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At-term sacroiliac motion and shoulder dystocia From: Todd Gastaldo (gastaldo@gte.net) Tue Jul 8 00:25:35 1997 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Roberta Speyer: "Re: A puzzler from Women's Health Forum" Previous message: MARK LAWSON: "I use placental grading" Next in thread: Ron Helm: "Re: At-term sacroiliac motion and shoulder dystocia" Maybe reply: Ron Helm: "Re: At-term sacroiliac motion and shoulder dystocia" Reply: Malcolm Griffiths: "Re: At-term sacroiliac motion and shoulder dystocia" Joina, I would be grateful if you would print this out and take it to the clinic of Prof. Moyses Paciornik in Curitiba, Brazil. He is the obstetrician who first called my attention to the grisly obstetric travesty discussed herein. Thank you, Joina... Obgyn-listers and Chiro-listers, This is my first post to the obygyn-list. Those who have seen my posts before know that I routinely write long posts. It's an affliction I guess - a subluxation. In regard to fetal skull squashing, I write as if I am sure - because I *AM* sure. So far, no one has refuted "my" biomechanics regarding fetal skull squashing - indeed, Williams Obstetrics published "my" biomechanics at my request - and British obstetrician and obgyn-lister Jason Gardosi has said some of the same things I am saying, but with "nicer" language... See below. Now I am looking at what appears to me to be obstetric fiction: impaction of the shoulders at the inlet as OBs claim that McRoberts doesn't increase any pelvic diameters... Were I a fetus, I would wonder why the routine fetal skull squashing continues - regardless of the "niceness" of the language used to describe this routine grisly travesty.... Were I a fetus, I would wonder why the McRoberts/inlet impaction fiction is perpetuated... Anyway, here goes with another long post. While browsing at Powell's Bookstore in Portland, Oregon I picked up Midwifery Today, a magazine highly recommended by obgyn-lister Dr. Malpani. In addition to publishing Dr. Malpani's praise, the Summer 1997 issue of Midwifery Today publishes an article by obgyn-lister Gail Hart, LDEM (Licensed Direct Entry Midwife) who writes: "[C]ontrary to popular belief, [McRoberts maneuver] does not increase pelvic diameters...[According to the Journal of Nurse-Midwifery [1988], McRoberts maneuver]...may make the pelvic outlet smaller..." When I got home, I searched Medline for the 1988 JNM reference Ms. Hart alluded to in making her claim that McRoberts maneuver makes the pelvic outlet smaller. I had no luck. If such an article exists, I would very much like the reference. Coincidentally, while scanning the obgyn-list archive that day, I came across obgyn-lister Dr. Jason Gardosi's use of a 1988 JNM reference to claim that McRoberts does not alter the dimensions of the pelvis. Dr. Gardosi wrote: "[T]he conventional McRoberts on the back does not alter the dimensions of the pelvis (Mahburn J, J Nurse-Midwifery, 1988;33:225-31)... jason.gardosi@nottingham.ac.uk OB/GYN, Queen's Medical Centre University of Nottingham, UK http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9601/0442.html Dr. Gardosi wrote further: I think that [McRoberts maneuver] may make the subpubic angle even smaller..." http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9601/0442.html Could Dr. Gardosi's "even smaller" claim have been the source for Ms. Hart's "smaller" claim? When I looked up Dr. Gardosi's 1988 JNM reference (Mashburn JNM 1988) I found neither support for Ms. Hart's claim that McRoberts "may make the pelvic outlet smaller," nor for Dr. Gardosi's claim that McRoberts "may make the subpubic angle even smaller." I did however find, in Mashburn's article, reference to the claim - made by both Dr. Gardosi and Ms. Hart - that McRoberts does not alter the diameters of the pelvis... To support this claim, Mashburn [JNM 1988] cited Gonik et al. An alternate maneuver for management of shoulder dystocia. Am J Obstet Gynecol 1983;145(7):882-4. Turning to Gonik et al. [1983] I did indeed find the claim that McRoberts does not alter the diameters of the pelvis...but no evidence for this claim. There was also no evidence - no reference given - for the Gonik et al. [1983] claim that shoulder dystocia involves the shoulders being impacted at the INLET... If the shoulders are truly being "held up" at the inlet, shoulder dystocia - birth of the head - is QUITE a stretch for the cervical spine of the fetus. More importantly, with the shoulders impacted at the inlet, how is the uterus able to push the head out? A graphic of inlet shoulder dystocia shows the side of the cervical spine facing the sacrum stretched... [Hankins et al. Operative Obstetrics Norwalk, CT: Appleton-Lange 1995:234] What force would stretch the cervical spine like that? All other shoulder dystocia graphics in Hankins et al. [1995] - and in another 1995 Operative Obstetrics text - show the shoulders at the outlet... Strangely, in writing about shoulder dystocia - and about how McRoberts doesn't increase any of the pelvic diameters - neither Mashburn [1988] nor Gonik et al. [1983] mentioned the sacroiliac motion so eloquently described to the obgyn-list by Dr. Gardosi - who says that "many so-called 'shoulder dystocias'" involve problems at the outlet... Dr. Gardosi informed obgyn-list: "The anterio-posterior [OUTLET] diameter is reduced in recumbent and lithotomy positions where the weight is taken on the sacrum. The sacrum is capable of rotational movement through an axis at the upper part of the sacro-iliac joint..." Jason Gardosi MD FRCS MRCOG Queen's Medical Centre, Nottingham NG7 2UH, U.K. http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9705/0002.html Dr. Gardosi wrote further: "There have been several radiological studies suggesting that recumbent and lithotomy positions reduce the pelvic outlet. Ironically, this is the position in which many women end up for instrumental delivery due to failed progress - a particularly high risk situation for real shoulder dystocia!" jason.gardosi@nottingham.ac.uk Ob/Gyn, Queen's Medical Centre University of Nottingham, UK http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9510/0015.html And finally, Dr. Gardosi wrote: "Many so called 'shoulder dystocias' are just difficult deliveries caused by a recumbent position. Apart from the sacrum being pushed upward, reducing the AP diameter, it is difficult to allow lateral flexion when the presenting shoulder abuts on the mattress...." jason.gardosi@nottingham.ac.uk Ob/Gyn, Queen's Medical Centre University of Nottingham, UK http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9510/0015.html In contrast to Dr. Gardosi's claim that McRoberts DOESN'T increase any pelvic diameters... British obstetrician Malcolm Griffiths told obgyn-list that "Mc Robert's manouevre MAY increase AP diameter of inlet [sic] by >2.5cm…" (Emphases added.) Malcolm Griffiths MD,MRCOG,MFFP,Cert.Mgmnt Obstetrician & Gynaecologist Luton & Dunstable Hosp.,UK. http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9610/0507.html Dr. Griffiths's claim that McRoberts "may" increase the AP inlet diameter accords with his "European" shoulder dystocia definition as the shoulders being "held up" at the inlet: "[S]houlder dystocia ( as referred to in European practice ) is due to the shoulders being held up at the pelvic inlet..." http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9704/0827.html I'll ask again: if the shoulders are truly being "held up" at the inlet, how on earth is the uterus able to push the head out? Since a graphic of inlet shoulder dystocia mentioned above shows the side of the cervical spine facing the sacrum stretched... [Hankins et al. Operative Obstetrics Norwalk, CT: Appleton-Lange 1995:234] What force would stretch the cervical spine like that? Again, all other shoulder dystocia graphics in Hankins et al. [1995] - and in another 1995 text - show the shoulders at the outlet... Based on bizarre obstetric behavior that occurred when I informed obstetricians about at-term sacroiliac motion, I believe the forces involved in these "European" "inlet" shoulder dystocias are, wittingly or unwittingly, propagandistic - not real or biologic. Dr. Griffiths seemed quite sincere when he told me awhile back in the sci.med.midwifery newsgroup that he wasn't aware of any studies or biomechanics indicating that the sacrum is jammed up to 4 cm into the fetal skull in standard medical delivery position. (See Gardosi's remarks above; and see Gastaldo Birth 1992;19:230.) Not so unwitting, I suspect, were the authors of the 1993 Williams Obstetrics, who reacted to my pointing out information on sacroiliac motion by printing it (see below) - and by suggesting that McRoberts works because the outlet is increased when the woman gets off her sacrum. Oddly, however, they then referred the the reader to a part of the text that indicates that McRoberts doesn't increase any pelvic diameters... (!) Similarly, the authors of Williams Obstetrics indicate that dorsal lithotomy does widen the pelvis and that it does not... Here is the text that appeared in the 1993 Williams Obstetrics after my request: "It should be noted...that the increase in the diameter of the pelvic outlet occurs *only* if the sacrum is allowed to rotate posteriorly, that is, only if the sacrum is not forced anteriorly by the weight of the maternal pelvis against the delivery table or bed." [Cunningham, MacDonald, Leveno, Gant and Gilstrap, Williams Obstetrics Appleton-Lange 1993:285, original emphasis] Can semisitting and dorsal delivery - jamming sacral tips up to 4 cm into fetal skulls - be killing fetuses? Both the 1993 and now the 1997 Williams Obstetrics state, in effect, that if the mother is on her sacrum, the sacral tip is jammed up to 1.5 to 2.0 cm into the outlet; and the graphics clearly show the mother on her sacrum. Moreover, the 1993 (and now the 1997) Williams Obstetrics claim that 0.5 to 1.0 cm of fetal skull distortion can cause a fatal brain bleed. Australian obstetrician Norman Beischer believes that "10-15% of stillborn infants die just before delivery without there having been any evidence of distress..." Dr. Beischer was so quoted by Cochrane Center Director Iain Chalmers, M.D. in Chalmers I. The perinatal research agenda: whose priorities? Birth 1991;18(3):137-41. In that same article, Dr. Chalmers criticized Dr.Beischer for making his "10-15% of stillborn infants die" statement without making clear that it was an anecdotal observation. Dr. Chalmers once told me that women don’t really need to be informed of the radiographic and clinical evidence that obstetricians (and CNMs) are jamming tailbones up to 4 cm into fetal skulls - until there are randomized, controlled trials demonstrating that such fetal skull squashing causes problems. (I doubt such trials will ever occur. No woman - given the facts - is going to volunteer to risk jamming her sacrum up to 4 cm into her baby's skull. ) Interestingly, Chalmers stated in Effective Care in Pregnancy and Childbirth (1989); and again in Guide to Effective Care in Pregnancy and Childbirth (1992); that radiographic evidence indicates that squatting increases pelvic outlet diameter. Strangely, after I informed Dr. Chalmers and his co-editor Murray Enkin, M.D. that the radiographic evidence can more usefully be stated as indicating that standard delivery positions CLOSE the pelvic outlet, mention of these radiographic studies was mysteriously eliminated from the 1995 edition of Guide to Effective Care in Pregnancy and Childbirth. (I emphasize the word CLOSE here because, to a fetus with a trapped after-coming head, the pelvic outlet is indeed effectively CLOSED.) I thought Chalmers’ and Enkin’s censorship behavior particularly odd because Chalmers directs the Cochrane Collaboration which conducts and publishes systematic reviews of the effects of health care; and because the Cochrane Collaboration believes it important to offer readers the reasons that changes are made. Before engaging in his censorship, Enkin told me by telephone that he was relying on studies by "the Lilford Group" which, he claimed, refuted the earlier "squatting" radiographic studies - the studies which he ultimately deleted/censored from the 1995 Guide. Enkin also told me that Effective Care and the Guide only carry information about randomized controlled trials - which simply is not true. I pointed out to Enkin that the studies by "the Lilford Group" were extremely flawed (details on request) and that they most certainly were not randomized controlled trials. I added that simple biomechanics indicates that most of the randomized controlled trials in Effective Care and the Guide were carried out with tailbones jammed up to 4 cm into fetal skulls. Chalmers’ and Enkin’s brand of obstetric "science" is actually anti-science - mothers and fetuses be damned. While Beischer, mentioned above, should clearly label his thinking as clinical impression not scientifically-tested; lack of scientific testing should not be used to discourage people from speaking up about what they observe. Routine jamming of tailbones into fetal skulls may indeed cause some unexplained fetal deaths. See my letter in the July 1997 Mothering magazine, reproduced below. The Cochrane Collaboration LOOKS so very scientific - but if one takes a closer look, one can see that "science" is being used as an excuse to be very ANTI-scientific - mothers and fetuses be damned. I do hope the same thing isn't happening with the Cochrane review pertaining to spinal manipulation now being conducted by Pim Assendelft... Here now is the letter I authored which currently appears in the July 1997 Mothering - with some unauthorized deletions... <<<<<<<<<< BEGIN Gastaldo's letter in the July 1997 Mothering >>>>>>>> BRAIN BLEEDS AND NEONATAL ENCEPHALOPATHY: ARE THEY CAUSED BY STANDARD MEDICAL DELIVERY POSITIONS? At my request, the authors of Williams Obstetrics stated [in effect] in their 1993 edition (and more recently in their 1997 edition) that if a woman is placed on her sacrum (on her buttocks) at delivery, her sacral tip is jammed 1.5 to 2.0 cm into her pelvic outlet - into her baby's skull. Many parents may not be aware that there is evidence that 4.6% of "healthy" babies are born with brain bleeds and up to 10% are born with neonatal encephalopathy. (Neonatal encephalopathy is "an important clinical problem...associated with neonatal mortality and morbidity as well as unfavorable long term neurodevelopmental outcome" [Adamson et al. Br Med J 1995;311:598-602] According to Berg [1996], "[S]ubarachnoid and/or intraventricular blood [brain bleeds - TDG] can result from...disproportion in the size of the fetal head." [Berg BO(ed). Principles of Child Neurology NY: McGraw-Hill 1996:942-3]) The original author of Williams Obstetrics found that in some women the sacral tip is jammed up to 4 cm into the pelvic outlet. (See Gastaldo Birth 1992;19:230.) Incredibly, according to the 1993 and 1997 editions of Williams Obstetrics, fetal skull distortion of 0.5 to 1.0 cm - far less than the average 1.5 cm of fetal skull distortion reported by Williams Obstetrics - can cause a fatal brain bleed in the fetus. Women can easily avoid this grisly obstetric tomfoolery - just by assuming the many alternative delivery positions which keep them off their sacra (hands-and-knees, kneeling, standing, squatting, side-lying, McRobert's maneuver). McRobert's maneuver, just mentioned, has been likened to "squatting while on your back." It involves rolling the woman offer her sacrum while she is on her back. Incredibly, the American College of Obstetricians and Gynecologists informed me in 1992 that women don't need to be informed of these matters - because obstetricians use McRoberts when the shoulders get stuck. In other words, obstetricians routinely use McRoberts AFTER the fetal skull has been distorted! -- Todd D. Gastaldo, D.C. 8948 SW Barbur Blvd. #6 Portland, OR 97219 gastaldo@gte.net <<<<<<<<<< END Gastaldo's letter in the July 1997 Mothering >>>>>>>> What if the "European" "shoulders impacted at the inlet" fiction and the "McRoberts doesn't increase pelvic diameters" fiction are products of obstetrician fear? According to Operative Obstetrics by O'Grady et al. [Williams and Wilkins 1995]: "If a medical judgement falls below the standards of ordinary knowledge, skill, care and diligence required of an obstetric specialist, such judgement will be considered negligence." (p. 352) The authors of the Operative Obstetrics' chapter on shoulder dystocia (two attorneys, one an obstetric specialist) offer not one word about how to open the pelvic outlet up to 4 cm... (!) Shouldn't obstetric specialists know how to open the pelvic outlet up to 4 cm? I suspect that a reasonable person would say yes. Paraphasing the non-obstetric specialist attorney who co-authors O'Grady et al.'s 1995 effort, res ipsa loquitur - if the thing itself speaks - you don't need an expert for this one. Robert Wooley, M.D. recently turned a doctor's own word (incompetence) against him: <<<<I think I am quite justified in concluding that your continuing to perform episiotomies is a demonstration of professional ignorance or obstinacy, either one of which is a pretty good indicator of "incompetence", as you phrase it.>>>> According to the attorney authors of Operative Obstetrics - James J.Nocon and Les Weisbrod (Nocon is the MD obstetric specialist): "Make a big episiotomy. Although there is no evidence that it does anything other than enhance the ability to insert one's hand in the vagina, it will indicate that the operator is functioning in a logical and systematic manner. Again, the failure to perform an episiotomy has not been shown to contribute to any injury." (p. 349) Is an obstetric specialist who performs an episiotomy as he jams the sacral tip up to 4 cm into the outlet really "functioning in a logical and systematic manner?" How many obstetric specialists on the obgyn-list read Dr. Gardosi's opinion that "Many so called 'shoulder dystocias' are just difficult deliveries caused by a recumbent position...the sacrum being pushed upward, reducing the AP diameter..." - and still do recumbent and, worse, semisitting deliveries? The journal of the Royal College of Midwives recently reported that 60% of British deliveries are performed semisitting... Semisitting, of course, just offers that much more force jamming the sacral tip up to 4 cm into the pelvic outlet. [Gastaldo Birth 1992;19:230] Back to "European" "inlet" shoulder dystocia... NONE of the graphics in O'Grady et al.'s Operative Obstetrics [1995] show the posterior shoulder impacted at the inlet. All posterior shoulders seem to be in the hollow of the sacrum - where they might be EXPECTED to be after delivery of the head. (Yes, the "turtle's sign" is described, but this sign doesn't sound like a boney impaction to me. It sounds more like soft tissue/muscle fighting the uterus at the end of a uterine contraction. Again, were the shoulders truly impacted at the inlet, what force would stretch the cervical spine and birth the head?) I want to again emphasize that this chapter showing the shoulders at the outlet does not mention that it is quite easy to offer the fetus up to 4 cm of "extra" AP outlet diameter. Is this the work of competent obstetric specialists? There is yet another text titled Operative Obstetrics and published in 1995... This second Operative Obstetrics has multiple authors, two of whom (Cunningham and Gilstrap) were co-authors of the 1993 Williams Obstetrics...which perhaps explains a passing reference (citing obgyn-lister J. Kurokawa, CNM) to the fact that "Squatting has been suggested in order to increase the capacity of the pelvic outlet..." (p. 250) A brief mention of squatting is as far as this second Operative Obstetrics text goes... There is one graphic of the shoulders being entrapped at the inlet - but all the rest clearly show the shoulders at the outlet... And the graphics clearly show the mother on her sacrum - which position, according to the 1993 (and now the 1997) Williams Obstetrics jams the sacrum 1.5 to 2.0 cm into the outlet. Moreover, the 1993 (and now the 1997) Williams Obstetrics claim that 0.5 to 1.0 cm of fetal skull distortion can cause a fatal brain bleed. This second Operative Obstetrics notes that "Many authors suggest suprapubic pressure as one of the initial measures to overcome shoulder dystocia..." (p. 244) While suprapubic pressure might be useful with the mother rolled off her sacrum (McRoberts), this text states that "Initial management should include gentle downward traction..." In other words, if and when these two initial measures are used, as one obstetric specialist MAKES SURE the sacral tip is forced upward into the outlet (suprapubic pressure), another pulls the neonate's neck - already (ostensibly) stretched clear from the sacral promontory - down onto the sacral tip... (!) "...I have seen shoulder dystocias which have led to both Erb's palsy and even fetal death...My definition of shoulder dystocia is that the shoulders won't deliver by a combination of maternal effort and SAFE obstetrician or midwife downward traction. Malcolm Griffiths MD,MRCOG,MFFP,Cert.Mgmnt Obstetrician & Gynaecologist Luton & Dunstable Hosp., LU6 2DT, UK. "It is dangerous to be right on a subject on which the established authorities are wrong." (Voltaire) "But sometimes it's fun :-)" (Griffiths) http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9705/0014.html Obstetric specialists are not acting competently. Paraphrasing Dr. Wooley (regarding obstetricians who do routine episiotomies), many obstetric specialists are acting incompetently. In "Arguments against episiotomy and in favor of squatting for birth" [Birth 1990;17:104-5] - Brazilian obstetrician Moysés Paciornik made clear his belief that fetal skull squashing, as occurs in dorsal and semisitting delivery, causes brain damage and perineal tears. American College of Nurse-Midwives (ACNM) President Joyce Roberts [Roberts and Woolley 1996] recently cited Paciornik [1990]; but ignored Paciornik’s reference to brain damage. Roberts and Woolley [1996] promoted semisitting - but then offered a "word of caution": Citing Paciornik [1990], they stated that PERINEAL TEARS may result from "encroachment of the sacrum and coccyx on the pelvic outlet when the woman is sitting or semisitting." [Roberts and Woolley. A second look at the second stage of labor. JOGNN (Jun)1996;25:415-23] Why mention perineal tears and not brain damage? I personally informed Dr. Roberts in 1992 of the evidence that up to *4* cm of "encroachment" occurs in some women; this according the clinical pelvimetry of J. Whitridge Williams [1911] cited in Gastaldo Birth 1992;19:230. I informed her also in 1992 that Thoms [1915] did further clinical pelvimetry and arrived at a 3.5 cm maximum in his series; and that various authors note that clinical pelvimetric estimations of sagittal pelvic outlet diameter are quite accurate; indeed, the average 1 to 2 cm values observed by Williams [1911] and Thoms [1915] using clinical pelvimetry were verified by Borell and Fernström [1957] using radiologic pelvimetry. In discussing squatting delivery, Roberts and Wooley (1996) join Paciornik (1990) and others in inferring that Gardosi, Hutson and B-Lynch’s 1989b paper - "Randomised controlled trial of squatting in the second stage of labour" - was a trial of squatting delivery. In fact, nobody squatted in Gardosi, Hutson and B-Lynch’s 1989b "squatting" trial. Instead, women delivered in the semirecumbent position using Gardosi’s "Birth Cushion." Gardosi, Hutson and B-Lynch (1989b) perhaps felt secure in calling theirs a "squatting" trial because they reported "having shown previously" that few women in western populations are able to maintain a squatting posture "during the bearing down phase and delivery." In their previous paper (Gardosi, Sylvester and B-Lynch, 1989a), Gardosi et al. cited Borell and Fernström (Acta Rad Scand 1957) to indicate that, in the semi-recumbent position the sacrum cannot "swing backwards...[and]...a proportion of maternal weight is on the sacrum and coccyx, which can decrease the antero-posterior diameter." Stated more graphically, in semirecumbent delivery, the sacrum is jammed into the fetal skull - up to 4 cm in some cases. See Gastaldo Birth 1992;19:230. Gardosi, Sylvester and B-Lynch (1989a) ignored Borell and Fernström’s radiographic evidence and made the following rather grisly "important compromise" with the "fully trained" midwives who conducted the 1989a trial: To "win the[ir] cooperation," they allowed midwives the option of moving women to "an accustomed semi-recumbent position" at the moment of crowning. "I think the first and best maneuvre in any suspected [shoulder dystocia] is to get the mother squatting or kneeling. Many good midwives already do this, before (and usually instead of) hitting the panic button." Jason Gardosi MD FRCS MRCOG Queen's Medical Centre, Nottingham NG7 2UH, U.K. http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9705/0002.html I have always wondered why Gardosi et al. [1989a] made the fetus squashing "important compromise" with the "fully trained" midwives... Significantly, Gardosi, Hutson and B-Lynch's 1989b trial of "squatting" on a semi-recumbent cushion reported "an observation of 12,000 squatting deliveries in Curitiba, Brazil (C. Paciornik, personal communication)"; with most of these 12,000 squatting deliveries accomplished with sedentary women squatting (without cushions) only "during the bearing down phase" (30-60 sec. during contractions). According to M. Paciornik, Gardosi, Hutson and B-Lynch (1989) simply failed to inform readers that these squatting deliveries were accomplished by urban Brazilian women who are probably every bit as sedentary as women in "western" populations. (M. Paciornik, personal communication.) Samra, Tang and Obhrai (1989), resonating with Gardosi's 1989b sedentary-women-can't-squat-to-use-the-position-during-labor malarky, told The Lancet [(Nov11)1989:1150-51] that squatting is "dangerous"; and that a woman who tried to squat had sat on her baby's head. Dr. Moysés Paciornik responded to The Lancet, emphasizing the importance of BRIEF periods of squatting, reporting 20,000 squatting deliveries, most in sedentary women. (The Lancet refused to publish Paciornik’s response; after which Birth published it [1992;19(4):230-1].) Had Gardosi et al. used their 1989b paper to inform Samra, Tang and Obhrai that Gardosi had visited the Paciorniks in Brazil and had personally witnessed squatting births "á moda índia" [Paciornik M. Episiotomia: argumentos contra. Femina 1991;19(3):228-36] - had Gardosi et al. informed Samra, Tang and Obhrai that Gardosi had witnessed the use of BRIEF periods of squatting - Samra, Tang and Obhrai might have informed this woman of the benefit of BRIEF periods of squatting prenatally and they might perhaps have avoided the grisly incident they later reported to The Lancet. Gardosi sent Gastaldo a copy of Samra, Tang and Obhrai's anecdote to support his claim that "non-visualising the perineum" is a problem in the squatting position. In response, Gastaldo pointed out in an October 24, 1990 response that Samra, Tang and Obhrai had clearly stated, "On squatting, bulging membranes, stained green with meconium, were visible." (emphasis added.) When Gastaldo suggested to Gardosi, who had personally witnessed a few of C. Paciornik's thousands of squatting deliveries using BRIEF squatting periods (see Paciornik M. Birth 1992;19(4):230-1), that perhaps he had now changed his mind - and that perhaps "Western" women in England COULD squat - Gardosi replied, "I have, incidentally, never changed my stance on whether unsupported squatting was a viable option here; two randomised controlled trials performed in English hospitals have clearly shown that it is not." [Personal communication, Gardosi to Gastaldo, Sept. 30, 1990, emphasis Gardosi's. Jason Gardosi, FRCS, MRCOG, Director, Perinatal Research and Monitoring Unit, Floor D, East Block, Queen's Medical Centre, University of Nottingham, NG7 2UH ENGLAND, tel: 44-60-270-9240] As noted above, Dr. Gardosi is now telling obygyn-list that squatting IS a viable option... Todd D. Gastaldo, D.C. -- IMPORTANT NOTE: I am not currently practicing chiropractic - except insofar as the practice of chiropractic includes freedom of speech. While in Oregon doing library research I have voluntarily forfeited my California chiropractic license so as not to have to pay the annual licensing fee. (Under California law, any licensed D.C. may voluntarily forfeit his/her license, and may, at any time, reactivate said license by providing the Board of Examiners with "twice the annual amount of the renewal fee...[He or she]...shall not be required to submit to an examination for the reissuance of the certificate." [Section 12, Act Regulating the Practice of Chiropractic...Issued by the Board of Chiropractic Examiners...Act Includes Amendments Through October 1993] "Yes, I sold [Gastaldo] a modem. That was one of the biggest mistakes of my entire life and I regret it more than any other error of my life." Howard Leighty, D.C. Next message: Roberta Speyer: "Re: A puzzler from Women's Health Forum" Previous message: MARK LAWSON: "I use placental grading" Next in thread: Ron Helm: "Re: At-term sacroiliac motion and shoulder dystocia" Maybe reply: Ron Helm: "Re: At-term sacroiliac motion and shoulder dystocia" Reply: Malcolm Griffiths: "Re: At-term sacroiliac motion and shoulder dystocia"

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