Below is an essay written by my good friend, the midwife, naturopath, voice of reason, mother, herbalist, and all around wise woman Alison Bastien. When I saw the picture below I was horrified at the new depth of depersonalization happening in obstetric care but Alison managed to frame my knee jerk response in a far more useful way.
There is a lot of information available these days. Access to the
Internet has made hundreds of journals, books, and opinions available to us
wherever we live. What fascinates me, though, is all of the information I
obtain by what is not being said. It is sort of like those brain teaser pictures,
depicting a white vase but actually, when you focus on the blackness, you
realize you are looking at two ladies in profile. It's not even that it “wasn't”
a picture of a white vase, really, it's more like there's more than meets the eye.
Modern health care paradigms feel like this to me. It's not just what they
“say” is good practice, it's the assumption behind it, the ladies in profile that
become revealed when we stop admiring the vase.
For example: As a midwife and as an interpreter I attended some of the emergency
obstetrical trainings for doctors and midwives in my state in central Mexico.
They are presented by an international medical association composed of
doctors and nurse-midwives who travel all over the Americas giving excellent, and
succinct workshops on the latest updates in lifesaving techniques for the
most common obstetrical emergencies. They simultaneously train the
attendees to become trainers themselves, to share the knowledge in their
medical communities and with their peers.
One of the workshops was on Shoulder Dystocia, a very scary situation
in which a babies shoulders may become stuck, or wedged behind the
pubic bones of the mother on delivery, so you have the babies head outside
her body, and the body unable to rotate and slip out. If not resolved, this
emergency could result in brain damage, or even death by asphyxia to the
baby. Timing is then essential to recognizing and resolving the situation.
The instructors, using their Power Point presentations to emphasize the
steps, and their large model torso of a woman with a removable belly-
cover and the model baby to be stuck inside her, take us through the
options and the steps to resolving the problem:
- 1. Call for help
- 2. Consider an episiotomy (cutting the perenium to “get more room”)
- 3. the “McRoberts”maneuver, flexing the womans legs up by her ears, to “open the pelvic outlet”
- 4. Suprapubic pressure (someone pushes really hard on the outside, while someone else is putting traction on the baby)
- 5. Internal maneuvers (is this starting to sound like a war room strategy yet?)
- A) the “Ruben“ maneuver, inserting ones fingers behind the anterior shoulder of the baby and trying to push it towards the baby's chest, so it can turn and scoot out.
- B) the“Woods-Corkscrew” maneuver, whereby one presses ones hands on the posterior shoulder of the baby and presses the opposite direction.
These maneuvers are simple and useful, provided one can even slide their fingers in along the stuck baby
in the first place. Though the textbook then mentions as a footnote, the “roll on
fours” (or “Gaskin” maneuver) in the workshop the teacher moved straight on to
worst case scenario measures, such as breaking the baby´s clavicle to get it out,
pushing the baby back in and doing a cesarean, or breaking the woman's pubic bone
(no easy task!)
“Excuse me..” A nurse midwife from the midwest also attending the
workshops waves her hand up, “What about the Gaskin Manuever?”
I was wondering the same thing. The Gaskin Manuever was popularizad
by midwife, Ina May Gaskin, as result of her observations of other
empirical midwives in the highlands of Guatemala in the 1970s. This
consisted of turning the birthing woman over onto a hands and knees position
which , it was found, spontaneously or with minimal interventions, rotated the babies
100 percent of the time with no negative outcomes to mother or babies.
Personally, and for my nurse midwife friend, it was always our first choice for its
much lesser risk of trauma to both mother and baby. In this position, there is no
pressure on the coccyx and the baby's own weight presses the on the pubic bone. It
gives us automatically a little more room in case we still need to use any gentle traction
or maneuvering.
The instructor cleared his throat. “Well, the Gaskin maneuver? It almost always
works. That's why it's last on the list. If all else fails, that one will almost assuredly
rotate the baby and get it out. “
“That's crazy!” The nurse-midwife blurted out, “ Why would you waste all
that valuable time and effort and risk all the tissue trauma on all those other things
first if you yourself just acknowledged this is usually better?”
There followed much loud murmuring and muttering by the several dozen
Obstetricians and gynecologists in the room.
The presenter of the workshop shrugged his apology: “I know it's counter-intuitive, but like these docs are saying, we've got women with
intravenous tubes in their arms, fetal monitoring belts on, and they are mostly
lying prone on the hospital beds. It's a lot more tricky to get them into the
all-fours position with all those wires and tubes. Most of the women have epidural
anesthesia as well, with tubes in their spinal column and no feeling down below.”
The doctors are all nodding in agreement as I translate.
“Really, it's a mess trying to get someone to turn onto all fours on a
slippery metal hospital gurney, especially if their legs are already tied up
in the stirrups.”
My midwife friend seethed, conceding the point.
The Question behind the Question was: “ So why are we still putting women
on their backs on a slippery hospital gurney with tubes and wires all over them and
their legs up in the air in stirrups in the first place, if it hinders them in getting their
babies out?
This isn't just some third world issue by any means. Just last week I was
at a prestigious Ivy League Nurse-Midwifery school. In this case, I was
being given a tour of the teaching facilities. My student guide led me to
the robot teaching models. Actually, we had used an only slightly less sophisticated
model in some of the CPR courses and in the emergency courses in Mexico.
In these versions, a life-like plastic dummy woman with the removable belly
and baby featured a mechanical system whereby everything was programmed into
a nearby laptop computer, to simulate a variety of complications of delivery.
The baby could exhibit asynclitism, malpresentations, as well as the dreaded
shoulder dystocia for the students to practice resolving the problems while
the robot baby and mother exhibit life-like responses in their vital signs
to reflect the “what ifs” of proper or improper management in techniques
and choices. The robot woman had a life sized labia and cervix which dilated
to 10 cm. so the students could also practice checking dilation and station.
I had seen these robots in the medical supply catalogs stacked up for free
perusing and purchasing in the nursing department locker room. I had read
up on all the cool simulator robots just the night before, in a fit of uncharacteristic
insomnia. The teaching mama and baby goes for about 18,000 dollars.
“So, pretty neat, huh?”
I nodded agreement with my enthusiastic student guide, who was at that
very moment demonstrating some hand maneuvers up our robots vagina and
cervix
“So, uh, do you guys ever learn about the Gaskin maneuver for shoulder
dystocia? “ I wondered. It wasn't a far fetched question — Ina May Gaskin
often toured the Ivy league medical schools and did grand rounds in
prestigious hospitals sharing her points of view and representing her own books
on the subject and the Midwives Alliance of North America.
“Oh, sure, “ The student paused, “You mean the hands and knees thing?
Yeah, they mention that, too.”
I repeated what the doctors had protested in the obstetrical emergency workshops,
about how impractical it was , given the I.V.s and the fetal monitors and
such.
“Yeah , well, that's the thing…” The student shrugged, simulating a baby
getting swirled around by the corkscrew maneuver half inside the mother
as we talked. “We've got, like, a 90% epidural rate around here. “
That's the thing, I thought. It's pretty hard to practice getting a woman onto
her hands and knees when she has no arms or legs.
And that's the metaphor for many of our issues in health care. People
nod, say “Oh yeah, I've heard of that ...” but have no real models, no
access, no support with which to safely explore and practice the options.
Practitioners will be hard pressed to moving someone to their hands and knees
(ie: a grounded, self-motivated position in which internal changes may then
occur spontaneously) when that someone has no arms or legs!
We need to begin sharing our experiences and intuitions more boldly,
To ask the Questions behind the Question—in this case, if you can't do it because
the mother is on a narrow uncomfortable bed and has too many tubes in her,
then why do we have her on a narrow uncomfortable bed with so many tubes in
her? Is all that part of the problem or part of the solution?
Some people call this “thinking outside of the box” . But I think when
we identify ourselves as inside or outside of a box, that's actually part of the problem.
The question behind the question is: Where the heck did the box come from? At what
Point in our collective consciousness did we agree there even is a box? And then, whose
got a leg to stand on around here?
-Alison Bastien
May 08
