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Re: Symphysiotomy for Shoulder DystociaFrom: Anna Meenan, MD (annam@uic.edu)Mon Feb 21 11:25:41 2000
At Sun, 20 Feb 2000, Scott Wiersma wrote: >
"Only"
>8.1% of mothers had serious morbidity attributable to the procedure To me that's too much morbidity when there is a noninvasive maneuver available that has so far only been found to have 1.2% maternal morbidity (one case of postpartum hemorrhage not requiring transfusion) and 4.9% neonatal morbidity (one baby with a fractured humerus and one-minute apgar of 2, another baby with a one-minute apgar of 2, and a baby with a 5-minute apgar of 6. The 5-minute apgars of the first two babies were 7 and 9, respectively.) As a female-type person, I really think I'd prefer my morbidity in the form of "postpartum hemorrhage not requiring transfusion" than in the form of vesicovaginal fistulas, urethral incontinence requiring collagen injections, urethral/bladder lacerations, or long-term pain and disability. As far as I know, there are no published reports of failure of the Gaskin (all-fours) maneuver to get the baby out.
Not
>only are there no reports of unsuccessful symphysiotomy for shoulder My case report in the Journal of Family Practice (Vol.32, No.6, 1991) reports that "the 3940g infant literally squirted out onto the bed" once the mom pushed in the all-fours position.
>So symphysiotomy works well (even when all else fails) and has less There have been no reports of dead babies with the use of the Gaskin Maneuver, and it has virtually no learning curve. It has been taught to obstetricians on the spot by L&D nurses in our hospital, and used successfully by inexperienced midwives doing their very first deliveries.
>
Please do not perpetuate the confusion between the knee-chest position
and the all-fours maneuver for shoulder dystocia. The knee-chest
position is mechanically completely different from the all-fours
maneuver and has never been evaluated for resolution of shoulder
dystocia. In the knee-chest position, the normal lordotic curve of the
lumbosacral spine is exagerated and could theoretically place the sacral
promontory more firmly in the way of the posterior shoulder, if that is
where it is hung up.
Again, I am not aware of any reported cases where this simple,
noninvasive maneuver which can be done by any provider in almost any
situation (I've even done it with an epiduralized patient) has failed to
result in delivery of a live infant, and all this talk of
symphysiotomies is making me feel ouchy in the urethral region.
>
-- Anna Meenan, MD, FAAFP
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