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Re: OB: OA vs. OP From: Steve & Eryl Raymond (eryl@intekom.co.za) Sun Dec 31 11:40:09 2000 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Steve & Eryl Raymond: "Re: OB: OP versus OA" Previous message: Steve & Eryl Raymond: "Re: Multiracial babies - was: poop hits the fan" Maybe in reply to: Danny Tucker: "OB: OA vs. OP" Next in thread: Betsy Hyde: "Re: OB: OA vs. OP" Manual rotations always require that the head be disempacted from the pelvis - a highly dangerous manoeuvre. Secondly manual rotations have a high rate of failure. Thirdly there is no need to use a special "OP cup" (though nice to have) when using a vacuum extractor. The rule is to apply the cup as far back on the head as possible. Rotation may occur when descent occurs or it may not, but either way delivery can usually be achieved.. Fourthly the OP position is always accompanied by some degree of deflexion - look at the diameters presented. This will usually disappear spontaneously when rotation is carried out. Even the so-called undeliverable face presentation with mento-posterior position has been known to deliver vaginally after rotation to mento-anterior, because flexion is spontaneous on correction of position. The same can be said of the brow presentation. Turn it twice if necessary and it will usually disappear. The "3 cigar delivery" I have never heard of before. It bothers me though as the length of the second stage is related to perinatal asphyxia. Iif the FH is fine, the mother is not getting exhausted and it does appear that progress is being made then I can't argue with the idea of waiting. However the reason the Kiellands (and other forceps) were invented in the first place was to take care of delays or arrest in the second stage and it seems that there is a way to deal with a delayed second stage due to most of the known factors. If there is no delay then there is no problem - if it aint broke don't fix it. As for using ultrasound to delineate something that your fingers can tell you in seconds - the position and station, that's usng a machine gun to kill a cockroach. Steve > >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. > > > 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. > -- Dr. S.H. Raymond Department of Obstetrics & Gynaecology Empangeni Hospital Private Bag X20005 Empangeni South Africa 3880 Ph. (+27) (035) 7721111 Fax (+27) (035) 7922596 Next message: Steve & Eryl Raymond: "Re: OB: OP versus OA" Previous message: Steve & Eryl Raymond: "Re: Multiracial babies - was: poop hits the fan" Maybe in reply to: Danny Tucker: "OB: OA vs. OP" Next in thread: Betsy Hyde: "Re: OB: OA vs. OP"

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