OB-GYN-L Messages for September, 2000: Re: The 'Infamous' Ina May Gaskin

Re: The 'Infamous' Ina May Gaskin

From: Kathi Wilson

wilsonk@gtn.on.ca

Sat Sep 30 13:45:44 2000

> Kathy - I am interested in your earlier posts in which you stated (I
> believe I'm restating this accurately) as a matter of practice you
> wait for the next contraction to attempt delivery of the shoulders.

Actually, it was Kay that said that :-) But I'll respond anyway. I do like to wait and see what's happening w/ the kiddo just after the head's out. Get the mother to really relax (if she's unmedicated) and get her legs adequately apart. I've had some babies do really bizarre maneuvers as they appear to corkscrew *themselves* through the pelvis -- those are the ones that come out, start to restitute one way, and then swing all the way around to the other direction (which is also why I don't artificially restitute heads after the birth). I really believe that a healthy baby actually contributes to being born thro' it's tone and wiggling. The worst SD I ever had, in terms of length, was with a dead baby, and I'm sure that that's because of lack of tone. Other pracititioners I know have said the same thing about dead babies. At the same time as I'm watching, I'll also slide my fingers up and see if I can feel the shoulders and/or the axilla-- always reassuring.

> I was always taught that if a shoulder dystocia is present, additional
> contractions serve to impact further the shoulder under the symphysis.
> Thus I always attempt delivery of the anterior shoulder as a
> continuous process after delivery of the head if a large baby or small
> pelvis is expected. I do this before I suction or do anything else.

Yeah, this is the argument for getting the shoulders out before internal rotation occurs, as a preventative measure. I find that there's one problem w/ this line of thought. It's my belief that in a true shoulder dystocia, the shoulders are often *already* in the AP diameter and hung up by the time the head is out. In fact, as far as I'm concerned, a worse sign than an AP head turtling, is the big head that restitutes as it's being born, or snaps to the OT position immediately upon coming out (and then turtles). You just *know* you got trouble then....

> Are you saying if you see a "turtle" sign, you wait until the next
> contraction to attempt delivery? I'm very interested in this
> difference in approach to this problem.

I've had heads that have appeared to turtle, but then, as the baby wiggled and the contraction started, internal rotation happens as it should (w/ the anterior shoulder coming under the symphysis) and out it comes. Some other things I've noted about SD's (because we sit through the entirety of second stage, it's taught me several things). I would say that most of the hung up shoulders I've seen have been in babies that have rotated from OP to OA during second stage. I think that what happens is that, as the head rotates, the body doesn't completely follow, and may in fact both swing the shoulders into the AP diameter, and square them up, military fashion. If I have what I think is a reasonably large baby in an OP at the beginning of second stage, then my worry index elevates somewhat, and I get prepared. Also, w/ big babies, sometimes the posterior shoulder is trying to come first -- the symphysis seems to act as a pivot which cause it to emerge first. My first "maneuver", if you will, is to use *upward* traction to see if the posterior shoulder will release first, and it's surprising how often it does. I don't consider that to really be sticky shoulders, rather just a different mechanism of action. Lastly, I think we create a lot of "sticky" shoulders in the hospital situation (at least where I work) when women have epidurals and then get "jack-knifed" into position in the fancy damned birthing beds, w/ their legs in calf supports and their backs elevated. In that position, where else is there for the anterior shoulder to go but *behind* the symphysis. Call me a midwifery heretic, but if a woman is so blocked that she needs calf supports (I don't use them unless she really has no motor control, and I don't have human leg holders available), then I get her head much farther down. She'll usually push w/ much better effect, w/o getting the shoulders jammed up.

> WRT the definition issue, clearly there is no way to standardize what
> is a shoulder dystocia unless we all do deliveries the exact same way
> (which we surely don't!). My personal definition is that if I feel my
> heart rate rising, I call that a dystocia :)

It is a problem, isn't it? Not only do we have to deliver babies all the same way, but we have to get those *babies* to all behave in the same way, and not get up to any silly nonsense in there, like putting their arms behind their backs and so on. My feeling is just that you should always be prepared, and, yeah, tachycardia and diaphoresis are my usual indicators. Haven't passed any meconium yet... :-)

-- Kathi Wilson, RM Ilderton, Ontario, Canada mailto:wilsonk@gtn.on.ca ********************** Thames Valley Midwives 346 Platts Lane,

London, Ontario, Canada

http://tvm.on.ca mailto:info@tvm.on.ca

Women's Insurance Checklist from Auto Insurance Quote

use when must restrict search to only the ob-gyn-l forum...
Enter search keywords:
	Returns per screen: Require all keywords: