Re: Ob: After delivery inspection/exploration
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Fri Jun 8 21:14:23 2007
Art:
What a wild study!
You are sooo very good in doing research and are a true resource for us
all.
Sincere thanks.
Garry
At Fri, 8 Jun 2007, art fougner, md wrote:
>
>OK this might be more than a little over the top ...
>
> JSLS. 2002 Apr-Jun;6(2):175-7.
> "Endoview" project of intrapartum endoscopy.
> Petrikovsky BM, Ravens S.
>
>Nassau University Medical Center, Department of Obstetrics and
>Gynecology, East Meadow, NY 11554, USA.
>
>INTRODUCTION: The change in obstetrical practices over the last decade
>in favor of trials of labor in patients with uterine scars has resulted
>in increased incidences of uterine ruptures. Although neither repeat
>cesarean delivery nor a trial of labor is risk free, evidence from a
>large multicenter study shows vaginal birth after the cesarean (VBAC) is
>associated with shorter hospital stays, fewer postpartum blood
>transfusions, and a decreased incidence of postpartum maternal fever.
>The uterine rupture remains the most serious complication associated
>with VBAC. Factors associated with uterine rupture include excessive
>exposure to oxytocin, dysfunctional labor, and a history of more than 1
>cesarean delivery.2 Because uterine rupture may be a life-threatening
>event, intrapartum surveillance and the ability to perform an emergency
>surgery are both necessary when trial of labor is allowed. Until now,
>no early symptoms pathognomonic to uterine rupture had been described.
>We share our experiences with the novel approach to the problem - an
>intrapartum endoscopy. MATERIALS AND METHODS: Endoscopic examination
>was accomplished by using the intraoperational fiberscope (Olympus and
>Endoview system (Costa Mesa, CA, USA). A gas-sterilized 25-cm long
>fiberscope is introduced into the amniotic cavity through the cervical
>canal after rupture of the membranes. The distance between the
>fiberscope and the object varies from 3 to 50 mm. The fiberscope has a
>separate channel for the fluid infusion (normal saline) throughout the
>procedure; the surgeon looks through the eyepiece directly and exhibits
>control over the flexible scope. The duration of endoscopy is less than
>15 minutes. The inserting of the endoscopic device is very similar to
>that of insertion of an intrauterine pressure catheter. The IRB
>Committees of both participating institutions approved the study
>protocol. Twenty-eight patients with an unknown or poorly documented
>site of the uterine scar were included in the study. An ultrasound
>examination had been performed on all patients prior to endoscopy to
>assess fetal wellbeing and placental location. The ages of the patients
>ranged from 21 to 38 years. Eighteen women had 1 previous cesarean
>delivery, and 10 had 2. The performance of intrapartum endoscopy did
>not interfere with fetal monitoring; 21 fetuses were monitored
>externally, 7 internally. Indications for previous cesarean deliveries
>were as follows: fetal distress in 11 cases, failure to progress in
>labor in 8, placenta previa in 2, and unknown in 7. Twenty-one patients
>delivered vaginally; 7 had had repeat cesarean deliveries. All neonates
>were born in satisfactory condition. The Apgar scores at 1 minute
>varied from 7 to 9 and at 5 minutes from 8 to 10. The integrity of the
>uterine wall was assessed by manual postpartum uterine exploration in
>each case of vaginal delivery and by visualization and palpation of the
>scar site in each abdominal delivery. RESULTS: The lower uterine
>segment and contractile portion of the anterior uterine wall were
>visualized successfully in all patients. In 25 patients, the presumed
>scar site looked totally indistinguishable from the rest of the lower
>uterine segment and anterior uterine wall. Two scars were identified as
>vertical in 2 patients who were delivered by a repeat abdominal
>operation. A vertical scar appears as a groove running in a
>cephalad-caudad direction from the lower uterine segment into the
>contractile portion of the anterior uterine wall. The usefulness of the
>intrapartum endoscopy is best demonstrated by the following case reports
>(2 of 28 study cases).
>
>Art
>
>At Fri, 8 Jun 2007, Garry E. Siegel, M.D. wrote:
>>
>>I can't imagine that there is any evidence for it, and the evidence
>>against it probably doesn't exist, either. Art is right (or
>>somebody)--this is the art of medicine.
>>
>>The numbers of missed lacerations due to a lack of inspection, or
>>"found" ones are probably so small that a huge study would have to be
>>undertaken to prove any evidence of a significant difference.
>>
>>I can certainly understand that a uterine exploration is not done
>>commonly, but not inspecting the sidewalls and cervix (which takes
>>moments and is easy and can be done quickly, even if there is no
>>anesthesia) seems foolish to me, FWIW.
>>
>>Garry
>>
>>At Fri, 8 Jun 2007, ainsron wrote:
>>>
>>>I agree
>>>
>>>Ronald E. Ainsworth, MD, FACOG
>>>
>>>-----Original Message-----
>>>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of FRANCES
>>>WREN
>>>Sent: Friday, June 08, 2007 1:18 AM
>>>To: Multiple recipients of list OB-GYN-L
>>>Subject: Re: Ob: After delivery inspection/exploration
>>>
>>>my assessment after delivery
>>>SVD...with no problems....a quick look,congratulations and a smile.
>>>forceps..I look at vagina...up to area of cervix....I do not routinely
>>>explore round the cervix ,unless it seems to be bleeding excessively.
>>>epis...I check to make sure I have got the "top"...I do not check the rectum
>>>unless i have real reason to believe I have got any sutures into there.
>>>if a 4th degree...hopefully not ..i may check in the rectum after repairing
>>>the epis.
>>>VBAC..i do not routinely explore , unless it has been a dicey one (that I
>>>wish I had C/S.)..or if there is excess bleeding.
>>>
>>>i am inclined to be a "let sleeping dogs lie...unless thy look like they may
>>>be snarly ones"
>>>
>>>>>>>----- Original Message -----
>>>From: garrys@mindspring.com (Garry E. Siegel, M.D.)
>>>Date: Thursday, June 7, 2007 8:54 pm
>>>Subject: Ob: After delivery inspection/exploration
>>>
>>>> Listers:
>>>>
>>>> What do you routinely assess after delivery?
>>>>
>>>> Does your routine vary by what was done (SVD, Forceps, epis, no epis,
>>>> VBAC, etc.)?
>>>>
>>>> Garry
>>>>
>>>> FWIW:
>>>>
>>>> I explore the uterus if possible; always visualize the sidewalls
>>>> and do
>>>> a rectal exam, and, duh, look at the perineum, labia and periurethral
>>>> areas.
>>>>
>>>> --
>>>> Garry E. Siegel, M.D.
>>>> Private Practice
>>>> Roswell, GA
>>>>
>>--
>>Garry E. Siegel, M.D.
>>Private Practice
>>Roswell, GA
>>
>--
>art fougner, md
>"May The Wings of Liberty Never Lose a Feather." - Jack Burton
>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
