Your letters

August 5, 2016

Readers weigh in on the best forceps for a Scanzoni rotation and the reasons behind our high cesarean rate.

Which forceps are best?

I read with great interest the article titled “Get a handle on the Scanzoni maneuver” by Drs Cigna, Gabba, and Larsen (Contemporary OB/GYN, June 2016).

As an academician who continues to teach forceps use and a clinician who still performs operative vaginal deliveries, I commend the authors on their thoughtful and educational manuscript. The Scanzoni maneuver is a difficult one to employ due to its infrequent use and potential for maternal injury, especially if the wide arc described by the authors is not performed properly. I disagree, however, with the use of Tucker-McLane forceps for this procedure. Their overlapping shanks do not allow for sufficient room with a markedly molded head, as is often encountered in occiput posterior positions. Rather, I prefer to use Simpson forceps (with their parallel shanks) for this type of delivery.

 

Frederick Friedman Jr, MD

New York, New York

 

In reply:

We appreciate the letter from Dr Friedman regarding his preference for Simpson forceps, rather than Tucker-McLane forceps, to perform the Scanzoni rotation. We generally recommend that the operator start with the Tucker-McLane forceps to correct asynclitism. We have also found that the Luikart modification allows them to slide more easily and is associated with fewer cheek marks and less tearing of the vaginal mucosa and introitus.

Scalp edema is usually not an obstacle, but occasionally there is so much caput and molding that the Simpson forceps with their non-overlapping shanks are better able to accommodate this, as suggested by Dr Friedman.

 

Sarah T Cigna, MD

Nancy D Gaba, MD

John W Larsen, MD

 

 

Scanzoni avoids cesarean

As a retiring 69-year-old ob/gyn having practiced for 35 years, I would like to join the other voices lamenting the demise of forceps deliveries in this country. In response to the timely article on Scanzoni rotation in the June 2016 issue of Contemporary OB/GYN, I would simply say that I have always used Luikart-Simpson’s, have never used abdominal assistance, and I rotate in whichever direction is nearest to occiput anterior. With the next contraction, I apply traction with the handles downward to further engage the vertex, to prevent spontaneous reversion to occiput posterior, and reapply the forceps. They should be removed with crowning to minimize lacerations.

One of my final deliveries was a 35-year-old primip on 5 medications for lupus nephritis and hypertension who presented at 35 weeks with premature rupture of membranes. Her nurse called me when she could not find the fetal heart rate (FHR), and as I entered the room the hospitalist had just finished her exam, stating that the patient was completely dilated, the vertex was +1, the IFE was not registering, and the nurse could not find the FHR externally.

As the hospitalist ran to set up the section room, I examined the patient, asked her to push, and felt slight descent with the vertex occiput posterior. I asked for forceps, completed a Scanzoni rotation, and delivered a healthy baby boy who responded quickly to the neonatology team’s efforts. He had a tight nuchal cord and a true knot, which were constricting with his descent.

Our hospital has an outstanding nursing and anesthesiology staff, and I have delivered emergently in from as little as 12 to as many as 20 minutes, depending on the circumstances. An emergency cesarean delivery in this case could have had a much less satisfactory outcome. In light of our current medicolegal climate, I completely sympathize with my colleagues who eschew operative vaginal deliveries for fear of shoulder dystocia, complications of prolonged second stage, and time constraints on their individual practice regimens. Unfortunately, the consequent increase in repeat cesareans will inevitably take its toll in known complications. 

 

Peter Geittmann, MD

Arlington Heights, Illinois

 

In reply:

We were pleased to read Dr Geittmann’s letter. The situation he described is a good example of the timely use of forceps for fast medically indicated delivery. In our method we have found subjective benefit in using an abdominal assistant as an enhancement to help the corpus of the fetus to roll while the head is turned with the forceps.  We also agree that training the next generation to utilize this tool will empower future ob/gyns to provide a safe option that will reduce the cesarean delivery rate and possibly improve outcomes.

 

Sarah T Cigna, MD

Nancy D Gaba, MD

John W Larsen, MD

 

 

Lower cesarean rate may not mean best outcome

As an obstetrician who trained at the advent of electronic fetal monitoring, ultrasound evaluations, epidural anesthesia, fathers in the delivery room, and increasing litigation for perceived poor outcome, I can bear witness to the factors that contribute to increased cesarean delivery rate: and that would be: “all of the above.” The future of obstetrics and the problematic cesarean delivery rate lies in the decision for the ob practice model of the future: either the traditional private practice model or the laborist approach.

The traditional “private” time-proven model gives us a “get-her-done” (and go home for dinner) incentive; and because that comes with a close patient friendship, it creates a great fear of a bad outcome and then the anxiety of having to answer directly to the patient (or her lawyer). This easily explains an inherently fear-driven higher cesarean delivery rate. The newer laborist model allows a more “expectant,” time-irrelevant approach to the labor curve, but with a consequent lower cesarean delivery rate and maybe a slippery slope into a “next shift syndrome.”

I think we know the direction in which we are going, due to the economics of medicine and the future plans for the coveted practice style of our residents (ie, quality of lifestyle reigns). This inevitability will most likely lower the cesarean delivery rate (perhaps a statistic that has created its own overblown importance); but will this truly give us better long-term outcomes for our newborns and our patients’ pelvic function?

How do you want this to work out for your daughters and granddaughters-a low cesarean delivery rate for statistical bragging rights, or just a best obstetrical outcome? I truly hope that individual obstetricians can indeed make that decision on an individual basis, rather than the heavy, uncaring hand of bureaucracy for statistical political correctness.

 

E Lawrence Langan III, MD

Malvern, Pennsylvania