Re: OB: OA vs. OP
From: art fougner, md (evsono@pipeline.com)
Sun Dec 31 11:20:48 2000
with regard to decels and OP, you don't think that pressure exerted in
the region of the large fontanel might be the culprit?
art
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
--
art fougner, md
A series of 1000 cases begins with but a single anecdote.
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