Just Fetal Headaches

Many people are aware of radiologic reports of about an inch of "extra" sagittal pelvic outlet diameter in the squatting position...

But most are quite astonished to hear that the same radiologic reports indicate that semisitting and dorsal lithotomy (common medical delivery positions) jam the sacral tip about an inch into the fetal skull. [Gastaldo Birth 1992;19(4):230]

When I mentioned this latter fact to Cochrane collaborators Enkin and Chalmers - they became so astonished that they deleted from their 1995 "Guide to Effective Care in Pregnancy and Childbirth," all mention of these "squatting" radiological reports. (The reports were mentioned in their 1992 "Guide.")

Enkin told me that a "Lilford group" disproved the "squatting" radiologic reports in 1991; but for some reason Enkin forgot to mention "the Lilford group's" work when he deleted the "squatting" radiological reports. (I don't have Enkin's "Lilford group" cite with me; but I believe the primary author was Gupta and the journal was the European Journal of Obstetrics, Gynecology and Reproductive Biology. See also the 1993 Williams Obstetrics, noted below.)

Two Australian researchers claimed, circa 1991, to have corroborated a 1989 squatting study by "the Lilford Group." (I believe the journal was Aust NZ J Obstet Gynecol edited by Norman Beischer, M.D.)

The paper by the Australians had bigger holes than the 1989 and 1991 papers by "the Lilford group" put together.

Even if routinely jamming sacral tips into fetal skulls only causes fetal headaches, women should be informed well in advance of delivery of all the easy ways NOT to jam the tailbone into the fetal skull at delivery.

After publishing the above cited 1992 letter to Birth, I've again become interested in this subject. There are reports in neurology texts that 4% to 7% of apparently healthy term neonates suffer unexplained brain bleeds; as well as reports of 1% to 10% of term neonates suffering unexplained encephalopathy.

In response to my request, Williams Obstetrics co-author Norman F. Gant added to his chapter in the 1993 edition the fact that the sacrum can't move back if the mother is sitting on it.

That's the good news. The bad news is that Dr. Gant failed to correct the error that first called my attention to Williams Obstetrics - the false claim that Borell and Fernstrom's radiologic report [Act Rad (Scand) 1957] demonstrates that dorsal lithotomy WIDENS the pelvic outlet. Dr. Gant kept this false claim in his text inspite of my having called his attention to it; and inspite of the fact that his text's normal delivery position graphics (which presumably illustrate the dorsal lithotomy position) clearly show the sacrum in contact with the delivery surface...

As noted in my 1992 letter to Birth, with a woman on her back in dorsal lithotomy, in addition to the weight of her pelvis, there is the weight of her thighs ALSO jamming her sacral tip into her fetus's skull. Her thighs are doing this by cranking down on both acetabulo-sacroiliac lever arms.

As alluded to above, the 1993 Williams Obstetrics cites the 1991 study by "the Lilford group" (Gupta et al.) as evidence that sacroiliac motion is negligible in "the usual Western delivery position" - with the trunk 30 degrees from the horizontal. In fact, "the Lilford group" compared squatting lateral x-rays with x-rays taken with women seated, feet on the floor and the trunk 30 degrees from the VERTICAL.("The Lilford group" did call this "the usual Western delivery position.) Try it. 30 degrees from the vertical does NOT weight the sacrum - especially if one sits up "straight" and leans back 30 degrees. This is but one major hole in the 1991 paper by the "Lilford group." Lilford and Gupta's 1989 paper is worse; and worse still is the Australian effort circa 1991 noted above.

I believe there is a conspiracy afoot to cover-up one of Western obstetrics' most grisly secrets.

I might add that some midwives also use semi-sitting delivery routinely.

It should stop. Women at least should be informed - even if fetal skull squashing only causes fetal headaches...