Re: Episiotomy question
From: R. Daniel Braun (rd.braun@gmail.com)
Tue Feb 19 09:12:46 2008
On Feb 18, 2008 9:46 PM, Betsy Hyde <elishyde@att.net> wrote:
>
> On Feb 18, 2008, at 9:18 PM, AllanHo@aol.com wrote:
>
> If you really think about it - rotating the mother hips may actually not
> be so physiologically dissimilar to the Wood Screw or Rubin's Maneuvers.
>
> I don't think so. IMO the problem with SD is in the AP diameter and
> impingement of the shoulder behind the symphysis pubis....and I can't see
> how rotating the hips will change that. McRoberts has been radiographically
> shown to increase the AP diameter. I have never had to do Gaskin maneuver,
> because other maneuvers have always worked (fortunately) but the option
> certainly is always present should I not be able to release the shoulder.
> Since I usually have the bed broken, when I suspect a SD I drag the woman's
> buttocks off the end of the bed so the sacrum has room to rotate
> posteriorly.
>
You know back in the old days we had shoulder stops that we put on the bed
so that the patient couldn't scoot her buttocks back up on the table.
Nowadays with epidurals we don't need them, we just need to get the buttocks
down over the end of the table. IMHO, 95% of what gets labeled shoulder
dystocia today is really "Table Dystocia". Both McRoberts and Gaskin
Maneuvers do the same thing, i.e they allow the coccyx to float posteriorly,
Dan
>
> One thing I have found helpful is to have the assistant do suprapubic
> pressure into one of the obliques, depending on which way I want to rotate
> the shoulder. It has never made sense to me for the assistant to do
> suprapubic pressure in an AP direction if, for instance, I am trying to
> rotate from 1 o'clock to 11 o'clock. Then suprapubic pressure just gets in
> my way and inhibits rotation. It seems to me that suprapubic pressure in the
> AP diameter only works if the bisacromial diameter is directly AP, and you
> want to compress it....which it rarely is.
>
> I always very clearly identify the shoulder, decide in which direction to
> rotate, take my opposite hand and place it on the maternal abdomen and tell
> the assistant how I want pressure abdominally.
>
> I often extract the posterior arm, unless it is extended. A trick I was
> taught by one of my OB colleagues is a "shoe horn" maneuver in which I place
> my hand around the posterior shoulder, and apply pressure cephalad, and then
> anteriorly. This tends to release the shoulder and then redirect so it
> comes under the pubic symphysis. I've only had to do this a few times,
> though.
>
> I have only had to do an episiotomy a few times, and that was when I did
> not have room to get my hand in the vagina to do whatever maneuvers I wanted
> to perform. SD is not a soft tissue problem....it is a bony pelvis problem.
> For medical legal reasons, however, I am always careful to document
> "episiotomy considered but not performed due to ample room to insert hands
> into vagina for maneuvers."
>
> We have many women with epidurals, and I often have them push on hands and
> knees (and often birth in that position), so I don't worry about having them
> assume that position if there is suspected SD. And I've never seen anyone
> sit on their baby's head!
>
> Perhaps I am fortunate, but I have never had a bad SD or permanent
> brachial plexus injury, so I guess I must be doing something right!
>
> Betsy Hyde CNM
> Branford, CT
>
--
R. Daniel Braun, MD FACOG(L) ABMP CMTh
Professor Emeritus
Dept. of Obstetrics and Gynecology
Indiana U. School of Medicine
R. Daniel Braun
"Science without Religion is LAME; Religion without Science is BLIND"
Einstein 1941
