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June 2013
Crisco is an effective vaginal lubricant
I’ve been in ObGyn practice since 1976—and have recommended Crisco to my patients as a vaginal lubricant for just about as long. I laughed at the mention of storing Crisco in a crystal jar because it sounded like one of my ideas.
Many of my patients use Crisco prior to exercise and other activities because it tends to protect them from irritation. I also have used Crisco as a base for some sexual lubricants that I have compounded, and it seems to work very well.
Another novel remedy: I often recommend cold milk to relieve vaginal irritations and to boost the effect of topical steroids prior to their use—I even patented the treatment and am in the process of licensing it to a consumer company. I previously had a product on the market for treating diaper rash, sore breasts from nursing, irritation from exercise, and other complaints using the same technology and patent.
I now have my patients wet and then freeze a panty liner, apply skim milk to its surface, and wear it until it is no longer cold. It provides great relief from irritation, hair removal, herpetic attacks, and so on.
Stephen M. Renzin, MD
Larchmont, New York
There are better lubricants than Crisco!
The suggestion of Crisco as a vaginal lubricant was distasteful. There are so many products on the market; even olive oil is a better alternative. Crisco stains, gets hot when placed on the body, and is messy. I doubt our male colleagues would apply it to their bodies.
Lisa Riha, DNP, FNP-BC
Yorktown, Virginia
Migraine drug relieves vasomotor symptoms
In over 30 years of practice, I have found that the old migraine drug Bellergal‑S (belladonna, ergotamine, and phenobarbital) works very well to relieve vasomotor symptoms and insomnia. It is clearly inappropriate for women with heart disease, and the brand is no longer made, but it can be compounded, as necessary.
Tanja Todd, MD
Germantown, Tennessee
Dr. Barbieri responds
I appreciate the observations of Dr. Renzin and Dr. Todd regarding the use of cold milk to treat vaginal irritation and a compounded version of Bellergal-S to treat vasomotor symptoms and migraine headache.
In regard to Dr. Riha’s criticism of the use of Crisco as a vaginal lubricant, I agree that there are no large-scale clinical trials comparing the effects of Crisco versus an alternative agent in women. However, many postmenopausal patients with vaginal symptoms report improvement with Crisco.
Outpatient vaginal hysterectomy places undue burden on the family
In her commentary on the study of outpatient vaginal hysterectomy, Dr. Rosanne Kho did not discuss the impact that postoperative care of these patients can have on the family. It is a tremendous challenge for the family to care for a woman who has undergone vaginal hysterectomy. I had two friends, both of whom had excellent support at home, who experienced complications. One had a breakdown of the vaginal cuff and bled. The family transported her to the emergency room (ER), where packing was applied. She was ultimately returned to the operating room and given 2 U of red blood cells, followed by a 3-day hospital stay.
The other friend developed a pulmonary embolus on postoperative day 5, as she had been sedentary due to pain. She was taken to the ER, given heparin, and hospitalized for 3 days. She is now on long-term anticoagulation therapy.
Lisa Riha, DNP, FNP-BC
Yorktown, Virginia
“UPDATE ON MENOPAUSE”
ANDREW M. KAUNITZ, MD (JUNE 2013)
Two questions on menopause management
I have two questions about Dr. Andrew Kaunitz’s Update on Menopause:
- How should I manage a 70-year-old patient who has been taking hormone therapy (HT) for 20 years (transdermal estradiol plus progesterone) and is doing well with stable health? Can Dr. Kaunitz offer any guidelines on dosing, weaning, or maintaining the status quo until the HT is medically contraindicated?
- Does ospemifene have other benefits, such as breast protection and bone health? The package insert, other articles, and my pharmaceutical rep say nothing about additional sites of action. If the drug offers nothing besides protection against vaginal atrophy, is it worth the risk of venous thromboembolism (VTE)?
Maureen O’Regan, MD
Arlington, Virginia
Dr. Kaunitz responds
Dr. O’Regan thoughtfully raises two clinical questions relevant to menopausal practice: management of extended use of HT, and selection of appropriate treatment for symptomatic genital atrophy.
I have several patients in their 70s who are ongoing users of HT. Regrettably, no data from randomized trials are available to provide guidance to providers or patients about the benefits or risks of extended HT. Because the patient Dr. O’Regan describes is taking estradiol and progesterone, she presumably has an intact uterus. We know that the risk of breast cancer increases with increasing duration of estrogen-progestin therapy, so it is important to counsel long-term users proactively about this concern and encourage them to keep up to date with screening mammography.
Even at age 70, there is a substantial risk that vasomotor symptoms will return if HT is discontinued, and it is not clear whether tapering the dose of HT offers any advantages over abrupt discontinuation in this regard.1 Given that age is an independent risk factor for VTE, I agree that transdermal estradiol is more appropriate than oral estrogen in a 70-year-old woman.
In my practice, I encourage older HT users to consider trying a lower dose. If bothersome vasomotor symptoms do not recur, I either continue with a very low dose (especially if the patient has risk factors for osteoporosis) or ultimately discontinue hormone therapy.
Although we know that the selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene provide protection against osteoporosis and breast cancer, I am not aware that ospemifene has been studied in regard to these outcomes. For most of my patients with symptomatic genital atrophy, I plan to continue recommending vaginal estrogen (creams, ring, or tablets). For symptomatic women who would prefer oral therapy, however, ospemifene should prove to be a welcome new option.
Reference
- North American Menopause Society. Position statement: The 2012 hormone therapy position statement of the North American Menopause Society. Menopause. 2012;19(3):257–271.
Another technique for resolving shoulder dystocia
I find another maneuver useful for a shoulder dystocia emergency: I locate the axilla of the anterior shoulder and place my index finger or index and middle finger in the axilla from the posterior aspect and gently rotate the anterior shoulder anteriorly (adduction), thereby reducing the diameter of the shoulders. This maneuver has an effect similar to that of Rubin’s maneuver: It reduces pressure on the shoulder under the pubic bone by applying traction posteriorly toward the maternal perineum.
A key point: To avoid injury, do not apply pressure into the pit of the axilla.
Daniel Sacks, MD
West Palm Beach, Florida
My first maneuver: Deliver the posterior shoulder
I agree with Dr. Barbieri that delivering the posterior shoulder is the preferable method of resolving a shoulder dystocia emergency. If the posterior arm is fully extended, then by applying pressure in the cubital fossa and pushing it posteriorly, one might facilitate flexion of the arm and make it easier to reach the forearm and follow it to the wrist, finally grasping and pulling it. A large mediolateral episiotomy is essential.
This procedure also can be applied during cesarean delivery for a macrosomic fetus. Delivering the posterior shoulder will facilitate the delivery and reduce the risk of extending the incision laterally into the uterine vessels.
Raymond Michael, MD
Marshall, Minnesota
Help the baby “deliver itself”
I first attempt to elevate the head, the opposite approach to what everyone else suggests. This maneuver causes the posterior shoulder to move past the plane of the pubic symphysis and helps disengage the anterior shoulder. Then, with or without suprapubic pressure, I rotate the posterior shoulder anteriorly while ensuring that the “turning of the screw” keeps this shoulder moving anteriorly in front of the plane of the pubic symphysis, and the baby usually just delivers itself.
This maneuver has yet to fail, so I have not had to move on to other techniques, which have usually been performed before I am called.
Robert Graebe, MD
Long Branch, New Jersey
Article on shoulder dystocia prompted anxious memory
The May issue of OBG Management was superb, with great information about cervical management, menopause, cesarean delivery, and more. But the article about shoulder dystocia gave me anxiety because it took me back to the one time I experienced this frightening emergency. After my patient had had a normal pregnancy and uneventful labor, it happened…and the instant “Oh no!” moment of fear. That moment was followed by immediate recall and focused, determined implementation of necessary maneuvers to remedy the matter as soon as possible.
I am happy to report that the baby (just under 7 lb at birth) is now grown and doing quite well.
Melody T. McCloud, MD
Atlanta, Georgia
Dr. Barbieri responds
I appreciate the pearls provided by Dr. Sacks, Dr. Michael, and Dr. Graebe. We thank them for sharing their clinical expertise with the OBG Management community.
As Dr. McCloud reports, a severe shoulder dystocia is a particularly frightening event, forever etched on the memory of the obstetrician. As she attests, a quick response involving a relentlessly rehearsed series of interventions calms the nerves and is the secret to successful resolution of this obstetric emergency.
The robot is unnecessary for benign hysterectomy
The physicians in my practice work in a 210-bed hospital in a sparsely populated state. We don’t have the privilege of using a robot for surgery, so we began performing total laparoscopic hysterectomy (TLH) without the robot about 3 years ago. A few of our earlier cases took as long as 3 hours to complete, but we now are able to perform TLH on almost any benign condition in 30 to 90 minutes.
We have avoided the need to convert to open laparotomy in more than 100 consecutive cases, and have performed TLH in uteri as large as 850 g, as well as in women with stage 4 endometriosis.
The partners in my practice who perform TLH did not find the procedure difficult to learn. Even with laparoscopic suture closure of the vaginal apex, we feel that the robot is unnecessary for laparoscopic hysterectomy for benign conditions.
Our overall abdominal hysterectomy rate for the past 5 years is about 12%, by the way.
Philip Wagner, MD
Cheyenne, Wyoming
June 2013
Crisco is an effective vaginal lubricant
I’ve been in ObGyn practice since 1976—and have recommended Crisco to my patients as a vaginal lubricant for just about as long. I laughed at the mention of storing Crisco in a crystal jar because it sounded like one of my ideas.
Many of my patients use Crisco prior to exercise and other activities because it tends to protect them from irritation. I also have used Crisco as a base for some sexual lubricants that I have compounded, and it seems to work very well.
Another novel remedy: I often recommend cold milk to relieve vaginal irritations and to boost the effect of topical steroids prior to their use—I even patented the treatment and am in the process of licensing it to a consumer company. I previously had a product on the market for treating diaper rash, sore breasts from nursing, irritation from exercise, and other complaints using the same technology and patent.
I now have my patients wet and then freeze a panty liner, apply skim milk to its surface, and wear it until it is no longer cold. It provides great relief from irritation, hair removal, herpetic attacks, and so on.
Stephen M. Renzin, MD
Larchmont, New York
There are better lubricants than Crisco!
The suggestion of Crisco as a vaginal lubricant was distasteful. There are so many products on the market; even olive oil is a better alternative. Crisco stains, gets hot when placed on the body, and is messy. I doubt our male colleagues would apply it to their bodies.
Lisa Riha, DNP, FNP-BC
Yorktown, Virginia
Migraine drug relieves vasomotor symptoms
In over 30 years of practice, I have found that the old migraine drug Bellergal‑S (belladonna, ergotamine, and phenobarbital) works very well to relieve vasomotor symptoms and insomnia. It is clearly inappropriate for women with heart disease, and the brand is no longer made, but it can be compounded, as necessary.
Tanja Todd, MD
Germantown, Tennessee
Dr. Barbieri responds
I appreciate the observations of Dr. Renzin and Dr. Todd regarding the use of cold milk to treat vaginal irritation and a compounded version of Bellergal-S to treat vasomotor symptoms and migraine headache.
In regard to Dr. Riha’s criticism of the use of Crisco as a vaginal lubricant, I agree that there are no large-scale clinical trials comparing the effects of Crisco versus an alternative agent in women. However, many postmenopausal patients with vaginal symptoms report improvement with Crisco.
Outpatient vaginal hysterectomy places undue burden on the family
In her commentary on the study of outpatient vaginal hysterectomy, Dr. Rosanne Kho did not discuss the impact that postoperative care of these patients can have on the family. It is a tremendous challenge for the family to care for a woman who has undergone vaginal hysterectomy. I had two friends, both of whom had excellent support at home, who experienced complications. One had a breakdown of the vaginal cuff and bled. The family transported her to the emergency room (ER), where packing was applied. She was ultimately returned to the operating room and given 2 U of red blood cells, followed by a 3-day hospital stay.
The other friend developed a pulmonary embolus on postoperative day 5, as she had been sedentary due to pain. She was taken to the ER, given heparin, and hospitalized for 3 days. She is now on long-term anticoagulation therapy.
Lisa Riha, DNP, FNP-BC
Yorktown, Virginia
“UPDATE ON MENOPAUSE”
ANDREW M. KAUNITZ, MD (JUNE 2013)
Two questions on menopause management
I have two questions about Dr. Andrew Kaunitz’s Update on Menopause:
- How should I manage a 70-year-old patient who has been taking hormone therapy (HT) for 20 years (transdermal estradiol plus progesterone) and is doing well with stable health? Can Dr. Kaunitz offer any guidelines on dosing, weaning, or maintaining the status quo until the HT is medically contraindicated?
- Does ospemifene have other benefits, such as breast protection and bone health? The package insert, other articles, and my pharmaceutical rep say nothing about additional sites of action. If the drug offers nothing besides protection against vaginal atrophy, is it worth the risk of venous thromboembolism (VTE)?
Maureen O’Regan, MD
Arlington, Virginia
Dr. Kaunitz responds
Dr. O’Regan thoughtfully raises two clinical questions relevant to menopausal practice: management of extended use of HT, and selection of appropriate treatment for symptomatic genital atrophy.
I have several patients in their 70s who are ongoing users of HT. Regrettably, no data from randomized trials are available to provide guidance to providers or patients about the benefits or risks of extended HT. Because the patient Dr. O’Regan describes is taking estradiol and progesterone, she presumably has an intact uterus. We know that the risk of breast cancer increases with increasing duration of estrogen-progestin therapy, so it is important to counsel long-term users proactively about this concern and encourage them to keep up to date with screening mammography.
Even at age 70, there is a substantial risk that vasomotor symptoms will return if HT is discontinued, and it is not clear whether tapering the dose of HT offers any advantages over abrupt discontinuation in this regard.1 Given that age is an independent risk factor for VTE, I agree that transdermal estradiol is more appropriate than oral estrogen in a 70-year-old woman.
In my practice, I encourage older HT users to consider trying a lower dose. If bothersome vasomotor symptoms do not recur, I either continue with a very low dose (especially if the patient has risk factors for osteoporosis) or ultimately discontinue hormone therapy.
Although we know that the selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene provide protection against osteoporosis and breast cancer, I am not aware that ospemifene has been studied in regard to these outcomes. For most of my patients with symptomatic genital atrophy, I plan to continue recommending vaginal estrogen (creams, ring, or tablets). For symptomatic women who would prefer oral therapy, however, ospemifene should prove to be a welcome new option.
Reference
- North American Menopause Society. Position statement: The 2012 hormone therapy position statement of the North American Menopause Society. Menopause. 2012;19(3):257–271.
Another technique for resolving shoulder dystocia
I find another maneuver useful for a shoulder dystocia emergency: I locate the axilla of the anterior shoulder and place my index finger or index and middle finger in the axilla from the posterior aspect and gently rotate the anterior shoulder anteriorly (adduction), thereby reducing the diameter of the shoulders. This maneuver has an effect similar to that of Rubin’s maneuver: It reduces pressure on the shoulder under the pubic bone by applying traction posteriorly toward the maternal perineum.
A key point: To avoid injury, do not apply pressure into the pit of the axilla.
Daniel Sacks, MD
West Palm Beach, Florida
My first maneuver: Deliver the posterior shoulder
I agree with Dr. Barbieri that delivering the posterior shoulder is the preferable method of resolving a shoulder dystocia emergency. If the posterior arm is fully extended, then by applying pressure in the cubital fossa and pushing it posteriorly, one might facilitate flexion of the arm and make it easier to reach the forearm and follow it to the wrist, finally grasping and pulling it. A large mediolateral episiotomy is essential.
This procedure also can be applied during cesarean delivery for a macrosomic fetus. Delivering the posterior shoulder will facilitate the delivery and reduce the risk of extending the incision laterally into the uterine vessels.
Raymond Michael, MD
Marshall, Minnesota
Help the baby “deliver itself”
I first attempt to elevate the head, the opposite approach to what everyone else suggests. This maneuver causes the posterior shoulder to move past the plane of the pubic symphysis and helps disengage the anterior shoulder. Then, with or without suprapubic pressure, I rotate the posterior shoulder anteriorly while ensuring that the “turning of the screw” keeps this shoulder moving anteriorly in front of the plane of the pubic symphysis, and the baby usually just delivers itself.
This maneuver has yet to fail, so I have not had to move on to other techniques, which have usually been performed before I am called.
Robert Graebe, MD
Long Branch, New Jersey
Article on shoulder dystocia prompted anxious memory
The May issue of OBG Management was superb, with great information about cervical management, menopause, cesarean delivery, and more. But the article about shoulder dystocia gave me anxiety because it took me back to the one time I experienced this frightening emergency. After my patient had had a normal pregnancy and uneventful labor, it happened…and the instant “Oh no!” moment of fear. That moment was followed by immediate recall and focused, determined implementation of necessary maneuvers to remedy the matter as soon as possible.
I am happy to report that the baby (just under 7 lb at birth) is now grown and doing quite well.
Melody T. McCloud, MD
Atlanta, Georgia
Dr. Barbieri responds
I appreciate the pearls provided by Dr. Sacks, Dr. Michael, and Dr. Graebe. We thank them for sharing their clinical expertise with the OBG Management community.
As Dr. McCloud reports, a severe shoulder dystocia is a particularly frightening event, forever etched on the memory of the obstetrician. As she attests, a quick response involving a relentlessly rehearsed series of interventions calms the nerves and is the secret to successful resolution of this obstetric emergency.
The robot is unnecessary for benign hysterectomy
The physicians in my practice work in a 210-bed hospital in a sparsely populated state. We don’t have the privilege of using a robot for surgery, so we began performing total laparoscopic hysterectomy (TLH) without the robot about 3 years ago. A few of our earlier cases took as long as 3 hours to complete, but we now are able to perform TLH on almost any benign condition in 30 to 90 minutes.
We have avoided the need to convert to open laparotomy in more than 100 consecutive cases, and have performed TLH in uteri as large as 850 g, as well as in women with stage 4 endometriosis.
The partners in my practice who perform TLH did not find the procedure difficult to learn. Even with laparoscopic suture closure of the vaginal apex, we feel that the robot is unnecessary for laparoscopic hysterectomy for benign conditions.
Our overall abdominal hysterectomy rate for the past 5 years is about 12%, by the way.
Philip Wagner, MD
Cheyenne, Wyoming
June 2013
Crisco is an effective vaginal lubricant
I’ve been in ObGyn practice since 1976—and have recommended Crisco to my patients as a vaginal lubricant for just about as long. I laughed at the mention of storing Crisco in a crystal jar because it sounded like one of my ideas.
Many of my patients use Crisco prior to exercise and other activities because it tends to protect them from irritation. I also have used Crisco as a base for some sexual lubricants that I have compounded, and it seems to work very well.
Another novel remedy: I often recommend cold milk to relieve vaginal irritations and to boost the effect of topical steroids prior to their use—I even patented the treatment and am in the process of licensing it to a consumer company. I previously had a product on the market for treating diaper rash, sore breasts from nursing, irritation from exercise, and other complaints using the same technology and patent.
I now have my patients wet and then freeze a panty liner, apply skim milk to its surface, and wear it until it is no longer cold. It provides great relief from irritation, hair removal, herpetic attacks, and so on.
Stephen M. Renzin, MD
Larchmont, New York
There are better lubricants than Crisco!
The suggestion of Crisco as a vaginal lubricant was distasteful. There are so many products on the market; even olive oil is a better alternative. Crisco stains, gets hot when placed on the body, and is messy. I doubt our male colleagues would apply it to their bodies.
Lisa Riha, DNP, FNP-BC
Yorktown, Virginia
Migraine drug relieves vasomotor symptoms
In over 30 years of practice, I have found that the old migraine drug Bellergal‑S (belladonna, ergotamine, and phenobarbital) works very well to relieve vasomotor symptoms and insomnia. It is clearly inappropriate for women with heart disease, and the brand is no longer made, but it can be compounded, as necessary.
Tanja Todd, MD
Germantown, Tennessee
Dr. Barbieri responds
I appreciate the observations of Dr. Renzin and Dr. Todd regarding the use of cold milk to treat vaginal irritation and a compounded version of Bellergal-S to treat vasomotor symptoms and migraine headache.
In regard to Dr. Riha’s criticism of the use of Crisco as a vaginal lubricant, I agree that there are no large-scale clinical trials comparing the effects of Crisco versus an alternative agent in women. However, many postmenopausal patients with vaginal symptoms report improvement with Crisco.
Outpatient vaginal hysterectomy places undue burden on the family
In her commentary on the study of outpatient vaginal hysterectomy, Dr. Rosanne Kho did not discuss the impact that postoperative care of these patients can have on the family. It is a tremendous challenge for the family to care for a woman who has undergone vaginal hysterectomy. I had two friends, both of whom had excellent support at home, who experienced complications. One had a breakdown of the vaginal cuff and bled. The family transported her to the emergency room (ER), where packing was applied. She was ultimately returned to the operating room and given 2 U of red blood cells, followed by a 3-day hospital stay.
The other friend developed a pulmonary embolus on postoperative day 5, as she had been sedentary due to pain. She was taken to the ER, given heparin, and hospitalized for 3 days. She is now on long-term anticoagulation therapy.
Lisa Riha, DNP, FNP-BC
Yorktown, Virginia
“UPDATE ON MENOPAUSE”
ANDREW M. KAUNITZ, MD (JUNE 2013)
Two questions on menopause management
I have two questions about Dr. Andrew Kaunitz’s Update on Menopause:
- How should I manage a 70-year-old patient who has been taking hormone therapy (HT) for 20 years (transdermal estradiol plus progesterone) and is doing well with stable health? Can Dr. Kaunitz offer any guidelines on dosing, weaning, or maintaining the status quo until the HT is medically contraindicated?
- Does ospemifene have other benefits, such as breast protection and bone health? The package insert, other articles, and my pharmaceutical rep say nothing about additional sites of action. If the drug offers nothing besides protection against vaginal atrophy, is it worth the risk of venous thromboembolism (VTE)?
Maureen O’Regan, MD
Arlington, Virginia
Dr. Kaunitz responds
Dr. O’Regan thoughtfully raises two clinical questions relevant to menopausal practice: management of extended use of HT, and selection of appropriate treatment for symptomatic genital atrophy.
I have several patients in their 70s who are ongoing users of HT. Regrettably, no data from randomized trials are available to provide guidance to providers or patients about the benefits or risks of extended HT. Because the patient Dr. O’Regan describes is taking estradiol and progesterone, she presumably has an intact uterus. We know that the risk of breast cancer increases with increasing duration of estrogen-progestin therapy, so it is important to counsel long-term users proactively about this concern and encourage them to keep up to date with screening mammography.
Even at age 70, there is a substantial risk that vasomotor symptoms will return if HT is discontinued, and it is not clear whether tapering the dose of HT offers any advantages over abrupt discontinuation in this regard.1 Given that age is an independent risk factor for VTE, I agree that transdermal estradiol is more appropriate than oral estrogen in a 70-year-old woman.
In my practice, I encourage older HT users to consider trying a lower dose. If bothersome vasomotor symptoms do not recur, I either continue with a very low dose (especially if the patient has risk factors for osteoporosis) or ultimately discontinue hormone therapy.
Although we know that the selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene provide protection against osteoporosis and breast cancer, I am not aware that ospemifene has been studied in regard to these outcomes. For most of my patients with symptomatic genital atrophy, I plan to continue recommending vaginal estrogen (creams, ring, or tablets). For symptomatic women who would prefer oral therapy, however, ospemifene should prove to be a welcome new option.
Reference
- North American Menopause Society. Position statement: The 2012 hormone therapy position statement of the North American Menopause Society. Menopause. 2012;19(3):257–271.
Another technique for resolving shoulder dystocia
I find another maneuver useful for a shoulder dystocia emergency: I locate the axilla of the anterior shoulder and place my index finger or index and middle finger in the axilla from the posterior aspect and gently rotate the anterior shoulder anteriorly (adduction), thereby reducing the diameter of the shoulders. This maneuver has an effect similar to that of Rubin’s maneuver: It reduces pressure on the shoulder under the pubic bone by applying traction posteriorly toward the maternal perineum.
A key point: To avoid injury, do not apply pressure into the pit of the axilla.
Daniel Sacks, MD
West Palm Beach, Florida
My first maneuver: Deliver the posterior shoulder
I agree with Dr. Barbieri that delivering the posterior shoulder is the preferable method of resolving a shoulder dystocia emergency. If the posterior arm is fully extended, then by applying pressure in the cubital fossa and pushing it posteriorly, one might facilitate flexion of the arm and make it easier to reach the forearm and follow it to the wrist, finally grasping and pulling it. A large mediolateral episiotomy is essential.
This procedure also can be applied during cesarean delivery for a macrosomic fetus. Delivering the posterior shoulder will facilitate the delivery and reduce the risk of extending the incision laterally into the uterine vessels.
Raymond Michael, MD
Marshall, Minnesota
Help the baby “deliver itself”
I first attempt to elevate the head, the opposite approach to what everyone else suggests. This maneuver causes the posterior shoulder to move past the plane of the pubic symphysis and helps disengage the anterior shoulder. Then, with or without suprapubic pressure, I rotate the posterior shoulder anteriorly while ensuring that the “turning of the screw” keeps this shoulder moving anteriorly in front of the plane of the pubic symphysis, and the baby usually just delivers itself.
This maneuver has yet to fail, so I have not had to move on to other techniques, which have usually been performed before I am called.
Robert Graebe, MD
Long Branch, New Jersey
Article on shoulder dystocia prompted anxious memory
The May issue of OBG Management was superb, with great information about cervical management, menopause, cesarean delivery, and more. But the article about shoulder dystocia gave me anxiety because it took me back to the one time I experienced this frightening emergency. After my patient had had a normal pregnancy and uneventful labor, it happened…and the instant “Oh no!” moment of fear. That moment was followed by immediate recall and focused, determined implementation of necessary maneuvers to remedy the matter as soon as possible.
I am happy to report that the baby (just under 7 lb at birth) is now grown and doing quite well.
Melody T. McCloud, MD
Atlanta, Georgia
Dr. Barbieri responds
I appreciate the pearls provided by Dr. Sacks, Dr. Michael, and Dr. Graebe. We thank them for sharing their clinical expertise with the OBG Management community.
As Dr. McCloud reports, a severe shoulder dystocia is a particularly frightening event, forever etched on the memory of the obstetrician. As she attests, a quick response involving a relentlessly rehearsed series of interventions calms the nerves and is the secret to successful resolution of this obstetric emergency.
The robot is unnecessary for benign hysterectomy
The physicians in my practice work in a 210-bed hospital in a sparsely populated state. We don’t have the privilege of using a robot for surgery, so we began performing total laparoscopic hysterectomy (TLH) without the robot about 3 years ago. A few of our earlier cases took as long as 3 hours to complete, but we now are able to perform TLH on almost any benign condition in 30 to 90 minutes.
We have avoided the need to convert to open laparotomy in more than 100 consecutive cases, and have performed TLH in uteri as large as 850 g, as well as in women with stage 4 endometriosis.
The partners in my practice who perform TLH did not find the procedure difficult to learn. Even with laparoscopic suture closure of the vaginal apex, we feel that the robot is unnecessary for laparoscopic hysterectomy for benign conditions.
Our overall abdominal hysterectomy rate for the past 5 years is about 12%, by the way.
Philip Wagner, MD
Cheyenne, Wyoming