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Re: Shoulder Dystocia and the "all fours maneuver"From: OtisSam@aol.comSun Oct 1 21:28:04 1995
All fours is usually called "hands and knees" because it is a simple and easily remembered description. Ina May Gaskin, a community midwife, promotes this maneuver and is collecting data on it's use. There have been a few reports in medical lit, one is "A new (old) Maneuver for the mangement of shoulder dystocia" Meenan, A, et al, The Journal of Family Practice, Vol 32, No. 6, 1991, p 625-629. There is an excellent video demonstrating it's use for the birth of a 10 lb 4oz baby with no episotomy or tear. It is available from The Farm, Summertown TN, 38483 (USA). The midwives at the farm have used this method successfully 40 times out of 1900 births, perhaps explaining their c-section rate of 1.7% (that is not a typo 1.7%). The theory behind the maneuver is that by turning the woman over, the ability of the sacrum to move is maximized "allowing rotational movement around a transverse axis through the sacroiliac joint". The lithotomy postition is well known and fairly criticized for not maximizing the expansibility of the pelvis in a pregant woman. This position allows for full expansion of the pelvis and puts gravity to work to push the posterior shoulder anteriorly and under the sacral promontory. There are several hand movements which can be used to reach in and free the shoudlers if simply turning the woman to hands and knees does not work, this postion allows for more room to insert a hand to reach the posterior arm, which is no longer compressed against the vaginal wall by the weight of the baby and moms belly. This method is also recommended because, it will usually work where McRobert's fails, and does not require the skilled medical backup and OR facilities of the Zavanelli. Ms. Gaskin requests that case reports of the use of the manuever be forwarded to her at the Farm (address above). I will be happy to provide additional references or faxed copies of the two I mentioned to anyone interested. Samantha McCormick, RN, SNM
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