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Proper delivery technique a lost art.

I read with amusement two articles in the June 1, 2005, issue ("Incontinence Twice as Likely With Vaginal Birth," p. 17, and "Anterior Genital Trauma, Incontinence Link Studied," p. 29).

Right occiput posterior is the normal presentation at the pelvic inlet. The head flexes and rotates at the ischial spine. However, right occiput posterior to right occiput anterior is not a malpresentation. Every ob.gyn. should know how to flex and rotate a head with the index and middle fingers when the patient is dilated 6 cm. An ob.gyn. who doesn't know how to flex and rotate the head has been inadequately trained. Unfortunately, because of malpractice litigation, this technique is becoming a lost art.

When the ob.gyn. uses this technique, the fetal skull changes shape; primips will be complete in less than an hour and multips usually in 20 minutes with an epidural and pitocin running so you have an adequate contraction. The result is less avulsion of pudendal nerve fibers and less stretching of the perineum. I have supervised and delivered more than 18,000 babies and have had a very low incidence of anal incontinence and urinary stress incontinence. I have always taught Kegel exercises to hypertrophy remaining muscle where avulsion of pudendal nerve fibers has occurred despite early rotation. Further, midline episiotomies demand meticulous repair to prevent fistulas and anal incontinence. Anal sphincters must be repaired correctly at delivery.

At Cook County Hospital where I trained, we never allowed a patient to be complete for more than 1 hour. Among patients allowed to remain complete longer, there would be an occasional dead baby--electronic fetal monitoring had not yet been developed. But fetal monitoring leads to the false conclusion that it is safe to allow a patient to be complete for up to 3 hours. Unfortunately, subtle damage to the baby occurs during this time. The baby can crash and, despite an immediate C-section, there can be a bad result and litigation. When a patient pushes and is complete for 2+ hours, perineums are overstretched, pudendal nerve fibers avulse, and we have what prompted this letter.

Evan F. Evans, M.D.

Ogden, Utah
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Title Annotation:LETTERS
Author:Evans, Evan F.
Publication:OB GYN News
Article Type:Letter to the editor
Date:Aug 15, 2005
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