Mothering magazine, I have again quoted from my letter in your July 1997
issue to assist Dr. MALCOLM GRIFFITHS in understanding how the fetal
skull is distorted even when the McRoberts maneuver is used for shoulder
dystocia. Thank you for printing my letter...
Malcolm Griffiths, M.D. wrote:
<<<<...I wasn't sure how a manouevre intended to increase the AP
diameters of the pelvis to allow the shopulders through could "crush"
the fetal head once it was already out of the pelvis ! >>>>
--
Todd D. Gastaldo, D.C. remarks:
Dr. Griffiths missed the following point from my "At-term sacroiliac
motion and shoulder dystocia" post wherein I quoted from my letter in
the July 1997 issue of Mothering magazine:
"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!"
[Gastaldo TD. Letter. Mothering July 1997]
The same sacroiliac motion that increases AP OUTLET diameter actually
decreases AP INLET diameter - and vice versa. (The inlet diameter change
is far exceeded in magnitude by the outlet diameter change. See Young
[1940] referenced in the 1995 British Gray's Anatomy; and see Borell and
Fernstrom [1957] also referenced in the 1995 British Gray's...
Misunderstanding of this inverse inlet/outlet biomechanical relationship
may be the source of the erroneous notion that McRoberts makes the
outlet smaller...
Dr. Griffiths also wrote:
<<<<I forget now where we are with non-professionals posting to this
list !...
<<<<I found this post very confusing - I also couldn't understand how
come the post was misattributing comments to Jason and [me].>>>>
Jason Gardosi, MD added:
<<<<Just for the record, I have responded to Mr Gestaldo's comments when
he first wrote to me several years ago, and have nothing to add here. I
failed to make any headway then, and am not likely to succeed now, in
correcting his various misquotes and misinterpretations.>>>>
Dr. Gardosi appears to echo Dr. Griffiths' inference that I am a
"non-professional" by referring to me as "Mr." Gastaldo.
I am reminded of a joke my mother used to tell about a tour-guide giving
a tour of heaven. When he got to the door that said "Catholics," he
said to the tourists, "Shhhhhh...They think they are the only ones
here."
While obtaining my B.S. in Biochemistry from UCLA, I learned to
carefully document my work - and my careful documentation habits
continued on through my training as a Doctor of Chiropractic...
I checked my work before I posted - and now - on reading the criticisms
of Drs. Griffiths and Gardosi - I have gone back and checked my work
again. I see no errors.
I suspect that Drs. Griffiths and Gardosi are reacting out of
embarrassment - with disrespect and with pejorative inferences about my
documentation skills - but I will happily acknowledge any errors and
apologize - if they will show me where I have "misattributed,"
"misquoted," or "misinterpreted."
Obgyn-listers who deleted my post because it was so long - and who now
wish to check my work to determine for themselves whether Drs. Griffiths
and Gardosi are unfairly reacting disparagingly out of embarrassment -
can send me an e-mail request. I will gladly send another copy of my
post.
Here again are my quotes from Drs. Gardosi and Griffiths which go to the
crux of the matter of diameter changes with McRoberts maneuver:
Obstetric professional Gardosi claims in the obgyn-list archive that
McRoberts "does not alter the dimensions of the pelvis" - and that it
does - or at least "may" alter the dimensions ("it may make the subpubic
angle even smaller...")
http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9601/0442.html
Obstetric professional Griffiths, on the other hand, suggests in the
obgyn-list archive that McRoberts "may" widen the pelvic inlet - by more
than 2.5 cm...
http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9610/0507.html
One would think that obstetric specialists would know FOR SURE whether
the diameters of the true pelvis may be altered - and for sure HOW they
may be altered.
Given the fear expressed by obstetric specialists in cases of shoulder
dystocia (this fear is expressed in obstetric texts and in the
obgyn-list archive), one would expect more than disparagement and
disrespect - even if the dogcatcher presented compelling evidence that
McRoberts DOES widen the outlet and "European" (and American) "inlet"
shoulder dystocia is a fiction.
No one has addressed my question:
With the shoulders ostensibly impacted at the INLET, just exactly what
force stretches the neck and pushes the head out of the vagina?
Finally, I must address Dr. Gardosi's claim that he tried and failed to
make me understand something (or things) years ago...
I am afraid Dr. Gardosi has the situation exactly backwards... As I
noted in my post,
<<<<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]
<<<<...Dr. Gardosi is now telling obygyn-list that squatting IS
a viable option...>>>>
I noted in my post that 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.
[Gardosi, Sylvester and B-Lynch. Alternative positions in the second
stage of labour: a randomised controlled trial. Brit J Obstet Gynaecol
1989a;96:1290-6]
And now Dr. Gardosi tells obgyn-list:
"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 say again: I have always wondered why Gardosi et al. [1989a] made
their fetus squashing "important compromise" with the "fully trained"
midwives - in a paper in which they so clearly stated the biomechanics
demonstrated radiographically by Borell and Fernstrom in 1957...
This "important compromise" - which jams sacral tips up to 4 cm into
fetal skulls [Gastaldo Birth 1992;19:230] - is ROUTINELY made in the
Western world...as 4.6% of term neonates suffer unexplained brain bleeds
and up to 10% suffer unexplained neonatal encephalopathy..
As I noted in effect in my post, this grisly "important compromise"
appears to amount to obstetric gross negligence...
<<<<<<<<<<<< BEGIN excerpt from Gastaldo's obgyn-list post >>>>>>>
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?
<<<<<<<<< END excerpt from Gastaldo's obgyn-list post >>>>>>>>
I think my post points to the obvious negligence which lies at the root
of the routine vagina slashing habit of obstetricians...(I would use the
"nicer" term "episiotomy," but I don't think "episiotomy" is very nice
when performed to offer more room - with the sacral tip jammed up to 4
cm into the outlet.)
Paraphrasing Dr. Griffiths, "This is where we are with non-professionals
posting to this list..."
I stand behind my criticisms of comments made on this list (and in the
medical literature) by Dr. Gardosi and Dr. Griffiths.
I am sorry that Drs. Griffiths and Gardosi do not appear to regard me as
a professional.
As Dr. Griffiths says in his signature file:
"It is dangerous to be right on a subject on which the established
authorities are wrong." (Voltaire) "But sometimes it's fun :-)"
(Griffiths)
I do not perceive myself to be in danger - or to be having all that much
fun - but this does not make me wrong....
Obstetric specialists: Please stop the routine fetal skull squashing -
and the routine vagina slashing. They appear to be related to rather
obvious ongoing obstetric negligence.
And now, to obgyn-listowner Geffrey Klein, MD, I appreciated your
couteous private post requesting the "inspiration" for my first post to
obgyn-list.
My inspiration for posting to obgyn-list was the possibility that
obstetric specialists will end senseless practices that cause millions
of fetuses, infants and mothers to suffer each day.
As I noted at the beginning of my post, Obstetrics Professor Moyses
Paciornik, M.D. - and his obstetrician son Claudio Paciornik, M.D. -
were the first to introduce me to the fetal skull squashing biomechanics
discussed here.
My understanding is that the Paciorniks were stimulated to think about
these matters by observing the behavior of midwives indigenous to the
forests near Curitiba, Brazil... (Dr. Paciornik has a book in which he
tells an amusing story about how the usually reserved indigenous women
he was studying laughed uproariously when he laid down and put his feet
in the air in response to their query about how "the Portuguese" give
birth..."
I will probably make the Paciorniks uncomfortable with my effusiveness,
but I would like to see them share a Nobel prize in medicine for their
pioneering work in bringing obstetrics back into line with midwifery
practice...
When I first contacted the Paciorniks - because of a minor bibliographic
error in Birth - I found that they had also been thinking about allowing
and encouraging Western children to maintain into adulthood their innate
comfortable prolonged flat-footed squatting ability.
Currently the West robs children of this fundamental human rest and
labor and delivery posture.
Upon receipt of my 1988 article about Canadian orthopedic surgeon W.
Harry Fahrni's "chairless schools" [Gastaldo. Social Squatting 1988],
the Paciorniks took the matter to the bureaucrats and soon established
33 "chairless" schools in Curitiba, Brazil. The moving force -
then-Curitiba Mayor Jaime Lerner - is now the Governor of the State of
Parana - or he was awhile back.
As I noted in my 1990 correspondence with Dr. Gardosi, squatting appears
to have benefits which extend to psychiatry, obstetrics, midwifery,
orthopedics, urology, and proctology.
Most people are unaware, for example, that severe hip osteoarthritis is
virtually unknown in squatting cultures...
Why is this obvious-elusive massive culture-wide squat robbery not
discussed? Here in America, we pay BILLIONS of dollars per MONTH to
warehouse elderly persons, many of whom are warehoused because of
mobility problems. The obvious compression of morbidity - the fix - is
free... Children naturally squat. And adults around the world squat
into old age. As Dr. Fahrni noted, we don't have to teach children
anything. [Fahrni Orth Clin N Am 1975]
Final note: I am not a squatting dogmatist in regard to delivery
position. The Paciorniks' squatting dogma is not a bad dogma to have
though, when the usual dorsal/semisitting alternative is jamming the
sacrum up to 4 cm into the fetal skull.
It is downright INSPIRATIONAL to know that Dr. Gardosi now regards true
squatting as a "viable option." : )
Or is he now saying, as he told me in 1990, that squatting is NOT "a
viable option..."
He doesn't say.
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.
