OB-GYN-L Messages for February, 2008: Re: Episiotomy question

Re: Episiotomy question

From: Meenan, Anna

annam@uic.edu

Tue Feb 19 22:01:10 2008

A few thoughts on the points you have made:

I deliver all my babies in a hospital setting in the U.S. too. The first time I used the Gaskin Maneuver was during the delivery of a 255-lb mom who had precip'ed the head while still on a labor bed, which was actually a large cart with a 4-inch thick mattress that did not break off at the bottom (this was 1989 and we still "went back to delivery" in those days.) I had only heard of the maneuver shortly before that, but when I looked at the big mom, sunk into the mattress with no room to maneuver, that was what flashed through my mind---Get her butt out of the mattress--and that seemed the best way to do it. The mom didn't bat an eyelash when I told her what we needed to do, and was quite agile in spite of her size. It's really not as big a deal as you think it is.

Re: Tubes and wires: I usually pull the IUPC on the last few pushes and disconnect the scalp electrode as the head is delivered. Who uses pulse oximeters during labor? Really? When the baby's life is at stake, I've never known a mom to be too sedated to move. Adrenaline trumps sedation every time. Really, how often do you see moms sleep through second stage?

The patients that I have had to move to all-4's were ALL very grateful that they could play a part in saving their baby's lives, and I always make a point to congratulate them on their cooperation and quick action. Also impressed the heck out of the nurses the first time I did it, and to their credit, they pitched right in and did what I asked without arguing or questioning (this was almost 20 years ago, after all.)

Borrowing a line from an old Alka-Seltzer commercial: "Try it. You'll like it."

Anna Meenan, MD

>In a message dated 2/19/2008 10:41:39 AM Eastern Standard Time,
>inamaygaskin@gmail.com writes:
>
>Sometimes when the mother is on her hands and knees (whether she was
>already there before the dystocia or you had her turn over) and the
>position itself isn't enough to disimpact the shoulder, you can ask
>her to draw one knee forward and that will do the trick.
>
>A midwife I know who was put into McRoberts told me that she was
>unable to push in this position and that she could barely breathe
>either. Her point was that she would have preferred moving to all
>4's.
>
>Ina May
>
>I don't know how I got into the middle of this considering I did not
>even ask the initial question, but it has been a very interesting
>discussion. It is always nice to learn a new technique. One would
>never know when it would become useful...
>
>This discussion has gotten me thinking - when a fetus is
>stuck behind a pelvis, three things can help. 1. Make the opening of
>the pelvis larger. 2. Rotate the fetus that's stuck. 3. Rotate the
>pelvis that's blocking the shoulder. Now, I know the last point may
>be difficult for many people to accept, especially since I have
>neither eminence nor evidence. Just like we sometimes learn from
>children because of their unindoctrinated minds, I am just offering
>a fresh look at things. When Ina May have the women draw one knee
>forward during the Gaskin/ on-all-4 Maneuver, isn't she effectively
>rotating her pelvis?! And as Betsy discribed the baby's center of
>mass is up high within the uterus, wouldn't it be easier to rotate
>the pelvis, instead of the baby, using the mother's legs as a lever
>while maintaining the McRobert Maneuver? Also, you can rotate the
>pelvis one way, and rotate the baby another way for a synergistic
>effect.
>
>I have no objection to flipping the patient over if that is what it
>is going to take to deliver the baby. But if there was an
>alternative, the less drama the better. I deliver all my babies in
>a hospital setting. Flipping a patient over is never a pretty
>sight. There are the basic BP monitor, fetal monitor and pulse
>oximeter lines to deal with. Often there are the lV and epidural
>lines. And sometimes the oxygen and amnioinfusion lines too! Not to
>mention the patient might have received sedation. And the patient
>may weigh three hundred pounds! And now there is a baby's head in
>her butt! No wonder they say the first thing to do is to ask for
>HELP! Help! Lastly, I practice in the United States. My patients
>are used to sitting in cushy chairs, and sleeping on pillow topped
>mattresses. I am not sure they would appreciate the idea that their
>doctor have them delivering their precious ones like some less
>evolved creatures. So if I can achieve a similar effect without
>flipping the patient over, I would much rather prefer that.
>
>Allan
>
>Delicious ideas to please the pickiest eaters.
>the video on AOL Living.

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