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

Re: OB: Bladder Flap flap
From: Terrence.Jones@kp.org
Thu Jul 17 20:11:58 2003

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Oranges is fine - considering, after 3 hours, the caput is likely a banana. I'm not as much concerned about the 'after-coming' head, following delivery of the 'breech'. If anything, without the baby cramped inside the uterine cavity, the head would seem far easier to deliver, with or without elevation from below or with Barton's. (Tho the only green jnl ref i could find with Megison (WRT Barton's) was O/G '93 (Metaire, La - Lakeside) and referred to repeat c/s and other 'HIGH vtx' presentations). Vacuum has certainly been used by some here, with difficult del of the head at c/s - i've avoided it due to perceived lack of necessity and concern re: additive morbidity. (In some cases, avoiding forceps and vacuum was the REASON for their choosing a c/s!) In neither instance is there any relevance to delivery of a socked-in vtx as a breech. So, as you say - "whatever".
I like the idea of avoiding vertical extension and related morbidity (bleeding, potential ureteral injury). And if this can be accomplished by delivering the baby's bottom thru a low-transverse incision, then GREAT! However, this is a direction never pursued by myself, in the past. That it is interesting, and potentially less morbid suggests it be given attention.
Soooo -
Do you give 500 cc amnioinfusion after turning off the pit?
Do you purposefully make your uterine incision above (or as close to the upper end of) the vesico-uterine peritoneal reflection (to be closer to your target)? [Placing the rotational axis higher in the uterus]
Is the reduction in compliance (available space within which to maneuver), resulting from an anterior placenta a (rel.) contraindication?
Do you grab both feet and pull? What if the sacrum is anterior and won't rotate?
Is traction on the LE's more impt than traction over the sacrum? [WRT effectiveness, AS WELL AS morbidity (femoral Fx)].
Do you try and deliver both feet thru the middle of your incision - or do you rotate the baby to one (or the other) side and obtain flexion at the abdomen, deliver and extend the LE's, and then try for the breech?
Is it clear to you, when first reaching for the fundus, that there is "room" to negotiate (or not)?
What if you can only deliver to the knees, and no further? Do you extend upwards (in midline["T"] or to the side["L"])?
Does anesthesia administer (or have readily available) a relaxation agent (NTG?).
Lastly, from the 'intuitive' sense this approach provides plausibility. Is there any formal description of this in the (as Mats describes) litterature?
Venturing into "NEO"-realism need not be done so blindly. After all, we must "see" to know - which is the red pill. And 'abierto los ojos' is but the first step in the process of tidying up the 'symbolic order'. tj
DoctorJoe@aol.com Sent by: ob-gyn-l@obgyn.net 07/17/2003 04:08 PM Please respond to ob-gyn-l
To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net> cc: Subject: Re: OB: Bladder Flap flap
In a message dated 7/17/03 13:04:18, Terrence.Jones@kp.org writes:
Just trying to get the whole picture. The incision is made. The arm of the baby is now handing you its cord. The assistant is able to push the head upward. Suction is broken as the delivering hand meets the assistant's at the vertex. Flexion is accomplished. Despite every effort to elevate without "breaking the wrist" (as mentioned by another - abducting with flexing forward and facing cross-table); rotation when ears are visible; and reduction, below the vtx - there is now an eight cm vertical extension into the parametria and the ureter is now bathed in heme. This is the "apple" to which i'm referring. So - You reach in and grab the legs. Someone says they've seen femoral fractures with this appraoch. You suggest such fractures may be related to technique? Here's where i'm a bit lost.
I remember that they were talking about the various misadventures of the stuck head, and I merely commented that instead of going all out to get the head UP, you can try to reach up and get the feet and pull the baby out that way. I think once you've broken the suction and have a hand down in there, you keep on going for it. Some have used a single Barton forcep to lever the head out (Megison, Green Journal, few and sundry years ago). Some can stick a vacuum on it. Whatever . . . .
I was only commenting on the head the is DOWN there and difficult to get at anyway. So I guess I was talking about oranges.
Joe P.
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         Oranges is fine - considering, after 3 hours, the caput is likely a banana. I'm not as much concerned about the 'after-coming' head, following delivery of the 'breech'. If anything, without the baby cramped inside the uterine cavity, the head would seem far easier to deliver, with or without elevation from below or with Barton's. (Tho the only green jnl ref i could find with Megison (WRT Barton's) was O/G '93 (Metaire, La - Lakeside) and referred to repeat c/s and other 'HIGH vtx' presentations). Vacuum has certainly been used by some here, with difficult del of the head at c/s - i've avoided it due to perceived lack of necessity and concern re: additive morbidity. (In some cases, avoiding forceps and vacuum was the REASON for their choosing a c/s!) In neither instance is there any relevance to delivery of a socked-in vtx as a breech. So, as you say - "whatever".                 I like the idea of avoiding vertical extension and related morbidity (bleeding, potential ureteral injury). And if this can be accomplished by delivering the baby's bottom thru a low-transverse incision, then GREAT! However, this is a direction never pursued by myself, in the past. That it is interesting, and potentially less morbid suggests it be given attention.          Soooo -                 Do you give 500 cc amnioinfusion after turning off the pit?                   Do you purposefully make your uterine incision above (or as close to the upper end of) the vesico-uterine peritoneal reflection (to be closer to                 your target)? [Placing the rotational axis higher in the uterus]                 Is the reduction in compliance (available space within which to maneuver), resulting from an anterior placenta a (rel.) contraindication?                         Do you grab both feet and pull? What if the sacrum is anterior and won't rotate?                  Is traction on the LE's more impt than traction over the sacrum? [WRT effectiveness, AS WELL AS morbidity (femoral Fx)].                                  Do you try and deliver both feet thru the middle of your incision - or do you rotate the baby to one (or the other) side and obtain flexion at the                 abdomen, deliver and extend the LE's, and then try for the breech?                 Is it clear to you, when first reaching for the fundus, that there is "room" to negotiate (or not)?                  What if you can only deliver to the knees, and no further? Do you extend upwards (in midline["T"] or to the side["L"])?                   Does anesthesia administer (or have readily available) a relaxation agent (NTG?).                  Lastly, from the 'intuitive' sense this approach provides plausibility. Is there any formal description of this in the (as Mats describes)                         litterature?                   Venturing into "NEO"-realism need not be done so blindly. After all, we must "see" to know - which is the red pill. And 'abierto los ojos' is but the                 first step in the process of tidying up the 'symbolic order'.  tj <table width0%> <tr valign=top> <td> <td>DoctorJoe@aol.com Sent by: ob-gyn-l@obgyn.net 07/17/2003 04:08 PM Please respond to ob-gyn-l <td>                To:        Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>         cc:                 Subject:        Re:  OB: Bladder Flap flap</table> In a message dated 7/17/03 13:04:18, Terrence.Jones@kp.org writes: Just trying to get the whole picture. The incision is made. The arm of the baby is now handing you its cord. The assistant is able to push the head upward. Suction is broken as the delivering hand meets the assistant's at the vertex. Flexion is accomplished. Despite every effort to elevate without "breaking the wrist" (as mentioned by another - abducting with flexing forward and facing cross-table); rotation when ears are visible; and reduction, below the vtx - there is now an eight cm vertical extension into the parametria and the ureter is now bathed in heme. This is the "apple" to which i'm referring. So - You reach in and grab the legs. Someone says they've seen femoral fractures with this appraoch. You suggest such fractures may be related to technique? Here's where i'm a bit lost. I remember that they were talking about the various misadventures of the stuck head, and I merely commented that instead of going all out to get the head UP, you can try to reach up and get the feet and pull the baby out that way. I think once you've broken the suction and have a hand down in there, you keep on going for it. Some have used a single Barton forcep to lever the head out (Megison, Green Journal, few and sundry years ago). Some can stick a vacuum on it. Whatever . . . . I was only commenting on the head the is DOWN there and difficult to get at anyway. So I guess I was talking about oranges. Joe P. 

Next message: DoctorJoe@aol.com: "Re: OB: Bladder Flap flap"
Previous message: Glen Elrod MD: "Re: OB: Bladder Flap flap"
Next in thread: Efrain Ramirez: "Re: OB: Bladder Flap flap"
Reply: Efrain Ramirez: "Re: OB: Bladder Flap flap"

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