After years of recommending a large episiotomy for management of shoulder dystocia, the American Journal of Obstetrics and Gynecology (AJOG) has published a study that found episiotomy had no benefit in reducing brachial plexus injuries of the infant. Shoulder dystocia is a condition where the baby’s upper shoulder, after the birth of the head, becomes stuck behind the pubic bone and difficult or impossible to release. The brachial plexus consists of a number of nerves that control the motion of the arm and shoulder. Severe injury can result in a deformed arm that is basically non-functional, while the more common, milder injuries can cause temporary paralysis or decreased movement, but gradually return to normal function.
The traditionally taught steps for managing a shoulder dystocia have always included cutting a large episiotomy. Some entities even recommend a “procto-episiotomy”, which extends through the anal sphincter. Every class I have ever attended on management of shoulder dystocia has emphasized episiotomy as a legal protection for the provider. Many physicians will openly admit that episiotomy does nothing to help facilitate the delivery of a baby with shoulder dystocia, because it is not a tissue problem, but a bone problem. The shoulder is stuck behind bone, and cutting the woman’s perineal tissue does not resolve the problem. Then why do it? Most physicians I’ve spoken with admit it is simply a matter of protecting themselves legally: by cutting a large episiotomy, they can show they’ve done everything they could possibly do to try to deliver the baby.
Now, the AJOG studyhas cast doubt on this practice. As the rate of episiotomy in general declined, so did the frequency with which providers performed episiotomy with a shoulder dystocia. The investigators conclusion? “The episiotomy rate with shoulder dystocia dropped from 40% in 1999 to 4% in 2009 with no change in the rate of brachial plexus injuries per 1000 vaginal births.”
The American Academy of Family Practitioners conducts courses called Advanced Life Support in Obstetrics (ALSO). In their article on management of shoulder dystocia, they mention the Gaskin Maneuver, a non-invasive method of dealing with shoulder dystocia that midwives frequently use, but put it aside as impractical due to the length of time it would take to move a mom to her hands and knees (2-3 minutes) and the immobility problem of many women delivering in US hospitals with epidurals today.
As a midwife who currently works in a hospital setting, with many “immobile” women, I can assure you that it does not take 2-3 minutes to move a mom to her hands and knees, especially when she knows her baby is stuck. Additionally, even a fully immobilized woman (and most women with epidurals have some movement of their legs) can be moved by two nurses into a knee-chest position. I have done this several times in women with epidurals and it took about 30 seconds. The attitude of some physicians toward the Gaskin manuever simply underscores modern obstetrics’ difficulty with thinking outside the traditional delivery procedures they have been taught.
However, the AJOG study indicates there are physicians who ar stepping outside the norms of modern obstetrics and bypassing the episiotomy as a set in management of shoulder dystocia. Will more physicians join them, and jump on the no-episiotomy bandwagon with the results of this new study? Or will CYA-medicine continue to compel the majority to perform unnecessary surgery on women?
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