http://midwiferytoday.com/enews/enews0416.asp#main 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. - The Farm ----- Original Message ----- From: <[EMAIL PROTECTED]> To: <[email protected]> Sent: Saturday, June 25, 2005 10:11 AM Subject: Re: [ozmidwifery] broken collar bone & subsequent birth > hi can some one enlighten me about the gaskin manovure i have been taught the rubiks and the woods screw but havnt heard of the gaskin manovure. > thanks sharon > > > > ---- Janet Fraser <[EMAIL PROTECTED]> wrote: > > Can I ask, is the bone breaking manoeuvre being employed AFTER the Gaskin Manoeuvre has been unsuccessful? > > Thanks. > > J > > ----- Original Message ----- > > From: Mary Murphy > > To: [email protected] > > Sent: Saturday, June 25, 2005 3:52 AM > > Subject: RE: [ozmidwifery] broken collar bone & subsequent birth > > > > > > Jennifer wrote: A # clavicle is not a big issue in a > > > > neonate and doesn't necessarily mean excessive force was used. The neonates > > > > bones are pliable and the # is usually a 'greenstick' or partial break or > > > > > > > > Well, I have NEVER seen a #clavicle in 26 yrs of both hospital & home midwifery, even in big babies where some force has been used. MM > > -- > This mailing list is sponsored by ACE Graphics. > Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe. > -- This mailing list is sponsored by ACE Graphics. Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe.
