Shoulder Dystocia - Why do these things continue to surprise me? - Mothering Forums

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Old 12-10-2005, 10:58 PM - Thread Starter
 
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I found this in a report on shoulder dystocia written by an OB:

Quote:
All-fours maneuver

In 1976, Ina May Gaskin described a maneuver for the resolution of shoulder dystocia that involves placing the gravid mother on her hands and knees. (Bruner, 1998) used this procedure in 82 deliveries complicated by shoulder dystocia and was able to resolve it in 68 cases (82%) with this maneuver alone. The average time needed to move the mother into this position and to complete delivery was reported to be 2-3 minutes. Unfortunately, there was no detailed description of fetal and maternal outcome in this report. Also, reports about this procedure have generally been in the midwifery literature, involving a patient population less likely to have epidural anesthesia and thus more likely to be fully mobile.

It may be that the "all-fours maneuver" is merely another means of changing the angle of the symphysis in relation to the stuck shoulder, akin to McRoberts maneuver. Since the all-fours maneuver involves a gravid woman at the end of her pregnancy, exhausted by a long labor, often with an epidural in place, being moved quickly out of her delivery position onto all fours on her bed or on the floor, the practicality of this maneuver for a general obstetrical population is open to question. Unless more data is presented as to its efficacy and utility, it cannot be considered a standard procedure for the resolution of shoulder dystocia.
Why am I surprised? The guy goes on to list several protocols for managing shoulder dystocia...which maneuvers should be used first, second, etc. Every one of those protocols includes episiotomy and/or symphysiotomy. How on earth can any medical professional read something like the above, and not even begin to think that maybe, just maybe the epidural and "delivery position" are part of the freaking problem???

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Old 12-10-2005, 11:05 PM
 
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:eeek

OMG!


Gosh! Now I really really know why I will NOT go to hospital to have babies

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Old 12-10-2005, 11:09 PM - Thread Starter
 
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This guy really likes the McRoberts maneuver and suprapubic pressure...so if you have a problem with shoulder dystocia, you can have your legs "flexed" so that your thigh is pushing into your abdomen (under anesthetic...pulled hamstrings, anybody??) and/or someone's fist pushing into your pelvis to move your baby's shoulder. These two maneuvers combined have a "50-60%" success rate...yet they're preferable to suggesting that a woman get on her hands and knees, with a cited success rate of 82%????

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Old 12-11-2005, 01:43 AM
 
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That is crazy, but you have to remember that if most women who labor in a hospital do have an epidural, then the Gaskin manuever is going to be a challenge.

I just wrote about this in the midwife under investigation thread, but I know a lot about shoulder dystocia because I lost my 2nd baby to it. Its been 3 years and now I think about many other aspects of my son rather than what happened to him, yet I feel I have to chime in when its mentioned, because I read everything I can about it.

The Gaskin maneuver is not 100% successful though, it didn`t work for us and it was the first thing tried, at home. It does bother me though that hospital "emergency drills" for s.d. rarely include it.

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Old 12-11-2005, 01:46 AM
 
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Well, it's pretty obvious that a woman with an epidural is not going to be able to hold herself in the hands and knees position, but what about those that DON'T have an epidural? He writes it off completely like there are people that never have natural birth unless they are at the Farm in TN.

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Old 12-11-2005, 01:52 AM
 
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I had this manuver when I had my dd.....luckily my mw knew about it and I was exhausted after hours of back labor.....I didn't know anything was wrong bc my MW knew I would've flippped out big time so she just suggested we change postions....since the hands and knees thing just wasn't working for us.....It was my first baby so I didn't know that someone pushing on your stomach wasn't normal per se but she's here and she's beautiful.....

It wasn't super successful for us but it helped lessen the dystocia so it was minor...I didn't know anything was wrong until they layed her on me for mere seconds and cut her cord (birthplan of hour to do anything and let cord stop on it's own out the window) and NICU rushed in but I had her 20 mi nutes later...Her first agpar was 1 and her second went to 8 so......If my MW hadn't tried that I know we would've lost her and my heart goes out to you liseux bc you did lose your dear one.....the nurse on hand didn't know what she was doing until the MW yelled at her.....
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Old 12-11-2005, 02:10 AM
 
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really, the all fours is an upside down version of McRoberts. sadly, with most women receiving epidurals, it isn't logical to attempt to move a woman numb on a narrow bed.

what i'd like to see is them stopping the practice of cutting an episiotomy for SD - and forced pushing.
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Old 12-11-2005, 02:12 AM
 
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after my son was born the nurses were looking at me like i was a freak cuz we had no problems whatsoever with fit through the pelvis...the only problem i had was being on my back so it was difficult to push him out. he was 9lbs 10oz. I hope that if i DID have that problem i would be allowed to use the hands & knees position. sheesh. that makes me mad he just wrote it off because it would be *difficult* (notice he didnt say impossible...the mother would just need supported!) for a woman with an epidural to manage it..and i know for ME the epidural did nothing for my legs or vagina...it just numbed my back and stomach. I certainly felt when he snapped my tendon in the side of my vagina (ouch!)

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Old 12-11-2005, 02:13 AM
 
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Quote:
Originally Posted by CalebsMama05
after my son was born the nurses were looking at me like i was a freak cuz we had no problems whatsoever with fit through the pelvis...the only problem i had was being on my back so it was difficult to push him out. he was 9lbs 10oz. I hope that if i DID have that problem i would be allowed to use the hands & knees position. sheesh. that makes me mad he just wrote it off because it would be *difficult* (notice he didnt say impossible...the mother would just need supported!) for a woman with an epidural to manage it..and i know for ME the epidural did nothing for my legs or vagina...it just numbed my back and stomach. I certainly felt when he snapped my tendon in the side of my vagina (ouch!)
just reread that and i'm not sure now it was a tendon LoL maybe it was just popped out of where it was supposed to be? I don't have any lingering pain...I'll have to ask about that...

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Old 12-11-2005, 02:14 AM - Thread Starter
 
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I've never had an epidural, but I can certainly understand that it would make it much harder to get up on hands and knees. I also know the hands and knees position isn't 100% successful...almost everything I can find seems to suggest something around 80% or so. There are no guarantees in life...including birth.

What gets me is the whole tone...it's better to go straight to an episiotomy than even try the hands and knees. It's better to hand out epidurals like candy than make sure women know that the limits on their mobility also carry limits on the ability to address possible problems. The report listed three different protocols that have been suggested for how to deal with SD. I can't believe none of them suggested hands and knees at any stage. It's mind-boggling to me that episiotomies and symphisiotomy (sp?) are considered more acceptable than getting someone on their hands and knees!

liseux: Thanks for your input to my "vent". I'm so sorry for your loss.

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Old 12-11-2005, 02:19 AM
 
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Quote:
Originally Posted by Storm Bride
Why am I surprised? The guy goes on to list several protocols for managing shoulder dystocia...which maneuvers should be used first, second, etc. Every one of those protocols includes episiotomy and/or symphysiotomy. How on earth can any medical professional read something like the above, and not even begin to think that maybe, just maybe the epidural and "delivery position" are part of the freaking problem???
So, yeah. I amnever gonna go to a hospital to have a baby. I just looked up 'symphysiotomy' and was thoroughly grossed out that this is considered an option before changing position. I've heard women mention being 'cut open from front to back' and wondered what they meant. This guys's 'recommended' protoccols are *beyond* barbaric!
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Old 12-11-2005, 02:19 AM - Thread Starter
 
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Quote:
Originally Posted by pamamidwife
really, the all fours is an upside down version of McRoberts. sadly, with most women receiving epidurals, it isn't logical to attempt to move a woman numb on a narrow bed.

what i'd like to see is them stopping the practice of cutting an episiotomy for SD - and forced pushing.
I've had spinals...I hate the numbness so much. I've never experienced any amount of pain that would be preferable to losing communication with half of my body. The McRoberts doesn't seem (from what I've read) to have the same success rate as the "Gaskin". And, getting on hands and knees isn't likely to strain anything...I can easily imagine pulled hamstrings, or at least pain in the hamstrings, from the McRoberts.

One of the protocols listed "generous episiotomy" as the second option - right after the McRoberts. Nice to know how important an intact perineum is to our "care" providers. :Puke

I'm definitely going for a HBA3C, if I have another baby...

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Old 12-11-2005, 02:20 AM - Thread Starter
 
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Quote:
Originally Posted by tie-dyed
This guys's 'recommended' protoccols are *beyond* barbaric!
They're not his...one of them is ACOG's. I can't remember where the other two were from.

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Old 12-11-2005, 02:40 AM
 
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Quote:
Originally Posted by Storm Bride
It's better to hand out epidurals like candy than make sure women know that the limits on their mobility also carry limits on the ability to address possible problems.
not to mention the fact that it limits your birth positions, causes problems etc etc. I'm hoping and praying I won't need one this time around...last time I had to deliver flat on my back and ended up with an episiotomy.

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Old 12-11-2005, 06:20 AM
 
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Quote:
Originally Posted by Storm Bride
One of the protocols listed "generous episiotomy" as the second option - right after the McRoberts. Nice to know how important an intact perineum is to our "care" providers. :Puke .
'

I know! It's a BONE dystocia, not a TISSUE dystocia! C'mon!

Silly sOBs!
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Old 12-11-2005, 01:53 PM
 
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I have to add that it IS totally a bone issue and the bones sometimes don`t budge, but, when they talk about doing a huge episiotomy its often just to get at the baby`s clavicle so it can be broken. That`s whats tried when nothing else works & before they go for the Zavanelli mauver, emergency Csec after pushing head back in. That last one rarely works. Doing an epis at the first sign of s.d. is crazy.

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Old 12-11-2005, 02:10 PM
 
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I had shoulder dystocia when I was born (my mom had no drugs but was in the "typical" flat on her back postion). I couldn't move my arm away from my body for 6 weeks and still have limited movement. My doctor (another one) thinks my right shoulder (not shoulder - halfway between my shoulder and neck - is that my clavicle?) was once broken and never healed right. My shoulder is sloped and I was told my middle deltoids never developed. My mom says I was sent to get tests on my nerves but no one bothered to do an x-ray. I am grateful to be alive but a little annoyed that no one bothered to do an x-ray....

Oh, and when I was pg with dd1 the OB I was going to tried to talk me into an elective c-section because of my history (this was at 20 wks) and said stuff like, "it runs in families - do you want your baby to be paralyzed?). Needless to say, I stopped going there...

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Old 12-11-2005, 11:39 PM
 
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The only thing I can agree with is that epidural moms are pretty hard to get into all-fours position. McRoberts is effective and works great for epidural moms. Episiotomies don't do anything for shoulder dystocia since the shoulders are usually stuck behind the pubic bone. Symphisotomy (sp?) is "better" than episiotomoy for SD ((better in quotes because something like that isn't really better than anything) Gaskin Manuever is most effective and in a natural-birthing woman, more effective than McRoberts. So many care providers (read; doctors/OBs) see drugged moms though that they don't even know to do it, so McRoberts it is.

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Old 12-11-2005, 11:49 PM
 
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I am slow today, so tell me what are:

Quote:
...symphysiotomy...
Quote:
...McRoberts manuever....
?
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Old 12-11-2005, 11:59 PM
 
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Quote:
Originally Posted by Storm Bride
I found this in a report on shoulder dystocia written by an OB:
Does he go on to say how complacated and dangerous the other manovers are? SOme how I dought it. But he is quick to dis on the Gaskin manover.
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Old 12-12-2005, 12:33 AM - Thread Starter
 
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Miriam: McRobert's maneuver is when the doctor flexes the mom's legs up...so that her thigh is pressing against her abdomen. It looks hideously uncomfortable to me, and I have to think there's a definite risk of strain, as the mom having it done is often (usually) under an epidural. The OB who did up the report cited it as having a 50-60% success rate. Apparently, they'd rather cut women up and break the clavicles of babies than try the hands and knees approach, if McRoberts doesn't work.

symphisiotomy...I can't really describe it. I read a description, and I followed it fairly well, but I couldn't express it myself, Maybe try a google search. It's an unpleasant procedure.

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Old 12-12-2005, 12:47 AM
 
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Symphysisiotomy is not even taught in medical school anymore, it is a very old solution that kind of involves splitting apart tendons in your pubic symphysis area to make more room in your bones. It is super hard to do & most women who have had it done have trouble walking for the rest of their lives. Thats why it was so ludicrous that Abby on ER did one in a s.d. delivery last year. Its just not realistic to do it safely and quickly enough.

Thank you Storm Bride to you too.

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Old 12-12-2005, 01:00 AM
 
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Oh, for the love of....! :

Reason #35256 why I plan to have #4 at home -- not that I'm pregnant now, but it's the only way I'll deliver again. I had #3 at a birthing center, and it was nice but it still wasn't the same.
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Old 12-12-2005, 01:25 AM
 
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I found a support group for it, but I was unable to download it.

[DOC] The NWCI – who we are and what we do
File Format: Microsoft Word 2000 - View as HTML
Launch of Survivors of Symphisiotomy self help group May. Survivors of
Symphisiotomy (SOS) is a group of women who approached the NWCI for a meeting space ...
www.nwci.ie/documents/annrep03.doc - Similar pages

Thank you Storm Bride.

The symphisiotomy was done over a hundred years ago and it often left women crippled.
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Old 12-12-2005, 03:42 PM - Thread Starter
 
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I'd thought from things I read here that it wasn't used, anymore. But, it was definitely mentioned in one of the protocols this guy referenced. Maybe I'll try to find the year...

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Old 12-12-2005, 03:48 PM - Thread Starter
 
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Oh, blech...the report is copyrighted 2004, and this is what he says about sympisiotomy:

Quote:
Symphysiotomy is a procedure that had been performed in the past and is now performed only in areas remote from the ability to perform Cesarean sections on a rapid basis. However it has enjoyed something of a renaissance in the literature in recent years.
The italics are mine. I think I'm going to puke...again.

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Old 12-12-2005, 06:55 PM
 
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OMG... what a male jerk (the author of the article). Sorry, but I don't want an OB- particularly a male one! Then again, I saw a really bad female OB once too so it goes both ways I guess.

My friend JUST gave birth about six weeks ago and had SD. Hosp. birth no epidural. She was most comfortable laboring and pushing on her side but they kept rolling her onto her back and ended up holding her legs back while the doctor put his hand inside along baby's back to "help" him out and a nurse pushed the top of her uterus. There was some meconium so they wanted baby out asap. Her third baby- I'm sure the Gaskin would have worked for her. In the process, she ended up with a small tear and a small uretha tear and her tailbone was broken. Surprisingly the OB recommends a c/s next time.

I had never heard of symphysiotomy before. YIKES.
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Old 12-13-2005, 02:15 AM
 
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Enjoying a renaissance...indeed!!!!!

I learned what a sympisiotomy is when what's-her-face did one on ER last year. Ga-ross.

ER is sooooooooooooooooooooooo special. Mostly, I love how all sorts of OB cases are not sent up to the OB floor, but rather handled by the bafoons in the ER. Whatever. That show is sooooooo fakey. :
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Old 12-13-2005, 03:38 AM
 
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I've seen sObs and medwives discussing how breaking the baby's clavicle is no biggie. But then people who think cutting a perineum protects it from damage are likely to have all manner of weird ideas in their heads...
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Old 12-13-2005, 03:40 AM
 
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There is a lay midwife in my state that is known to do symphisotomy on women, in rare cases. She works in rural areas with women typical of very rural areas. She may not be in this state anymore, I'm not 100% sure, but I think she is. Don't ask her name, I don't remember. What I do remember is a doula coming from a birth with her absolutelyhorrified to watch her perform this...on a full concious, undrugged woman. And it's not the first time she's done it. I felt awful for everyone invloved,but especially the poor mother. One of the reasons it isn't done so much these days is because of access to c/s, but that's based on the assumption that most women arebirthing in a hospital where a stat c/s is a readily available option. I would much rather take my chances having someone break the baby's clavicle than have someone hacking at my pubic bone with a knife. And I think I'd rather have a c/s too... symphisitomies are nasty, painful, often crippling or disfiguring. I was just describing it to my husband a day or so ago and he was completely horrified.

Namaste, Tara
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