Cohort study of use of the hands-and knees-position as the first approach to resolving shoulder dystocia and preventing neonatal birth trauma

1 Introduction

The incidence of shoulder dystocia was reported to range from 0.15% to 0.38% in the 18th century¹ and has risen to 2.4% (234/9767) in 2014,^2–4 complicates 0.3%–3% of all vaginal deliveries in recent report,⁵ despite great effort on training and more liberally using of caesarean section. Brachial plexus injury is a significant sequela of shoulder dystocia, and the rates of Brachial plexus injury have not been reduced even with the liberal use of caesarean section.⁶

By the late 1990s, the McRoberts' maneuver (women placed with the thighs up and with the knees to the chest position while in the supine position), which was described as a simple and effective procedure for overcoming shoulder dystocia, had become widely known and adopted in many obstetric units as one of the first procedures to be used in cases of shoulder dystocia.⁷ But, despite the dramatic increased use of the McRoberts’ maneuver, the outcomes of shoulder dystocia did not change. Moreover, two studies from the West Midlands in the United Kingdom suggested that the rate of brachial plexus injury after shoulder dystocia had increased, from 1:77 in the early 1990s to 1:4 in 2003.⁸

Reported by Hoffman,⁹ the successful resolution of 46% of shoulder dystocia cases when using the McRoberts' maneuver as the first procedure was similar to the 40% and 42% success rates reported for other maneuvers. What was surprising, as reported in this study, was the lack of effect on the rate of brachial plexus injuries, with 19 of the 20 cases shoulder dystocia since 2001 managed with the McRoberts’ maneuver resulting in brachial plexus injury, compared with only eight of 13 cases before 2001.⁹

However, the recently professional consensus still recommended that McRoberts' maneuver, with or without a suprapubic pressure, is recommended in the first line (grade C). In case of failure, if the posterior shoulder is engaged, Wood's maneuver should be performed preferentially.¹⁰

Thus, new approaches should be considered in the management of shoulder dystocia.

Use of the hands-and-knees position to resolve shoulder dystocia was first described by the midwife Ina May Gaskin who learned of it from traditional midwives in Central America.¹¹ When using this method, which is also called the Gaskin maneuver, the laboring woman is positioned with all four limbs on the floor or bed so that her abdomen is suspended and her hips are at a right angle to the floor or bed. Use of the hands-and-knees position during delivery has been reported to result in a wider pelvic diameter as compared with the supine position and hence facilitate rotation of the baby and delivery.¹² The hands-and- knees position is assumed to have many benefits,¹³ and In a study 83% of shoulder dystocia cases were resolved using the Gaskin maneuver alone.¹⁴ However, two important elements, waiting for the shoulders to emerge after the head is delivered and using the Gaskin maneuver to resolve shoulder dystocia, have been largely absent from current clinical practice.^15–17 One possible reason for the absence of this maneuver is the adherence to the widely accepted shoulder dystocia management protocol, the “HELPERR” protocol, where the second “R” stands for the Gaskin maneuver. The placement of the Gaskin maneuver in this mnemonic may make the staff in clinical settings reluctant to apply this maneuver as a first step in resolving shoulder dystocia, even though the HELPERR protocol does not state which maneuver should be used first and “there is no one maneuver superior to another”.¹⁸

The hypothesis of this study is that by both waiting for the shoulder in all vaginal deliveries and using the Gaskin maneuver as the first approach in suspected cases of shoulder dystocia (defined as the “W-R” method) there will be a decreased rate of baby injury and fewer cases of shoulder dystocia.

2 Methods

3 Results

In control group, among 103 reported cases of shoulder dystocia there were 15 cases of baby injury, including 14 clavicular fractures,1 permanent brachial plexus injury. There were three temporary arm movement disorders that resolved within 7 days and those cases were not calculated as baby injury cases. In the experimental group there was one case of clavicular fracture, three cases of temporary arm movement disorder that resolved within 3 days, and no permanent brachial plexus injury. The rate of baby injury was higher in the control group [14.6% (15/103)] than in the experimental group [1.7% (1/58)], and this difference was statistically significant [   ​= ​6.834 ​P ​= ​0.009. OR ​= ​1.150 (1.055–1.254)]. There was no difference in maternal BMI or birth weight between the groups (Table 1).

Table 1

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Maternal and neonate outcomes in the two groups (±SD).

Multiple logistic regression showed that using the McRoberts' maneuver as the first approach in cases of shoulder dystocia [OR ​= ​19.609 (1.620–273.430)], mother's employment status [OR ​= ​1.909 (1.118–3.262)], and intravenous dripping of oxytocin [OR ​= ​5.969 (1.391–25.605)] are risk factors for baby injury (Table 2).

4 Discussion

Use of the Gaskin maneuver (hands-and-knees position) as the first approach for reducing the rate of baby injury.

The Gaskin maneuver was first reported by Ina May Gaskin in 1966. This maneuver is implemented by moving the patient to her hands and knees in cases of suspected shoulder dystocia; it is not the knee-chest position in the supine position. Brunauer et al.¹⁴ reported that out of 82 patients with shoulder dystocia who were managed with this technique 68 (83%) delivered without the need for any additional maneuvers. The authors concluded that the maneuver seems to be a rapid, safe, and effective technique for reducing shoulder dystocia in laboring woman.

Why the Gaskin maneuver works is unknown; the mere act of turning a woman from the supine to the hands-and-knees position may provide sufficient movement to displace the fetus. Borell and Fernstrom have proposed that when laboring patients are moved from the supine position during delivery to the all-fours position, there is an increase in the true obstetric conjugate by as much as 10 ​mm and an increase of up to 20 ​mm in the sagittal diameter of the pelvic outlet.¹⁹

This procedure has recently been included in the curriculum for the American Academy of Family Physicians’ course “Advanced Life Support in Obstetrics” as the additional “R” in the HELPERR mnemonics.²⁰

The all-fours maneuver takes advantage of the laxity of the sacroiliac joint at term, which may result in an increase of 1–2 ​cm in the sagittal diameter of the pelvic outlet. The dorsal lithotomy position restricts this posterior movement of the sacrum. The all-fours maneuver eases the delivery of the posterior fetal shoulder.²¹ All maneuvers should aim to disimpact the shoulder without resulting in excessive impaction of the fetal head. Jevitt⁶ also described the management of shoulder dystocia with maternal position changes (left lateral and Gaskin maneuver), which are often omitted from management protocols but which have been demonstrated to be effective in decreasing the incidence of and/or alleviating shoulder dystocia.

One previous study suggested that managing shoulder dystocia with the primary maneuvers McRoberts’ and suprapubic pressure resulted in the lowest percentage of neonates with an injury (6.1%–14.0%). The Gaskin maneuver was performed 22 times in this stusy, with one neonatal injury, this rate of baby injury 4.5% (1/22) is lower than observed when the McRoberts’ maneuver and suprapubic pressure were applied, but unfortunately the author did not include the Gaskin maneuver in the final analysis.²²

In this study in the control group in which the McRoberts' maneuver was applied as the first approach in resolving shoulder dystocia, the rate of baby injury was 14.6% (15/103), which was similar to the rate of baby injury rate mentioned above. In the experimental group, the rate of baby injury was lower than that in control group [1.7% (1/58)], and this difference was statistically significant [ χ² ​= ​6.834, P ​= ​0.009; OR ​= ​1.150 (1.055–1.254)]. Multiple logistic regression analysis has revealed that using the McRoberts’ maneuver as the first approach in cases of shoulder is risk factors to baby injury [OR ​= ​19.609 (1.620–273.430].

The rate of baby injury in this study is similar to that of the control group and higher than that in the experimental group in our study. The findings of the current study, in which the widely used primary maneuvers McRoberts’ and Gaskin were compared, support the hypothesis that the Gaskin maneuver performed as the first approach has the potential to reduce baby injury.

5 Conclusions

Use of the Gaskin maneuver (turning women from the supine position to the hands-and-knees position) as the first approach in cases of suspected shoulder dystocia reduced the rate of baby injury without increasing neonate asphyxia. The application of the Gaskin maneuver in the management of shoulder dystocia should be seriously considered for better neonatal outcomes.

Declaration of competing interest

We declare that there is no conflict of interest.