I wish to add a postscript to the excellent article “Delivery dilemmas: shoulder dystocia,” by Drs. Gimovsky and Michael [December]. For many decades, traditional rescue techniques for this unforeseeable emergency changed little—until the Zavenelli maneuver (vertex replacement followed by emergency cesarean section) came along several years ago. Perhaps others had attempted this process but never reported it. I have an alternative maneuver to suggest.
Returning to my hometown in northeastern Pennsylvania from an academic residency at the University of Pennsylvania in 1978, I had to adjust my obstetrical techniques and adopt new skills to practice in one of the nation’s pioneer hospitals for family-centered obstetrics: Nesbitt Memorial Hospital.
Among these many adjustments was performing a bed delivery on an old-fashioned flat stretcher. In this delivery environment, shoulder dystocia typically is handled with McRobert’s maneuver (flexion of the mother’s legs upward toward her abdomen), gentle and continuous downward traction on the baby’s head, a generous mediolateral episiotomy, and suprapubic pressure. On a stretcher-bed, few of the other maneuvers are applicable.
Inspiration from desperation: If you cannot rotate the baby, rotate the mother instead. Thus, with continuous, gentle downward traction on the baby’s head, rotate the mother completely onto her side, away from the baby’s face. If the shoulder does not slide easily out from under the symphysis pubis, rotate the mother a full 180° in the opposite direction, to her other side. With continued gentle downward traction, the impacted shoulder should deliver at some point in this rotational process.
This straightforward technique is simple to learn and execute, especially on today’s modern birthing beds.
—LOUIS FREEDMAN, MD
Dr. Gimovsky responds:
I enjoyed Dr. Freedman’s commentary on this challenging delivery environment. When circumstances dictate delivery on a stretcher-bed, consider Sims position (lateral position of the mother). Though not commonly taught nowadays, Sims position is a lifesaver under certain circumstances.