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Re: OB: OA vs. OP From: Efrain Ramirez (eramirez@icepr.com) Sat Dec 30 17:42:15 2000 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Efrain Ramirez: "Re: OB: OP versus OA" Previous message: DoctorJoe@aol.com: "Re: OB: OP versus OA" In reply to: O'Grady, Patrick MD: "OB: OA vs. OP" Next in thread: Garry Siegel: "Re: OB: OA vs. OP" Excellent post!! >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 Agree-- if you wait long enough this will be of no problem 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. Again - agree (maybe Carlos comment on epidurals was in this line - they hardly rotate because of the lack of "bearing down efforts" > iii. many posterior positions are complicated by recurrent variable type decelerations for reasons unknown to me What I have read is the vasovagal reaction to the pressure on the eyes -- beats me -- but it is true - > 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. I like to do manual rotations - I do not have long fingers - bit difficult > 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. I haven't done that -- some say is also good for shoulder dystocia -"Maya procedure" has another name - forgot. > 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. True -- in my view it is a "better" laceration than a laceration on the baby. > 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. Can't comment on vacuums - wasn't trained o vacuums - did quiet a few Scanzoni in my residency years - won't attempt one today. > 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. Haven't done that - I mean to apply or not a forcep - fingers --in my hands - will do but - good to know! "my $.02" -- "Life is neither the notes nor the silence between the notes, but the music that arises out of sound and silence felt as a living whole. Stop choosing...between chaos and order, and live at the boundary between them, where rest and action move together..." Next message: Efrain Ramirez: "Re: OB: OP versus OA" Previous message: DoctorJoe@aol.com: "Re: OB: OP versus OA" In reply to: O'Grady, Patrick MD: "OB: OA vs. OP" Next in thread: Garry Siegel: "Re: OB: OA vs. OP"

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