> > > 4) Shoulder Dystocia > > The explanation for the success of the all-fours [Gaskin] maneuver > probably lies in movement at the sacroiliac joints at term, which can > result in a l-cm to 2-cm increase in the sagittal diameter of the > pelvic outlet. The lithotomy position restricts posterior movement of > the sacrum, while placing the mother on her hands and knees with > weight evenly distributed over all four extremities allows rotational > movement around a transverse axis through the sacroiliac joints. > Additional benefit is probably obtained from the movement involved in > the actual change of position, which may help disimpact the shoulders, > and the addition of gravity to the forces tending to push the > posterior shoulder anteriorly, allowing it to slide over the sacral > promontory. This would make it particularly useful in severe bilateral > shoulder impactions. > > Critics of the all-fours position will claim such a change in position > is time-consuming and difficult to accomplish, precluding the use of > other maneuvers. In the unlikely event that this maneuver is not > successful, several other suggested maneuvers can be performed in this > position, including attempting to rotate either shoulder toward the > fetal back or chest, and attempting to deliver the posterior arm. > Although delivery of the posterior arm in the lithotomy position has > been reported to be difficult in some cases because of inability to > insert a hand into the vagina, the all-fours position offers the > potential for increased space between the shoulder and the vaginal > wall because of the mobility of the sacrum and the fact that the > weight of the maternal abdomen and fetus are not resting directly on > the posterior arm. Though fundal pressure and suprapubic pressure > would be difficult if not impossible in this position, they are not > likely to be necessary or useful in attempts to deliver the posterior > shoulder. Deliberate fracture of the clavicle would be no more > difficult in this position, and as a last resort even the Zavanelli > maneuver can be performed in this position. > > It takes as little as 30 seconds to get a patient to her hands and > knees even in the event of an unexpected shoulder dystocia. > *Encourage the mother to assume the all-fours position at intervals > during labor. It is a very comfortable position, especially when the > baby is occiput posterior, and it is useful for facilitating rotation > and descent. Admittedly, not all mothers will be comfortable in this > position, or it may be one of many different positions assumed by the > patient during the course of her labor, but it will help if she > becomes familiar with this position in advance of the birth. Advise > her that it may become necessary to assume this position again for > delivery of the shoulders. > *Avoid intravenous lines. A heparin lock can provide emergency venous > access without the restrictions of dangling IV lines. > *For the same reason, avoid continuous electronic fetal monitoring > equipment, or remove the belts as the vertex is delivered. > *Along the same lines, avoid stirrups and extensive sterile drapes, > and for obvious reasons, avoid epidural anesthesia. > *Have at least two assistants present at the birth. Labor coaches can > help facilitate rapid changes in position if necessary. > *Deliver the baby in a bed, not on a narrow delivery table. Consider > using the lateral decubitus position, or better yet, complete the > entire delivery in the all-fours position in those patients at high > risk for a shoulder dystocia. > Source: http://www.thefarm.org/lifestyle/dystocia.html > ==== > > Differentiating "sticky shoulders" from true shoulder dystocia isn't > easy, but I define true shoulder dystocia as one that takes multiple > maneuvers to release, results in a depressed baby, and leaves the > midwife with sore arms, wrists and fingers... > > McRoberts doesn't always work. Standing doesn't always work. > Suprapublic pressure doesn't always work. Trying to deliver the > posterior arm doesn't always work. Breaking the baby's clavicle isn't > always possible. Even cutting a big episiotomy, a favorite technique > of the medical profession, probably won't do a thing to help release > most babies. > > The key to delivering a baby with shoulder dystocia is to keep one's > mind clear enough from panic and fear so that you can direct the woman > into various positions, try multiple techniques, and never quit until > the baby comes out. If you don't know the techniques, you must learn > them and review them often. A severe shoulder dystocia may not happen > until a practitioner has delivered hundreds of babies. You can never > get cocky and think you have the right technique or position to > prevent shoulders from getting stuck. Sticky shoulders aren't all that > uncommon -- they'll come with just a trick or two. Real shoulder > dystocia is different and deadly, and every midwife who delivers > enough babies will have this experience some day. I know of midwives > who stopped practicing after experiencing true shoulder dystocia. The > fear and sense of helplessness became unshakable and polluted their > ability to see birth as a normal process. The accountability became > too much to cope with. > > I cope with the aftermath by trying to keep my boundaries clear. I > didn't cause it to happen -- I just happened to be the one there who > had to deal with it. I do the best I can at any moment, which is all > any of us can do. I know the various techniques and I use them all > until the baby comes, and then I make sure I know how to resuscitate > the baby. It's the birth that woman got; it's the birth that I got. > Bad things happen sometimes and we have to live with them and move on, > knowing that we do not have supernatural powers, that we're only human > with limited ability to control life and death. > -Gretchn Brauer-Rieke, CNM, Midwifery Today Issue 55 > ==== > > TO ORDER MIDWIFERY TODAY ISSUE 55 (theme: second stage): > http://www.midwiferytoday.com/products/MT55.htm > o=o=o=o=o=o > > > 5) Check It Out! > > ~~~WWW.MIDWIFERYTODAY.COM~~~ > A Web Site Update for E-News Readers > ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ > > CONFERENCE AUDIOTAPES FOR THIS WEEK'S THEME > > Shoulder Dystocia > http://www.midwiferytoday.com/products/001T1030.htm > Second Stage Difficulties Roundtables > http://www.midwiferytoday.com/products/972T702.htm > Surviving Shoulder Dystocia > http://www.midwiferytoday.com/products/972T669.htm > AND MANY, MANY MORE! > ~~~~ > > SHOULDER DYSTOCIA HANDBOOK > Are you prepared for shoulder dystocia? > > Order the SHOULDER DYSTOCIA HANDBOOK and learn about shoulder dystocia > management and techniques. You'll find birth stories, tricks of the > trade and accounts of shoulder dystocia moments that will give you > confidence to deal with this complication. > > For more information, click here: > http://www.midwiferytoday.com/books/shoulderdystocia.asp > To order the SHOULDER DYSTOCIA HANDBOOK, click here: > http://www.midwiferytoday.com/products/C514SD.htm > ~~~~ >
> 8) Question of the Week Responses > > Q: Does anyone have information about or experience with successful > VBACs with an extended uterine scar (8 in. vs. 4 in.)? A woman is > interested in homebirth who was attempting an unassisted homebirth > with her last baby. Upon SROM she found a foot presenting. She and her > husband went to the hospital and the doctor on call did a c-section > but had to extend the incision to get the baby out. He assured and > reassured her that she had a perfectly good chance of delivering > vaginally next time, given she has a care provider. > -Anon. > > A: I would want to know if a single or double closure was used to sew > up the uterus. Check the medical record. If it was a single -- well, > think twice. > -Sally Ann Miller, BSN, RNC, IBCLC > St. Louis Park, MN > ==== > > A: The risk assessed to VBACs because of previous surgery and scarring > has always interested me. In April 1991, during my 7th month of my > first pregnancy, I had an intestinal blockage. Exploratory surgery was > performed. From what I understand, my uterus was removed (or moved far > to the side) to allow for the blockage to be found and the repair > done. I was stitched and taped and left the hospital 3 days later with > an incision about 5-6 inches long. Because of IV fluids and hydration > my abdomen was 2 times larger than when I entered the hospital. At no > point was the incision or scar tissue mentioned following the surgery > or during labor. I went on to have an unmedicated vaginal birth of a 7 > lb 14 oz baby girl. I have to wonder, although a c-section includes > the uterus in the incision, how can a previous c-section years before > be any more of a risk than major abdominal surgery 2 months before > birth? > > On that note, a woman I know has had 7 c-sections and plans to have > 1-2 more children. How is carrying so many babies and having so many > c-sections approved of by a doctor? The reasoning just doesn't seem to > make any sense in our current medical policies. > -Chantel Haynes, pregnancy & birth assistant > o=o=o=o=o=o > > > 9) Switchboard > > International Connections > > I am a student midwife in South Australia. We are now unable to > qualify as a registered midwife due to lack of insurance coverage. Two > universities train midwives (direct entry training has started this > year). However, now no company will insure student midwives to attend > the required number of births to be able to register. One university > has no insurance and the other does not have insurance coverage after > June 2002. Independent midwives also are having huge problems with > professional indemnity insurance as well, and a large number are no > longer practicing because of it. > At a time when midwives are finally being trained to be respectful and > maintain a woman's rights throughout her pregnancy/birth and postnatal > period, it has all come to a grinding halt. Something must be done -- > why will it stop at midwifery students? This will surely affect > general nursing, medical students, etc. and therefore all areas of > peoples' lives. > -Wendy Scott > ~*~*~*~*~*~ > > It is noteworthy to add that permanent immunity to hepatitis B is not > absolute after receiving the standard series of three injections. It > is appropriate to have a follow-up blood test to check for the post > vaccination titer level. The older the recipient is, the more likely > the titer is not high enough, leading to the need for another > injection. Titer levels may also diminish with time. Makers of the > vaccine have literature available. > -L.B. > ==== > > The APGAR score [Issue 4:15] is calculated from five fundamental > physical signs: the infant's heart rate, respiratory effort, muscular > tone, reflex irritability and peripheral perfusion. Any birth > attendant who did not make these, and more, routine observations of > the neonate would be incompetent. If any or all of these assessments > were abnormal then you would use your clinical judgment to determine > appropriate management, from outright need to resuscitate to simply > continuing observation. For Marsden Wagner to suggest that we should > rethink the assessment of these physical signs because they do not > predict the later neurological development of the child is as flawed > as to suggest that we should stop taking temperatures because no study > has ever proven that it predicts the future occurrence of infectious > disease. > It is manipulative of BirthPsychology.com to suggest that the birth > attendant's assessment of these physical signs are part of some social > conspiracy to undermine a mother's confidence in her ability as a > parent. Until recently, the APGAR was used in quite the reverse: to > prove the incompetence of the birth attendant, and sue. > -Anon. > ==== > > I'm 39 years old and had my first child 11 months ago. For the past 3 > months I have had abdominal (ovaries area) pain and mood swings for > 1-2 wks at the end of each menstrual cycle. I am nursing, which may > account for some of my tiredness. I have had an ultrasound and it is > not cysts on my ovaries. Small fibroids were identified around the > ovaries. About 1997 I had a good-sized fibroid and endometriosis > removed from outside my uterus. I spent several years in various > infertility treatments and this baby was conceived with IVF. I have > changed my diet to organic. I tried (one week) dong qui, which seemed > to make my milk dry up. Suggestions? > -Anon. > ==== > > I am an obstetrician/gynecologist seeking info on collaborative > practice/midwifery. Our goal is to work on establishing this in our > area. However, upon reading the article by Dr. Wagner [What Every > Midwife Should Know About ACOG and VBAC, available online at > http://www.midwiferytoday.com/articles/default.asp?t=acog] I am > appalled at the tone of the content. It is very antagonistic and > inflammatory. As a physician who is actively seeking info I feel > turned off by the message given by your publication. There has to be a > moderating influence in your editorial board. How can you expect to > breech the divide between the disciplines if you publish extremist > material? To imply that rising maternal death rates are due to rising > c-sections and epidural rates undermines your credibility. It makes > you seem as dogmatic as old-style MDs who say you must have an > episiotomy WITHOUT any evidence to support the claim. I will look > elsewhere for a source that is supportive of a true collaborative and > truly progressive style of medicine. > -Parke Hedges, MD > San Antonio, TX > > Marsden Wagner responds: > This obstetrician has labeled me antagonistic and an extremist -- > another example of shooting the messenger if you don't like the > message. I fear that obstetricians have been in a position of power > for so long that some are unable to take criticism -- a dangerous > attitude to say the least. > My credibility is challenged because I suggest that the rising > maternal mortality rate in the US the past 15 years (a fact) may be > related to the rising rates of c-section and epidural. In fact, good > data in the literature shows c-section has a rate of maternal > mortality 6 times higher than vaginal birth. Even if you eliminate > emergency c-section and consider only elective c-sections, the > maternal mortality rate is just under 3 times higher than vaginal > birth (Hall M, Lancet, 354, 776, 1999). > Good scientific data in the literature reveals that the maternal > mortality rate is higher if epidural block is used for the pain of > normal labor -- ask any anesthesiologist. > Since the rate of c-section and the rate of epidural block for normal > labor pain both have been shown to be increasing in the US, it is not > extremist but logical to suggest the rising maternal mortality is > likely related to the increasing rates of c-section and epidural > block. > The tone in the message from this obstetrician is a familiar one -- it > represents what I call "tribal loyalty." Since I am a member of the > tribe -- a medical doctor -- I must never say anything that might be > considered critical of the practice of other doctors. But tribal > loyalty is a self-defeating strategy because it eliminates the > possibility for doctors to admit they make mistakes and therefore > improve their practice. An example: Between 1990 and 1999 many women > having VBAC in the US were given Cytotec induction. Finally in 1999 > published papers proved that Cytotec induction with VBAC markedly > increases the risk of uterine rupture, and ACOG finally said don't do > it. So we now know that during these years many women had uterine > rupture because obstetricians were making a mistake. But I have never > heard a single obstetrician admit to making this mistake, much less > express remorse. > Obstetricians and midwives will collaborate well together only when > there is mutual respect in an egalitarian professional relationship. > -Marsden Wagner MD, MSPH > o=o=o=o=o=o=o > > EDITOR'S NOTE: Only letters sent to the E-News official e-mail > address, [EMAIL PROTECTED], will be considered for > inclusion. Letters sent to ANY OTHER e-mail addresses will not be > considered. > o=o=o=o=o=o > > > 10) Classified > > Hands of Light -- Summer Intensives on the Southern Maine Seacoast: > Postpartum Doula June 12-15, Do I Want to Be A Midwife? June 17-21 and > Advanced Medical Skills Training June 24-28 -- Elizabeth Mazanec > 978-343-7384, www.holcenter.com > o=o=o=o=o=o > > Midwifery Today E-News is published electronically every Wednesday. We > invite your questions, comments and submissions. We'd love to hear > from you! Write to us at: [EMAIL PROTECTED] Please send > submissions in the body of your message and not as attachments. > > This publication is presented by Midwifery Today, Inc. for the sole > purpose of disseminating general health information for public > benefit. 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