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

Background:McRoberts'maneuver,turning the woman's thighs up in the supine position,has become the dominant method for resolving shoulder dystocia(defined as failure to deliver the fetal shoulder(s)with gentle downward traction on the fetal head,requiring additional obstetric maneuvers to effect delivery).Another method that is less commonly used is the Gaskin maneuver,which was first described by the midwife Ina May Gaskin,who learned of it from traditional midwives in Central America,and involves turning women to the hands-and-knees position.One retrospective observational study reported an 84%higher resolution of shoulder dystocia and less injury to the baby with the use of the hands-and-knees position as the first approach to resolving shoulder dystocia.The hands-and-knees position was reported to result in a wider pelvic diameter than the supine position and hence facilitate rotation of the baby and delivery,so it is possibly to resolving shoulder dystocia.The purpose of this study is to explore whether applying the Gaskin maneuver as the first approach for resolving cases of shoulder dystocia is a safer and better method than applying the McRoberts'maneuver first.Methods:A time series cohort study was conducted in Laiwu Maternal and Child Health Hospital in Shandong,China over a seven-year period.Between January 2011 and July 2013 all women receiving traditional support at delivery were enrolled as a control group.During this time period,when shoulder dystocia was suspected,McRoberts’maneuver(MR)was the most commonly employed first maneuver as described in the HELPERR mnemonics.Between October 2013 and December 2017,a change of practice was implemented for all vaginal births at the site,whereby midwives were instructed to use the Gaskin maneuver(i.e.,moving the mother onto hands-and-knees position)as the first protocol if shoulder dystocia was suspected.Patients in this group were assigned to the experimental group.The neonatal outcomes including birth asphyxia and baby injury in both groups were recorded and analyzed.Results:The injuries in the control group included 14 clavicular fractures,and one permanent brachial plexus injury,three temporary arm movement disorders that resolved within 7 days and those cases were not calculated as baby injury cases(the same in experimental group).In the experimental group,58 cases of shoulder dystocia were reported,with one case of clavicular fracture,three temporary arm movement disorders that resolved within 3 days,and no permanent brachial plexus injuries.The rate of baby injury in the control group[14.6%(15/103)]was higher than that in the experimental group[1.7%(1/58)],and this difference was statistically significant[χ^(2)=6.834,P=0.009;OR=1.150(1.055–1.254)].Multiple logistic regression analysis showed that using the McRoberts'maneuver as the first approach in cases of shoulder dystocia[OR=19.609(1.620–273.430)],the 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.There was no difference in neonate Apgar score between the two groups,and no baby died in either group.