The Questions behind the Question

by Alison Bastien

We have a lot of information available to us these days. Internet access has made hundreds of journals, books and opinions easy to obtain, regardless of where we live. What fascinates me, though, is all of the information I get 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 the picture “isn’t” a white vase; there’s just more than meets the eye.

Modern health care paradigms seem this way 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 an interpreter, I attended some of the emergency obstetrical trainings for doctors and midwives in central Mexico state.A state in central Mexico They are presented by an international medical association, which is 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 and to share the knowledge in their medical communities and with their peers.

One of the workshops was on shoulder dystocia, a situation in which a baby’s shoulders may become stuck or wedged behind the pubic bones of the mother during delivery. The baby’s head is outside of her body and the body is unable to rotate and slip out. If not resolved, this emergency can result in brain damage or even death by asphyxia to baby. Timing is essential to recognizing and resolving the situation.

The instructors, using a PowerPoint presentation and a large model of a woman’s torso with a removable belly-cover with a model baby 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 perineum to “get more room”); 3. Use the “McRoberts” maneuver, flexing the woman’s legs up by her ears, to “open the pelvic outlet;” 4. Apply suprapubic pressure (someone pushes really hard on the outside, while someone else puts traction on the baby); 5. Try internal maneuvers (is this starting to sound like a war room strategy yet?), such as a) the “Ruben” maneuver, which requires inserting one’s fingers behind the anterior shoulder of the baby and trying to push it toward the baby’s chest, so it can turn and scoot out or b) the “Woods corkscrew” maneuver, whereby one presses one’s hands on the posterior shoulder of the baby and presses in the opposite direction. These maneuvers are simple and useful, provided one can even slide fingers in alongside the stuck baby in the first place.

Though emergency course the textbook [cks1] 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 who was also attending the workshop waved her hand up, “What about the Gaskin maneuver?”

I was wondering the same thing. The Gaskin maneuver was popularized by midwife Ina May Gaskin, as result of her observation of other empirical midwives in the Guatemalan highlands in the 1970s. It consists of turning the birthing woman over onto a hands and knees position which, it was found, spontaneously or with minimal intervention rotates the babies nearly 100% of the time, with no negative outcomes to mother or baby. Personally, and for my nurse-midwife friend, it is always the first choice because it has a much lower risk of trauma to both mother and baby. In this position, there is no pressure on the coccyx and the baby’s weight presses on the pubic bone. It automatically provides a little more room, in case any gentle traction or maneuvering is still required.

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 caused by those other things first if you acknowledge that this is usually better?”

There followed much loud murmuring and muttering by the several dozen obstetrician/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 supine 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 all nodded in agreement as I translated. “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: “Why are we still putting women on their backs on slippery hospital gurneys 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 an issue for developing countries, by any means. Just last week I was at a prestigious Ivy League nurse-midwifery school, touring the teaching facilities. My student guide led me to the robot teaching models. Actually, we had used only a slightly less sophisticated model in some of the CPR courses and in the emergency courses in Mexico. In this version, a life-like plastic dummy woman with the removable belly and baby featured a mechanical system in which everything was programmed into a nearby laptop computer to simulate a variety of complications of delivery. The baby could exhibit asynclitism and malpresentation, as well as the dreaded shoulder dystocia. This allows 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 life-sized labia and a cervix that 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 set goes for about $18,000.

“So, pretty neat, huh?” I nodded agreement with my enthusiastic student guide, who was at that very moment demonstrating some hand maneuvers up our robot’s 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 books on the subject, as well as the Midwives Alliance of North America (MANA).

“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 IVs 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.

That’s a metaphor for many of our issues in health care. People nod, say, “Oh yeah, I’ve heard of that….” but they have no real models, no access, no support with which to safely explore and practice the options. Practitioners will be hard pressed to move someone to their hands and knees (i.e., 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. We need 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 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, who’s got a leg to stand on around here?

Need a bio. Alison Bastien CPM was an independent homebirth midwife for 12 years. Now she teaches midwifery, childbirth preparation,  and herbalism  and helps run a natural products store.She has a degree in anthropology. Feel free to visit her website www.lavictoriana.com for more articles, products, and contact info.