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OB: OA vs. OPFrom: O'Grady, Patrick MD (Patrick.OGrady@bhs.org)Sat Dec 30 15:07:36 2000
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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