McRoberts v. Gaskin

This is so very, very interesting!

A month or two ago, I posted an article in which I decried the neglect of the Gaskin maneuver in obstetrical texts covering treatment of shoulder dystocia. Specifically, I said:

"I have always found shoulder dystocia (a birth emergency in which the baby's anterior shoulder is impacted behind the maternal pubic bone, and which can cause injury to the baby if mishandled or death if is not resolved quickly) a fascinating subject. Why? Well, (1) it's equally an emergency at home or in hospital (because it's too late for a cesarean), and (2) it's an emergency in which natural childbirth - and thus a mobile mother - is a HUGE bonus, and (3) the best resolution is usually through the Gaskin Manoever, which was named after midwife Ina May Gaskin, who brought the procedure to the United States.

"I have also found the subject of shoulder dystocia rather amusing, because obstetric textbooks often ignore the Gaskin Manoever (which is basically hands-and-knees for the mother) in favor of more severe - and gruesome! - procedures, such as the symphysiotomy (cutting the pelvis open by cutting through the connective tissue of the pelvic bone - OUCH!) or the Zavanelli Manoever (shoving the baby back up the vaginal canal and doing a cesarean - very bad results due to trauma to the baby and time from emergency to birth). Turning a mama over on her hands and knees is much more pleasant - and effective!"

So, to review:

- Shoulder dystocia is the impaction of the anterior fetal shoulder behind the maternal pubic bone, i.e. baby is stuck. It is an extremely dangerous situation; I have heard it referred to as "every obstetrician's nightmare," and the same holds true for midwives. Why is it dangerous? Because (1) if left unresolved, it is fatal to the baby, and (2) if mismanaged (i.e. by grabbing the baby and pulling), it can result in severe injury to the baby.

The two major methods of resolution that I hear mentioned are:

- McRoberts - Mama is flat on her back, legs hyperflexed to her chest, which widens the pelvis and gets the lower spine out of baby's way. It's usually combined with suprapubic pressure, which is when an assistant (usually a student midwife or nurse) presses down firmly just over mama's pubic bone in an effort to dislodge the fetal shoulder. This is the method used almost 100% of the time on medicated mothers, since it does not require movement on the mother's part.

- Gaskin Maneuver - Flipping a mother on all fours, which also widens the pelvis and gets the lower backbone out of the way. Because mothers who can do Gaskin are almost always, by necessity, unmedicated, these mothers have the advantage of mobility, which in itself can help to shift a stuck or "sticky shoulders" baby. Gaskin cannot be combined with suprapubic pressure, as far as I know, but it can be combined with the screw maneuver (splinting fingers against the baby's shoulder and turning the baby to get the shoulder out of the way of the pubic bone).

Other, less common ways of resolving shoulder dysocia include the previously mentioned Zavanelli, the symphysiotomy, and clavicular fracture (breaking baby's collarbone to compress the fetal shoulder girdle width).

Now, on to new things. A day or two ago, I received a comment on the above-mentioned post from Dr. Nicholas Fogelson, also known as The Academic OB/GYN, famous in natural birth circles for (among other things) his published work on the benefits of delayed umbilical cord clamping. Dr. Fogelson writes:

"OB textbooks don't ignore the Gaskin maneuver, they just call it by the Obstetrician that described it before Gaskin was born - McRoberts.

"McRoberts and Gaskin are anatomically the same thing, except that in McRoberts the pt is supine and in Gaskin the patient is prone. The hips and pelvis are doing the same thing in both positions."

This was very interesting! I had never heard this before. After thinking about it, I recognized the gist of what he was saying, but still couldn't completely agree. So I wrote:

I see your point about the equivalency of Gaskin and McRoberts; however, at least from a hearsay point of view, I have heard substantially better results coming from Gaskin than McRoberts. Perhaps this is because Gaskin mums are, by necessity, unmedicated and are able to maintain better mobility to aid dislodging of the fetal shoulder? Or from coccyx mobility? Or just the widening of the pelvis from an upright position? The last estimate I heard said that a prone (error: I meant "supine") position decreased the pelvic diameter by 30% (though I may be abusing terms here, or statistics). Perhaps some commenters on this article who are more up on things like this can comment. I, alas, am not an expert in any sense (though I hope to be some day). Can you comment on this, Dr. F, or do you see equal results between Gaskin and McRoberts in your practice?

My blogging friend Kathy wrote:

"Dr. F., my understanding of the Gaskin maneuver, is not specifically the mother's positioning of her legs in doing it, but the moving of her body itself. The Gaskin maneuver is described as turning a mother over -- if she's on her back, to turn her to hands-and-knees (which has never in my mind seemed to indicate "turning her on her hands and knees, and then positioning her in a crouch so that her knees are pointed towards her ears"; nor does the description of McRobert's Position sound similar in any way to the description of the Gaskin maneuver), but also that if the mother is already in hands-and-knees, to turn her over on her back. Ina May has said that it is the large movement of the mother's body that helps to loosen the baby's shoulders, rather than the specific "end position" of mom being on her hands and knees.

"While McRoberts may allow for the same type of pelvic widening that occurs in the Gaskin maneuver, and would seem to be much easier to perform on a woman with an epidural, I don't see much if any similarity. And speaking as someone who has given birth without drugs, I'd much rather try the Gaskin maneuver first, than McRobert's position, which I can only describe as appearing to be extremely uncomfortable."

One side note: Wikipedia lists the following "shoulder dystocia protocol":

"A common treatment mnemonic is ALARMER

• Ask for help. This involves requesting the help of an obstetrician, anesthesia and pediatrics for subsequent resuscitation of the infant.
• Leg hyperflexion (McRoberts' maneuver)
• Anterior shoulder disimpaction (suprapubic pressure)
• Rubin maneuver
• Mannual delivery of posterior arm
• Episiotomy
• Roll over on all fours (i.e. Gaskin, note mine)

It then says: "The advantage of proceeding in the order of ALARMER is that it goes from least to most invasive, thereby reducing harm to the mother in the event that the infant delivers with one of the earlier maneuvers. Although this is questionable since, since the Gaskin Maneuver, or "roll over on all fours", is considered by some the most effective and least invasive maneuver, but it is rarely used in the medical setting." (emphasis mine)

Anyhow, I wanted to know more, so I posted the question "Is McRoberts the same as Gaskin???" on a local midwives' forum. Here are some answers:

From a midwife:

"I think that what the OB might be trying to get at is that both maneuvers are attempting to do the same thing. Open the pelvis and getting the spine out of the way to allow for the baby to pass. McRoberts is done with the mom flat on her back and Gaskin is done with mom on all fours. I believe that you do one or the other first depending on what position mom is in when the dystocia is noted.. With McRoberts you can also apply suprapubic pressure and sometimes that is needed to release the shoulder.

"I have used both maneuvers in different situations and thank goodness they were successful."

And another:

"Well there are similar elements, because McRoberts lifts the coxyx off the table. What is different is it is more like a laying down squat, knees by chest wall. Gaskin manuver does not rotate the hips as far. One of the key differences has to do with gravity, when you shift a mom into hands and knees the baby's whole mass moves. So you not only get the coxyx off the bed and free up space, the baby body falls toward the side of the uterus, this shift alone may help to shift the shoulder off the symphysis and helps the baby rotate. If the movement alone doens't shift the shoulders you can still grasp the shoulder from the top and try and assist a shift to the oblique"

Several commented on something noted above, that part of the usefulness of the Gaskin maneuver lies in the fact that mums who use it are mobile, and mobility (shifting, turning, walking, standing, etc.) are vitally useful in unsticking stuck babies:

From one midwife:

"Also, sometimes just the action of having Mom move gets the baby unstuck. I've had a couple dystocias come "unstuck" as Mom lifts her leg to get out of the birth pool."

And from a student midwife:

"I just have to share a really cool story... One of my best friends had her 7th baby, first homebirth .... about 6 years ago. I was lucky to be her friend/doula at the time. The midwife was stuck in traffic and so I was there with her and her husband as she was giving birth very rapidly. She was on her hands and knees and pushed and the baby's head popped out along with the water breaking. I was there and held the baby's head. I counted a few minutes and noticed that it was taking awhile and I turned to the Dad and told him he'd better be planning on catching because I sure wasn't so he came over to catch. A few minutes later, my friend just lifted up her right leg into the air. For no reason at all, she just lifted it up. and as she did that the baby's shoulder came out and baby rotated all the way out into Dad's hands. He was about 9 1/2 lbs. My friend didn't realize she had even done that and I was beyond floored with how instinctual my friend was! It was one of the first births I attended at home that wasn't my own and I was just in awe of my friend and the power of birth... if her baby had a dystocia, we dno't know. She just said she felt like lifting up her leg and so she did!"

From the above input, I would conclude the following:

(1) That though not identical, McRoberts and Gaskin do have similarities.
(2) Both McRoberts and Gaskin are vital tools to have in the mental tool kit of an OB or midwife.
(3) Having a mother unmediated and mobile is a definite plus when needing to rapidly resolve a case of shoulder dystocia.

I have a friend whose baby was so "stuck" that they ended up with not only shoulder dystocia, but what they afterwards called "tummy dystocia," LOL! They ended up using both McRoberts and Gaskin to get that little one out, and were thankful for both.

Any discussion, input, comments - always welcome! But all conversation must, as always, be civil, courteous, and kind, regardless of feelings.

Oh, and I wanted to make an apology - publicly. Sometimes, in reading over past entries of this blog, like the one Dr. Fogelson commented on, I am appalled at my tone - my attitude, despite my best efforts, can come across as combatant and sometimes arrogant. That is NOT the intention of this blog.

In America, we are waaayyyy too divided. It's a case of "pick sides, then pick up your weapon!" My vision for the birth community is not "Midwives win!" but a community in which there is mutual value and respect, where OBs and midwives can freely collaborate together with mutual respect, and where women will receive respected care in either home or hospital setting. I write a homebirth blog because I am passionate about the promotion and legalizing of homebirth, but not because I want to put down OBs or hospital birth. Indeed, I wish that there was more conversation between the obstetrical and midwifery communities, rather than the armed conflict that is so prevalent. Additionally, I have great respect for obstetricians and for their large body of knowledge, and I appreciate their input and their corrections.

So, with all that, an apology, with my promise to do my best to maintain mutual respect on this blog.

And now, comment time!

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Later note: You'll see from the notes that Kathy left this video link - check it out! Good stuff!

Shoulder Dystocia Workshop