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Re: OB: OA vs. OPFrom: mbhemmat@hotmail.comMon Aug 18 01:43:00 2003
At Wed, 3 Jan 2001, Anna Meenan, MD wrote: > >I just had occasion to rotate an OP to OA manually on New Year's Eve. >Called by resident that pt. had suddenly gone to anterior rim. Raced >over to hospital from New Year's Eve party in long black skirt and >sequined vest. Upon arrival in LDR pt who had history of 2-push >deliveries still grunting with anterior rim so figured it was probably >OP. Heart tones were in the 80's so decided not to bother changing. Put >on one sterile glove, reached in around resident, cupped occiput in palm >of hand and flexed and rotated while mom pushed, then jumped back as it >suddenly rotated and crowned. Resident delivered the baby and I >returned to my party without a drop of blood or fluid on my party >clothes. Kind of a comical scene in retrospect, but got the job done. I >think it helped that she was a multip with a dense epidural on board, >but then again, if she hadn't had the epidural, she may not have got it >down in there OP either. > >-- > Anna Meenan > >At Sat, 30 Dec 2000, O'Grady, Patrick MD wrote: >> >> Just a few passing comments on this issue. >> >> i. the OP's that are trouble are those that are >>deflexed. >> if deflection is advanced enough to present the brow >> then this position is usually undeliverable from >>below >> unless it is transitional only--which it rarely >>seems to >> be >> >> ii. it is correct that waiting ( "3 cigar >>delivery") is usually >> the best way to handle an OP , as long as progress >> continues at a reasonable pace. Most will rotate. >> >> iii. many posterior positions are complicated by >>recurrent >> variable type decelerations for reasons unknown to >>me >> >> iv. if progress ceases or markedly slows , >>especially >> if the head is deflexed, intervention is oft >>required. It >> is always reasonable to attempt a manual rotation, >> especially if the "O" is in the obliquity, pressing >>as >> the parturient bears down. If descent occurs, so >>usually >> will the O rotate. This may not work; but little is >>lost. >> >> v. at times, the older clinicians--and now the >>midwives >> on rediscovery--will attempt Puddicombe's maneuver >> where the parturient is manipulated into all fours >>or >> knee chest position. This is reputed to be effective >>in >> initating rotation. These that do rotate, of course, >>might >> have rotated anyway, but this could be attempted if >> the woman is willing and the anesthesia (if any), >> permissive. The theory is that gravity and >>repositioning >> combine to dislodge (?) the O, permitting rotation. >> >> vi. if instrumentation is used, the infant can be >>extracted >> as an OP (face to pubes). This may be difficult and >> oft results in a perineal laceration. A VE is not a >>good >> choice unless an OP type cup is available which can >> be applied to the pivot point correctly. If this can >>be done, >> with the initial traction, the head usually flexes >>and descent >> begins. Rotation, if it occurs, is spontaneous and >> need not be aided. Forceps can also be used and, in >>the hands >> of the highly experienced ( ie. a Scanzoni or >>Kjelland >> rotation ) can >> rapidly achieve delivery. These are less commonly >> attempted today but are acceptable in the hands of >> those with adequate training. As noted, these >>procedures >> risk fetal and maternal injury to some extent altho >>most >> such events are of trivial clinical import. >> >> vii. if there is any question about the cranial >>position >> or station, I use transabdominal and transperineal >> real time U/S to confirm the position PRIOR to >> attempting any maneuver. >> >> my $.02 >> >> jpogrady md >> baystate Med Ctr >> springfield, ma >
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