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Maughan’s Manoeuvre
""
HISTORY
o F
MEDICINE'"
,
MAUGHAN'S MANOEUVRE T.F. Baskett, MB, FRCSC,
Department of Obstetrics and Gynaecology, Dalhousie University
T
he defeat of a McGill medical student, by the eventual Argentinean winner of the gold medal, in the semi-final of the boxing competition at the 1932 Los Angeles Olympic Games helped to decide the student's future and, twenty-five years later, the Chairmanship of the Department of Obstetrics and Gynaecology at McGill University. The medical student was George Maughan and, as he was to write sixty-two it was probably the best result years after the Olympics: l
the Royal Victoria Hospital, Montreal after the teaching of Melhado. 2 This involved dislodging manually the occiput above the pelvic brim, rotating it to the occiputanterior or occiput-transverse position, applying forceps, and delivering the infant. Melhado pointed out that once the deflexed occiput-posterior was flexed in the occiput-anterior position, the smaller diameter usually made the forceps delivery easy. This manoeuvre produced good results in skilled hands. Maughan found that his hands were too big (size 8) to accomplish this manoeuvre easily. He wrote l : HUsing Dewees' forceps with a fenestrated blade I found that I could accomplish all of the manoeuvres of the Melhado
H ••••
because I might well have accepted one of several offers to tum 'pro,' considering the economic climate of 1932 and the impecunious state of most medical students at that time." Thus, he retired from boxing with, a nose broken several times and scars over both eyes .... ," returned to his medH •••
technique. Using one blade applied upside down to catch the fetal ear in the fenestration I could tum the head, apply the second blade in the transverse or AP position, ensuring a perfect application by locking the second blade to the first, and usually a take-your-time delivery. When the fetal head is not well enough flexed, more flexion can be acquired by loosening the lock on the forceps and applying fundal pressure. Even though their hands were much smaller than mine, many of our staff started using the procedure, but not until about ten years or more after publication did I leam that they had dubbed it the Maughan manoeuvre. Maybe I sold it to them by explaining that it was the difference between eating your dinner with a knife and fork rather than with your fingers!"
ical studies and eventual appointment as Professor and Chairman of the Department of Obstetrics and Gynaecology at McGill University, and Chief of Obstetrics and Gynaecology at the Royal Victoria Hospital, Montreal. The problem of arrested occiput-posterior or transverse positions in the second stage of labour has bedevilled obstetrics since the dawn of time. In the first part of the twentieth century, delivery using the Scanzoni manoeuvre or Kielland's forceps rotation became common. The other frequently used alternative was manual rotation of the occiput followed by forceps delivery. It was the latter technique that was most often used in
JOURNAL sOGC
680
JULY 1995
, , , Maughan presented the technique at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada in 1955 at Huntsville, Ontario, with publication the following year. J The paper provides a clear rationale and precise outline of the method. In those days, evidencebased results were not required. It was enough that a man of Maughan's standing finished his paper with the statement: "results with its use have been most gratifying over a number of years." At about the same time, a brief report appeared on a similar technique espoused by Dr. Ramirez Merchan of Bogota, Columbia.4 In some ways Maughan was applying the single blade of the forceps as a vectisused two centuries before to flex, but not to rotate occiput-posterior positions. s A recent study from the United States has also advocated this manoeuvre for the management of persistent occiput-transverse and posterior positiops. 6 Maughan's Manoeuvre is also mentioned in several modem obstetric texts. 7•9
Reflecting on this aspect of his career some half a century later, Maughan writes: "I was in my element! Worked in the OR in the morning and in the out-patient clin-
ics in the afternoon. Made rounds with Dr. Fraser around noon and with any other staff who wanted me, and saw all
patients in the evening. I was in my quarters in the late evenings and at night for on-call for emergencies, particularly in the case room. In one stretch, I remember I did not leave the hospital for six full weeks. I would get along on 4-6 hours of sleep a night and loved every waking moment. I t was, I believe the best year of my life and I am sure my athletic past was the reason I survived it." In 1939, George Maughan was appointed to the staff of the Obstetrics and Gynaecology Department at the Royal Victoria Hospital and Assistant Demonstrator at McGill University. He volunteered for service at the start of World War II but was turned down because of a mastoidectomy at 15 years of age. He was later accepted into the Navy and spent three years (1941-44) in the RCNVR, seeing convoy duty in the North Atlantic and acting as principal medical officer on the cruiser, HMCS
Uganda. After the war, Maughan immersed himself in a busy teaching and clinical practice. Despite being in academic obstetrics and gynaecology practice, he was still without a specialist qualification. In 1950, he sat the British Royal College examination, held in Canada, and obtained his MRCOG. Two years later, the Canadian Royal College allowed veterans with a suitable academic background to sit for the Fellowship by oral examination alone. Thus, he obtained the FRCSC. An acknowledged leader in his specialty, Dr. Maughan served on the Council of the Society of Obstetricians and Gynaecologists of Canada for six years, as Secretary from 1947 to 48 and President in 1962. In 1956, he was appointed Professor and Chairman of the Department of Obstetrics and Gynaecology at McGill University and Chief of Obstetrics and Gynaecology at the Royal Victoria Hospital, Montreal. He held these positions until statutory retirement in 1975. Maughan held an unorthodox view of tenure in those days. As he said, "I had always refused tenure during those
George Burwell Maughan was born in Toronto, 8th May, 1910, and moved to Montreal at the age of four. He was educated at Roslyn and Westmount High Schools. Entering McGill University at the age of 17, he got sufficiently high marks to be admitted to the Faculty of Medicine after two years, at the same time representing the University at football, swimming, and water polo. In medical school, his athletic endeavours were confined to boxing, culminating in winning the Canadian amateur title in May 1932, leading to the Los Angeles Olympics. Two years later, he graduated MD CM from McGill. He spent the first three years after graduation in junior housestaff positions in pathology, medicine, surgery, obstetrics and gynaecology. Guided by Dr. John Fraser, he spent a year in endocrinology and was awarded his MSc from McGill for work on the endocrinological basis for toxaemia of pregnancy. From 1938 to 1939, he worked as chief resident in obstetrics and gynaecology at the Royal Victoria Montreal Maternity Hospital, which at that time had 196 beds.
JOURNAL SOGC
years believing that I could quit when I wanted to and they could fire me when they wanted to. "I He did not and they did not. In 1977, McGill University appointed him Emeritus Professor of Obstetrics and Gynaecology. J SOGe 1995;17:680-2
681
JULY 1995
, , , REFERENCES 1. 2.
3.
4. 5. 6.
7.
8. 9.
Maughan, GB. Correspondence 23/02/1994. Melhado, Gc. The occipito-posterior position: a method of management, with an analysis of 976 cases. Trans Am Gynec Soc 1933;58: 187-95. Maughan, GB. The safe and simple delivery of persistent posterior and transverse positions. Am J Obstet Gynecol 1956;71 :741-5. Merchan RR. New obstetric manoeuver for dystocia. JAMA 1954;155:1442. Radcliffe W. In: Milestones in Midwifery. Bristol, John Wright & Sons Limited, 1967 pp. 48-50. Escamilla JO, Carlan SJ. One-blade rotation of a persistent posterior vertex. Am J Obstet Gynecol 1991 ;165:373-4. Rovinsky JJ. Abnormalities of Position, Lie, Presentation and Rotation. In: Iffy L, Kaminetsky HA (Eds). Principles and Practice of Obstetrics and Perinatology. John Wiley & Sons, New York. 1981 ;2:911. O'Grady JP. In: Modem Instrumental Delivery. Williams & Wilkins, Baltimore. 1988; 136-8. Oxom H. In: Human Labor and Birth. Appleton-CenturyCrofts New York, 4th Edition 1980;372.
J SOGe 1995;17:2419-20
JOURNALSOGC
682
JULY1995
HISTORY
o F
MEDICINE'"
,
MAUGHAN'S MANOEUVRE T.F. Baskett, MB, FRCSC,
Department of Obstetrics and Gynaecology, Dalhousie University
T
he defeat of a McGill medical student, by the eventual Argentinean winner of the gold medal, in the semi-final of the boxing competition at the 1932 Los Angeles Olympic Games helped to decide the student's future and, twenty-five years later, the Chairmanship of the Department of Obstetrics and Gynaecology at McGill University. The medical student was George Maughan and, as he was to write sixty-two it was probably the best result years after the Olympics: l
the Royal Victoria Hospital, Montreal after the teaching of Melhado. 2 This involved dislodging manually the occiput above the pelvic brim, rotating it to the occiputanterior or occiput-transverse position, applying forceps, and delivering the infant. Melhado pointed out that once the deflexed occiput-posterior was flexed in the occiput-anterior position, the smaller diameter usually made the forceps delivery easy. This manoeuvre produced good results in skilled hands. Maughan found that his hands were too big (size 8) to accomplish this manoeuvre easily. He wrote l : HUsing Dewees' forceps with a fenestrated blade I found that I could accomplish all of the manoeuvres of the Melhado
H ••••
because I might well have accepted one of several offers to tum 'pro,' considering the economic climate of 1932 and the impecunious state of most medical students at that time." Thus, he retired from boxing with, a nose broken several times and scars over both eyes .... ," returned to his medH •••
technique. Using one blade applied upside down to catch the fetal ear in the fenestration I could tum the head, apply the second blade in the transverse or AP position, ensuring a perfect application by locking the second blade to the first, and usually a take-your-time delivery. When the fetal head is not well enough flexed, more flexion can be acquired by loosening the lock on the forceps and applying fundal pressure. Even though their hands were much smaller than mine, many of our staff started using the procedure, but not until about ten years or more after publication did I leam that they had dubbed it the Maughan manoeuvre. Maybe I sold it to them by explaining that it was the difference between eating your dinner with a knife and fork rather than with your fingers!"
ical studies and eventual appointment as Professor and Chairman of the Department of Obstetrics and Gynaecology at McGill University, and Chief of Obstetrics and Gynaecology at the Royal Victoria Hospital, Montreal. The problem of arrested occiput-posterior or transverse positions in the second stage of labour has bedevilled obstetrics since the dawn of time. In the first part of the twentieth century, delivery using the Scanzoni manoeuvre or Kielland's forceps rotation became common. The other frequently used alternative was manual rotation of the occiput followed by forceps delivery. It was the latter technique that was most often used in
JOURNAL sOGC
680
JULY 1995
, , , Maughan presented the technique at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada in 1955 at Huntsville, Ontario, with publication the following year. J The paper provides a clear rationale and precise outline of the method. In those days, evidencebased results were not required. It was enough that a man of Maughan's standing finished his paper with the statement: "results with its use have been most gratifying over a number of years." At about the same time, a brief report appeared on a similar technique espoused by Dr. Ramirez Merchan of Bogota, Columbia.4 In some ways Maughan was applying the single blade of the forceps as a vectisused two centuries before to flex, but not to rotate occiput-posterior positions. s A recent study from the United States has also advocated this manoeuvre for the management of persistent occiput-transverse and posterior positiops. 6 Maughan's Manoeuvre is also mentioned in several modem obstetric texts. 7•9
Reflecting on this aspect of his career some half a century later, Maughan writes: "I was in my element! Worked in the OR in the morning and in the out-patient clin-
ics in the afternoon. Made rounds with Dr. Fraser around noon and with any other staff who wanted me, and saw all
patients in the evening. I was in my quarters in the late evenings and at night for on-call for emergencies, particularly in the case room. In one stretch, I remember I did not leave the hospital for six full weeks. I would get along on 4-6 hours of sleep a night and loved every waking moment. I t was, I believe the best year of my life and I am sure my athletic past was the reason I survived it." In 1939, George Maughan was appointed to the staff of the Obstetrics and Gynaecology Department at the Royal Victoria Hospital and Assistant Demonstrator at McGill University. He volunteered for service at the start of World War II but was turned down because of a mastoidectomy at 15 years of age. He was later accepted into the Navy and spent three years (1941-44) in the RCNVR, seeing convoy duty in the North Atlantic and acting as principal medical officer on the cruiser, HMCS
Uganda. After the war, Maughan immersed himself in a busy teaching and clinical practice. Despite being in academic obstetrics and gynaecology practice, he was still without a specialist qualification. In 1950, he sat the British Royal College examination, held in Canada, and obtained his MRCOG. Two years later, the Canadian Royal College allowed veterans with a suitable academic background to sit for the Fellowship by oral examination alone. Thus, he obtained the FRCSC. An acknowledged leader in his specialty, Dr. Maughan served on the Council of the Society of Obstetricians and Gynaecologists of Canada for six years, as Secretary from 1947 to 48 and President in 1962. In 1956, he was appointed Professor and Chairman of the Department of Obstetrics and Gynaecology at McGill University and Chief of Obstetrics and Gynaecology at the Royal Victoria Hospital, Montreal. He held these positions until statutory retirement in 1975. Maughan held an unorthodox view of tenure in those days. As he said, "I had always refused tenure during those
George Burwell Maughan was born in Toronto, 8th May, 1910, and moved to Montreal at the age of four. He was educated at Roslyn and Westmount High Schools. Entering McGill University at the age of 17, he got sufficiently high marks to be admitted to the Faculty of Medicine after two years, at the same time representing the University at football, swimming, and water polo. In medical school, his athletic endeavours were confined to boxing, culminating in winning the Canadian amateur title in May 1932, leading to the Los Angeles Olympics. Two years later, he graduated MD CM from McGill. He spent the first three years after graduation in junior housestaff positions in pathology, medicine, surgery, obstetrics and gynaecology. Guided by Dr. John Fraser, he spent a year in endocrinology and was awarded his MSc from McGill for work on the endocrinological basis for toxaemia of pregnancy. From 1938 to 1939, he worked as chief resident in obstetrics and gynaecology at the Royal Victoria Montreal Maternity Hospital, which at that time had 196 beds.
JOURNAL SOGC
years believing that I could quit when I wanted to and they could fire me when they wanted to. "I He did not and they did not. In 1977, McGill University appointed him Emeritus Professor of Obstetrics and Gynaecology. J SOGe 1995;17:680-2
681
JULY 1995
, , , REFERENCES 1. 2.
3.
4. 5. 6.
7.
8. 9.
Maughan, GB. Correspondence 23/02/1994. Melhado, Gc. The occipito-posterior position: a method of management, with an analysis of 976 cases. Trans Am Gynec Soc 1933;58: 187-95. Maughan, GB. The safe and simple delivery of persistent posterior and transverse positions. Am J Obstet Gynecol 1956;71 :741-5. Merchan RR. New obstetric manoeuver for dystocia. JAMA 1954;155:1442. Radcliffe W. In: Milestones in Midwifery. Bristol, John Wright & Sons Limited, 1967 pp. 48-50. Escamilla JO, Carlan SJ. One-blade rotation of a persistent posterior vertex. Am J Obstet Gynecol 1991 ;165:373-4. Rovinsky JJ. Abnormalities of Position, Lie, Presentation and Rotation. In: Iffy L, Kaminetsky HA (Eds). Principles and Practice of Obstetrics and Perinatology. John Wiley & Sons, New York. 1981 ;2:911. O'Grady JP. In: Modem Instrumental Delivery. Williams & Wilkins, Baltimore. 1988; 136-8. Oxom H. In: Human Labor and Birth. Appleton-CenturyCrofts New York, 4th Edition 1980;372.
J SOGe 1995;17:2419-20
JOURNALSOGC
682
JULY1995