The many uses of nitroglycerine.

The magic bullet in many cases of difficult fetal extraction is sublingual nitroglycerine spray. Most cases of impaction at cesarean delivery are caused by sustained uterine contraction or increased uterine tone. These situations can become easy deliveries in almost all cases when nitroglycerine is given. In our institution, all anesthetists carry nitroglycerine in the anesthesia cart, ready to go.

This approach is also useful when breech extraction of a second twin becomes difficult, and in cases involving podalic version of a second twin. It also is helpful in some cases of shoulder dystocia. In fact, this drug and its OB applications would be worth an entire article!

A common problem is not giving sufficient nitroglycerine quickly enough because of concern about maternal hypotension. I recommend giving 400 pg of sublingual spray every 30 to 60 seconds until the uterus relaxes or systolic blood pressure drops below 90 mm Hg.

Mark Jacobs, MD

Mill Valley, Calif