Next message: Elrod Darryl G MAJ 48 MDOS/SGOBO: "Re: Coding question" Previous message: Anna Meenan, MD: "Re: WSJ - Dentists Out-Earning Primary Care Docs" In reply to: Anna Meenan, MD: "Re: Shoulder Dystocia" Next in thread: Kaycnm@aol.com: "Re: Shoulder Dystocia"

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