OB-GYN-L Messages for July, 2003: Re: OB: Bladder Flap

Re: OB: Bladder Flap

From:

DoctorJoe@aol.com

Wed Jul 16 06:56:55 2003

>
> Hmm. I'd think Mats' recent classification of "litterature", and His former
> "Eminence-based Medicine" are 'profound'. So enlighten us, Joe. Your nullip
> with suspected macrosomia (based on abnl GTT, wt gain, obesity, and clinical
> assessment) has now been pushing 3.5 hrs with her epidural and 'adequate
> uterine contractions' (defined in any way you'd like). There is separation of the
> introitus with ctxs, but not in between. There is 3 cm caput, and the BPD is
> at the spines. There has been noticeably little progress in the past hour,
> and exhaustion is looming. A c/s is decided upon. You're in the peritoneal
> cavity, and palpate the baby's shoulder below the intended site of the bladder
> flap. Now, take us the rest of the way (carefully). I'm listening intently. As
> Bernard's suggestion of retrograde filling of the bladder with cord prolapse
> DOES change acuity. And tho, so far, more comfortable with the posterior arm
> in dystocia, Anna's "all-fours" is always in the back of my mind. Tell us how
> you proceed. And if time permits, how you decide (what clinical features
> determine) which 'profound truth' to follow. tj
>

Are we talking about the same apples??

I was in the discussion of how to get a stuck head out of the pelvis and added the observation (however eminent it might be or not) that an alternative of grunging up the head lodged in the pelvis (either with an intrauterine hand or with an assistant poking holes in the baby's brain straining to push the head - and bacteria and blood and yuch - up from below) was to reach UPWARD and pull the little feetsies down and deliver a breech. When you do that you have to GENTLY (as in Dirk) work the head upwards, as there's still a lot of suction on it if it's really impacted.

After that, there was a comment about fractured femurs, which may or may not be possible. I've never gotten close to that - never had the right kind of tension on the legs, as I recall. The only touchy part would be getting the head out of the suction maw of the pelvis.

I think I've done this about 3 times, since like many things (e.g. the fabled Zavanelli), it's not commonly needed. It's always worked like a charm, even the first time when I did it on the fly because the residents were fighting and grunging to get the head out and it wouldn't come, even WITH an assistant from below.

Nuff said.

Joe P.

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