The Gaskin maneuver is a technique used during childbirth in which the laboring person is turned onto their hands and knees to help free a baby whose shoulder has become stuck behind the pubic bone, a complication known as shoulder dystocia. Named after American midwife Ina May Gaskin, who adopted it from traditional birth attendants in Central America, the maneuver is one of the simpler interventions a birth team can attempt during what can quickly become a dangerous situation. Despite evidence that it works well, it remains surprisingly underused in hospital settings, and the reasons for that gap say as much about birth culture as they do about obstetric science.
What Shoulder Dystocia Is and Why It Matters
Shoulder dystocia happens when a baby’s head delivers normally but one or both shoulders get caught behind the mother’s pelvic bones. The birth stalls, and the clock starts ticking: the umbilical cord may be compressed, cutting off the baby’s oxygen supply. In a large U.S. study covering more than 132,000 vaginal deliveries, shoulder dystocia occurred in about 1.5% of cases, and roughly 5% of those resulted in a neonatal injury such as a fractured collarbone or nerve damage to the arm.1PubMed Central. A Comparison of Obstetric Maneuvers for the Acute Management of Shoulder Dystocia The situation is unpredictable. Although large birth weight and maternal diabetes raise the odds, most cases happen with no warning at all, so every birth attendant needs a plan for managing it.
The standard first response in most hospitals is the McRoberts maneuver, which involves sharply flexing the mother’s thighs back toward her abdomen while she lies on her back. A helper often applies pressure just above the pubic bone at the same time to nudge the baby’s shoulder free. When that fails, clinicians move through a sequence of increasingly hands-on interventions: rotating the baby’s shoulders internally, sweeping the posterior arm out, or in rare and extreme cases, pushing the baby’s head back in for a cesarean delivery. The Gaskin maneuver sits alongside these options, but in practice it is reached for far less often.
How the Gaskin Maneuver Works
The core idea is gravity and geometry. When a person rolls from their back onto all fours, several things change inside the pelvis. The sacrum, which is the triangular bone at the base of the spine, is no longer pressed against the mattress. Freed from that compression, it can tilt backward, creating more room in the pelvic outlet. Proponents of the technique point out that this lifting of the sacrum essentially pulls it away from the baby’s trapped posterior shoulder, opening extra space for the shoulder to slip past.2American Journal of Obstetrics & Gynecology. A Critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia
Computational modeling of pelvic dimensions during pregnancy supports the broader principle. A simulation study found that when a pregnant person shifts into an upright or squatting posture, the pelvic outlet expands meaningfully in both front-to-back and side-to-side dimensions, with the dynamic movement itself generating even more room than simply holding the position.3Journal of Biomechanics. The effects of squatting while pregnant on pelvic dimensions: A computational simulation to understand childbirth The hands-and-knees position works on a similar principle: by shifting body weight forward and letting the sacrum float freely, the bony canal through which the baby must pass becomes as roomy as it can get.
There is also a practical advantage. Once the person is on all fours, the birth attendant has much easier access to the posterior shoulder and arm. Delivering the posterior arm is one of the most effective single maneuvers for resolving shoulder dystocia, and a hands-and-knees position makes that reach far more straightforward than attempting it with the mother lying on her back. One group of clinicians reported that posterior arm delivery succeeded about 87% of the time in the all-fours position, compared with roughly 25% in the lithotomy (lying-back) position.4American Journal of Obstetrics & Gynecology. A Critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia
How Effective Is It?
The most widely cited evidence comes from a registry of 82 consecutive shoulder dystocia cases managed with the all-fours technique. In that series, 83% of the babies delivered without any additional maneuvers being needed. The average time from recognizing the dystocia to completing delivery was about two and a half minutes, with a range of one to six minutes.5PubMed Central. All-fours maneuver for reducing shoulder dystocia during labor Two and a half minutes may not sound fast, but for context, the entire management of shoulder dystocia often unfolds over a similarly short window, and speed matters because the baby’s oxygen supply may be interrupted.
Those numbers are promising, but the evidence base is thin compared with better-studied maneuvers. In the large U.S. study mentioned earlier, the Gaskin maneuver was used only 22 times out of more than 2,000 shoulder dystocia cases, making it difficult to draw strong statistical conclusions about injury rates. One neonatal injury occurred in those 22 uses.6PubMed Central. A Comparison of Obstetric Maneuvers for the Acute Management of Shoulder Dystocia By comparison, the most commonly used maneuvers in that study each had hundreds of uses, giving researchers far more data to work with. The important finding from that study was not about one maneuver versus another so much as a broader pattern: the total number of maneuvers performed correlated with the rate of neonatal injury, suggesting that resolving the dystocia quickly with fewer interventions is better than cycling through a long checklist.
Why It Is Not Used More Often
If the Gaskin maneuver is simple, requires no special instruments, and has a reasonable success rate, why was it used in barely 1% of shoulder dystocia cases in the largest available study? Several factors stack against it in the modern hospital setting.
The most practical barrier is epidural anesthesia. When a person has had an epidural, their legs may be partially or fully numb, making a rapid position change to hands and knees awkward, slow, or unsafe without multiple helpers. The American College of Obstetricians and Gynecologists has noted that the all-fours position may be useful for relieving shoulder dystocia specifically in women without anesthesia.7International Journal of Nursing Sciences. A review and comparison of common maternal positions during the second-stage of labor Since a majority of people giving birth in U.S. hospitals do receive epidurals, this caveat alone sidelines the maneuver for a large portion of births.
Hospital bed design is another obstacle. Standard labor beds are optimized for a reclined or semi-reclined position. They have stirrups, adjustable backs, and detachable foot sections, all built around the assumption that the person will be lying down. Rolling onto all fours on a narrow hospital bed, sometimes with IV lines, a fetal monitor belt, and an epidural catheter in place, is not something most birth teams practice. In a Dutch study, the all-fours position was nevertheless the second most commonly used maneuver after McRoberts failed, accounting for about a quarter of cases.8International Journal of Nursing Sciences. A review and comparison of common maternal positions during the second-stage of labor That suggests it is more accepted in some clinical cultures than others, and the barrier may be as much about habit and training as about genuine impossibility.
Training algorithms also play a role. Most shoulder dystocia protocols taught in residency programs and simulation drills list McRoberts and suprapubic pressure as the first-line response, with internal rotation and posterior arm delivery next. The Gaskin maneuver often appears at the bottom of the algorithm or as a footnote, which means many providers have never practiced it in a drill, let alone used it on a real patient. When shoulder dystocia happens, it is a high-adrenaline moment, and clinicians default to what they have rehearsed most. One group of researchers explicitly questioned why the all-fours position still lingers near the bottom of management lists, given its ability to facilitate posterior arm delivery.9American Journal of Obstetrics & Gynecology. A Critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia
Benefits for the Perineum
Shoulder dystocia aside, the hands-and-knees position during delivery has been studied for its effects on perineal tearing, and the results favor it. A study comparing women who delivered on all fours versus lying on their backs found that the hands-and-knees group had a dramatically lower rate of episiotomy (under 2% versus nearly 38%) and a much higher rate of delivering with the perineum completely intact (about 33% versus 15%).10International Journal of Nursing Sciences. Comparing maternal and neonatal outcomes between hands-and-knees delivery position and supine position When second-degree tears and episiotomies were combined, the all-fours group had a rate of roughly 10% compared with over 43% in the supine group.
These numbers reflect general hands-and-knees deliveries, not emergency Gaskin maneuvers during shoulder dystocia. But they illustrate that the position itself is gentler on tissue. The likely reasons are mechanical: with gravity pulling the baby downward and the perineum under less direct pressure, the tissue stretches more gradually. The lower episiotomy rate in the study also suggests that providers watching a hands-and-knees birth feel less compelled to cut, possibly because the slower emergence of the baby’s head gives the perineum more time to stretch on its own.
Hands-and-Knees Positioning for Fetal Malposition
The same family of positions has been explored for a different problem entirely: babies facing the wrong direction during labor. In an occiput-posterior, or “sunny-side up,” presentation, the baby’s face is oriented toward the mother’s belly rather than toward her spine, which often leads to longer labor, more back pain, and a higher chance of instrumental delivery or cesarean. A trial randomized women with occiput-posterior babies into three groups: a semi-prone position, a knee-chest position, and standard care. About 86% of the knee-chest group and 84% of the semi-prone group rotated to the more favorable forward-facing position by birth, compared with 66% in the standard care group.11PubMed Central. The Impact of Maternal Position in Labor on Occiput-Posterior Position of Fetus and Pregnancy Outcomes in Pregnant Women Without Epidural Analgesia
The knee-chest position is not identical to the Gaskin maneuver (knee-chest involves the chest being lower than the hips, whereas a true all-fours posture is more level), but both rely on the same principle: getting off the back and letting gravity and pelvic geometry work in the baby’s favor. For families laboring without an epidural who are told the baby is facing the wrong way, getting into a forward-leaning or hands-and-knees position is one of the least invasive things to try.
Where the Technique Came From
Ina May Gaskin is one of the most recognized figures in the American natural-birth movement. She founded a birth center at The Farm, an intentional community in rural Tennessee, in the early 1970s. By her account, she observed the hands-and-knees response to obstructed shoulder birth while working alongside traditional midwives in Guatemala. She began using it routinely and published her experiences, which is how it entered the English-language obstetric literature.12Gynecology and Obstetrics Clinical Medicine. Cohort study of use of the hands-and knees-position as the first approach to resolving shoulder dystocia and preventing neonatal birth trauma
The naming convention is unusual. Obstetric maneuvers are typically named after physicians: McRoberts, Rubin, Woods. Gaskin’s name on this one reflects both her advocacy and the fact that no physician had formally described and published the technique before she did, even though the position itself was almost certainly used for centuries in midwifery traditions worldwide. That origin story feeds some of the tension around the maneuver. In hospital-based obstetrics, techniques introduced by midwives have historically faced an uphill battle for acceptance, regardless of their merits. The fact that the hands-and-knees position requires no instruments and no specialized medical training may, paradoxically, work against it in a culture that tends to equate intervention with safety.
When the Gaskin Maneuver Is Not an Option
The clearest contraindication is a dense epidural block that leaves the person unable to support their own weight on their arms and knees. In that scenario, attempting the position change wastes time and could risk injury if the person collapses. Some providers have worked around lighter epidurals with the help of extra staff, but it requires the person to have enough sensation and strength to hold the position briefly.
Continuous electronic fetal monitoring, which is standard in many hospitals, also complicates the maneuver. External monitor belts can shift or lose signal during a position change, and in a shoulder dystocia emergency, losing the fetal heart rate tracing adds anxiety even if the monitoring itself is not helping resolve the problem. Wireless or waterproof monitors solve this issue in facilities that have them, but many do not.
Cord prolapse, where the umbilical cord slips ahead of the baby, is a separate emergency that requires keeping the person in a position where pressure can be held off the cord, typically with their hips elevated. In that situation the hands-and-knees position would not be appropriate because the management priorities are different.
Finally, there are situations where the person is simply unable to move. Advanced labor exhaustion, certain medical conditions, or complications like a magnesium sulfate infusion for preeclampsia can leave someone too weak or sedated to change positions safely. In those cases, the birth team relies on maneuvers that can be performed with the person on their back.
Simulation Training and the Rehearsal Gap
Shoulder dystocia drills are a cornerstone of obstetric training, and most labor-and-delivery units run them regularly. These simulations typically use mannequins on a standard hospital bed, reinforcing the supine position and the maneuvers designed around it. The Gaskin maneuver is harder to simulate realistically because it requires a participant who can actually roll over, and mannequins do not cooperate in the same way.
A randomized trial tested virtual-reality simulation against traditional mannequin-based training for shoulder dystocia management. Interestingly, the traditional training group outperformed the VR group on clinical skill scores and had faster diagnosis-to-delivery times.13Scientific Reports. Impact of a virtual reality-based simulation training for shoulder dystocia on human and technical skills among caregivers That finding highlights how much obstetric emergency training depends on muscle memory and physical rehearsal, not just visual familiarity with the steps. For a maneuver like the Gaskin that relies on repositioning a real human body, the absence of hands-on practice in training programs probably contributes to its low uptake in clinical emergencies. If you have never physically helped someone roll onto all fours during a drill, you are unlikely to think of it in the 30 seconds you have to make a decision during an actual shoulder dystocia.
Some midwifery programs integrate the hands-and-knees position into routine birth training, which may explain why it sees more use in midwife-attended births and in countries where midwifery-led care is the norm. The Dutch data showing the all-fours position as the second most common response to failed McRoberts likely reflects a healthcare system where midwives attend a larger share of births and where upright or non-supine birth positions are culturally more accepted.
What to Ask Your Birth Team
If you are planning a vaginal birth and want the Gaskin maneuver to be available as an option, the time to bring it up is during prenatal visits, not during labor. A few questions can clarify how your birth team approaches it. Ask whether the hospital or birth center practices shoulder dystocia drills that include the all-fours position. Ask whether your provider has ever used it or is comfortable with it. If you are planning an unmedicated birth, mention that you would like the freedom to change positions during pushing, including moving to hands and knees, since position flexibility is the prerequisite for the maneuver to even be possible.
For those choosing epidural anesthesia, it is worth knowing that lighter “walking” epidurals preserve more motor function and may allow position changes that a denser block would not. Discuss the trade-offs with your anesthesiologist. No one should forgo pain relief solely to keep the Gaskin maneuver on the table, but understanding how anesthesia choices affect your movement options is part of informed decision-making. Some birth teams use a compromise approach: if shoulder dystocia occurs, they help the person into a modified side-lying or asymmetric position that opens the pelvis without requiring full hands-and-knees weight-bearing.