Episode 8.11 Catheters in Labor, Occiput Posterior Fetuses, and Cesarean Scar Disorder
Do patients in labor need continuous bladder drainage? We will review the literature comparing intermittent to continuous drainage.
Next, we venture into the art and science of manual rotation for persistent posterior fetal presentations, a skillful maneuver that might just hold the key to lowering cesarean rates. Drawing from comprehensive reviews and trials, including the TURN-OUT trial and studies from UCSF, we debate the efficacy and applicability of manual rotation in various clinical settings. From ultrasound-guided techniques to hands-on learning, gain a nuanced understanding of how this practice might enhance delivery outcomes and reduce interventions.
Finally, we learn about Cesarean Scar Disorder, a relatively new diagnosis with important clinical ramifications.
00:00:10 Urinary Catheterization in Labor Management
00:16:10 Manual Rotation of the OP Fetus
00:49:32 Effectiveness of Labor Positioning Techniques
00:58:03 Cesarean Scar Disorder
Links Discussed
Bladder drainage during labor: a randomized controlled trial
Bladder Management With Epidural Anesthesia During Labor: A Randomized Controlled Trial
One-Time Catheterization in Short Gynecologic Procedures and Its Effect on Bacteriuria
Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position
What is your approach to the persistent occiput posterior malposition?
Get a handle on the Scanzoni maneuver
Hands-and-knees posturing and fetal occiput anterior position: a systematic review and meta-analysis
Cesarean scar defects and abnormal uterine bleeding: a systematic review and meta-analysis
Definition and Criteria for Diagnosing Cesarean Scar Disorder
Transcript
Announcer: 0:02
This is Thinking About OB-GYN with your hosts Antonia Roberts and Howard Herrell.
Antonia: 0:17
Howard.
Howard: 0:18
Antonia.
Antonia: 0:19
What are we thinking about on today’s episode?
Howard: 0:21
Well, we’re going to talk about occiput posterior fetal heads, mostly in response to a listener question. But first, what’s the thing we do without evidence?
Antonia: 0:30
Well, I’m going to challenge myself here on this one today. So how about routinely using Foley catheters to drain the bladder when patients are in labor and they’ve just gotten an epidural?
Howard: 0:41
Okay, sure, yeah, and I’d be surprised if we haven’t already mentioned this at least before, maybe when we talked about things during labor management or things like that. But it’s amazing how many things are different from one place to another, even from the places where we work. So in many places it’s automatic that you have an indwelling foley catheter placed as soon as a patient’s in labor and has an epidural, and then you remove it, maybe when you start pushing or maybe after you’ve pushed for a while and the patient’s ready to deliver. But then in a lot of other places there’s never catheters after epidurals, with some combination maybe of just the patient voiding on a bedpan or voiding spontaneously or having intermittent catheterization, and so lots of things that are just really cultural and not necessarily based in science or at least in good literature.
Antonia: 1:29
All right. Well, foleys continuous indwelling foleys have always been done for this reason, everywhere that I’ve worked and we actually went out of our way to develop some protocols for making sure women got these at the right time so they wouldn’t end up with urinary retention and this was at some of my prior duty stations. And I’ve gone through this both times, or I’ve gone through this twice myself now, and both times, as soon as I got my epidural, I said, just put that catheter in me. Now I don’t care if I’m not even numb yet, because I really don’t want a bladder injury from urinary retention. And then both times I’d say, okay, how much did it? It would be like 300, 400 mLs, and hopefully that’s not TMI to all our friends listening. But I would pat myself on the back and say, yeah, I didn’t get a bladder injury because I got that Foley right away. So it’s a shock to me to learn that it’s mostly unnecessary to do that.
Howard: 2:30
Yeah, and I’ll just say as a rule of thumb on things like this if you see one hospital always doing something one way and another facility never doing it that way or doing it a different way, or one doctor or surgeon always does a certain thing every time they do a procedure and another doctor or surgeon basically never does that, yet their outcomes are essentially equivalent between those different hospitals or facilities or physicians or surgeons, then that extra intervention, the extra thing you see a person doing, is almost always unnecessary. But they may have really good reasons and in this case, for avoiding urinary retention, why they believe it’s really important.
Antonia: 3:09
Yeah, and I’ve been now in in at least four different facilities, but three of them all operated on similar protocols, because that was in the military and and there may be other factors that play, like what are the standard fluid maintenance, fluid rates or fluid bolus rates or what goes into the epidurals, for example. But now I’m also, we also do this in a non-military setting, where I’m at now, but you don’t do this and you do not run into problems with urinary retention or anything else that could be related to this. So are there any trials that look at this practice?
Howard: 3:51
Yeah, so there are a few. In 2012, there was a small resident study where 139 patients were randomized to receive a bladder catheter if they got an epidural or to just have intermittent catheterization, and they found no difference in the time of delivery and the cost was roughly the same. They were still spending money on the catheter or the intermittent catheters, but they concluded that nurses preferred continuous drainage and therefore they recommended that people continue with continuous drainage because the nurses didn’t want to have to.
Antonia: 4:15
Maybe repeated intermittent cath is frankly, more work for the nurses after all, and both of these interventions still involve inserting something into the urethra to drain the bladder.
Antonia: 4:36
It’s just the question of whether to leave it indwelling or not.
Antonia: 4:39
So in case anyone’s wondering why we even care about this, catheter-associated UTIs are a risk especially of continuous drainage even intermittent, but more so continuous and they’ve become a quality metric in a lot of hospital systems and the electronic health record that I use right now always pops up a warning every time I put in my standard labor orders that do include using a Foley.
Antonia: 5:07
I put in my standard labor orders that do include using a Foley and a lot of systems will have some kind of warning for each additional day that someone still has an active Foley order, and one of the components of the enhanced recovery after surgery pathways is removing the Foley as soon as possible if there is one in place. But at the same time I’m certain that many nurses and even patients would prefer not to have to deal with bedpans or pure wick catheters and those sorts of things that a continuous catheter could replace, and sometimes those alternatives are uncomfortable or they can make a mess, like if they’re just peeing on themselves, and I’ve seen pretty bad vulvar rashes develop on people that have prolonged use of a Purwick catheter and if a patient does have urinary retention but otherwise meets criteria to go home. A lot of times in my experience, if they’re given a choice between intermittent cath or a continuous leg bag, a lot of them will just choose the leg bag because they don’t want to have to keep poking their urethra multiple times at home.
Howard: 6:09
Yeah, we definitely live, though, in an age where fewer catheters typically is thought to be better, and we’ve talked about some of these things briefly with gynecologic surgeries too. I rarely use, before minor procedures, any kind of bladder drainage. I have them void before they come to the operating room. It’s almost always sufficient, but all that’s in the spirit of removing any type of catheterization, intermittent or continuous. I never have continuous catheters in during my surgeries anymore, things like that, so we’re trying to avoid these. I do think we have to be careful about exchanging short-term convenience, say for the nurse, if we’re trading that out for a higher risk of infection or other risks plus cost. Even.
Howard: 6:49
I suspect that the authors of that resident trial they thought they would find shorter labors I think that was probably their intention by having the bladders continuously drained and then therefore having the head lower in the pelvis because the bladder wasn’t full, and they didn’t find any advantage or disadvantage really, so they just went with their observation about nurse preference. But in 2015, some nurses did a randomized controlled trial and they acknowledged that the traditional view of catheterization was that it would prevent urinary retention and promote fetal descent. They also acknowledged the risk of urinary tract infection, so they did a study of 123 patients with continuous versus intermittent catheterization and again they just found no difference in the length of the second stage of labor or overall labor duration and they found a similar low rate of urinary tract infections in the two groups. But they did find a much higher rate of cesarean delivery in the continuous catheterization group and they recommended that intermittent catheterization was the best practice. I think again because they found no differences, but maybe that one little difference in C-section rate.
Antonia: 7:49
Well, that’s a little weird. I’m not sure I understand why having a continuous catheter would increase cesarean risk, but they did have a 27% rate of cesarean in that group versus 10% in the intermittent catheterization group.
Howard: 8:08
Yeah, and I’m not sure I can wrap my head around that either. This is likely just an artifact in the data. It’s a good lesson that we do studies all the time and you find something that appears to be significant. But it’s just noise in the data, it’s just random difference, and maybe then don’t count that as a reason against Foley’s or something that you should immediately implement a different protocol here because of this finding. It’s certainly not from some small subset finding like that. But if there were a link, if I had to guess, maybe it’s related to how much they’re moving the patients around.
Howard: 8:36
Maybe the catheterized patients are just cathed and epiduraled and the monitors are on the right place and they just sit there in one spot for hours and have very little interaction or movement. And maybe the ones that aren’t cath, they’re moving them around and I don’t know. Who knows. It’s probably just an artifact in the data.
Antonia: 8:54
Okay, well, so far we’ve got two kind of lower quality trials, and they don’t really say much about this either way.
Howard: 9:01
Yeah, and that’s the story of a lot of this. So there is a systematic review that was done by your gynecology folks in 2019, and they found no difference in the urinary outcomes like you were talking about, or UTI urinary retention rates, or postpartum hemorrhage rates, for that matter.
Antonia: 9:17
I think I know why they’re looking at postpartum hemorrhages and that study, but could you explain this one for the listeners?
Howard: 9:23
Yeah, there’s certainly a traditional teaching that one of the first things you should do when you have a postpartum hemorrhage is drain the bladder, and the thought is perhaps that a full bladder physically blocks the uterus from contracting normally. I don’t know, and this goes back to Joseph DeLee, if I recall, and therefore it’d be associated with more postpartum hemorrhage. And though you still frequently see this listed as an intervention for postpartum hemorrhage, there’s really no scientific evidence that a fuller bladder causes patients to have more of a hemorrhage, but it might interfere with your ability to fill the uterus and massage the fundus effectively. So I think in the 1930s and 40s, where this came from, you couldn’t fill a firm uterus because the bladder was in the way, and then you drain the bladder and all of a sudden you can fill a firm uterus. So I literally think that’s the origin of this. It’s a longstanding belief. Anyway, in this study they found no difference between the strategies of intermittent catheterization and continuous catheterization vis-a-vis the postpartum hemorrhage outcomes.
Antonia: 10:15
The way I’ve always thought about it is that as soon as someone starts hemorrhaging, you need to establish accurate urine output.
Antonia: 10:23
Just like with a trauma patient or some other medically unstable patient. You need them pretty much supine on the bed while you’re managing them and you need all hands on deck, so you don’t really need people occupying themselves with these extra intermittent straight casts Just in this case. They have more important things to do. So pop it in and stop her bleeding. And, worst case, if you have to rush them to do so, pop it in and stop her bleeding. And worst case, if you have to rush them to the OR for surgical management, then you probably also want it in. For that reason, a lot of these studies look at intermittent catheterization as the alternative to continuous drainage with a Foley, but I’m not really confident that many patients actually would be getting regular intermittent catheterization in labor if they didn’t have a Foley. Probably again because it’s extra work, for really a lot of units are understaffed, it feels like, and they can’t have this extra work put on them if there’s another way to decrease it.
Howard: 11:21
That’s true and the argument there to be made is let’s get our units staffed appropriately and get them funded correctly so that patients have one-on-one care appropriately and don’t have nurses pulled in different directions so that they can be there and support the patient. You do see, unfortunately, in some units, this trend of tucking the patient away. She’s comfortable with her epidural and her catheter and the nurse is gone for three hours and that’s not good patient care either. I never put a catheter in when the patient has a hemorrhage. I think it’s another one of those cultural things where we might do it in completely different ways and imagine the reasons for it. So there’s so many of these things. I’ve been doing some work in a different unit and there’s so many of these things that are just like oh yeah, that’s totally different than what we do it. And I have a list and again it’s like it’s not that necessarily either place is doing it wrong. It’s just a cultural sort of inheritance of different backgrounds of nurses and doctors coming together. But that’s the point of science is we can try to look at these things and determine if they’re necessary or not.
Howard: 12:19
And there are a few more studies. I do think you’re right that a lot of patients don’t have episodes necessarily of intermittent casts Ours don’t. They may not have the epidural for very long, they may just have it for a couple of hours. They do void spontaneously. They void spontaneously when they’re pushing. If they have a hemorrhage and you massage their uterus, urine comes out, or it probably already was empty because they just pushed a baby out, that sort of thing. But I’ll put a link to another 2018 study that did this and said there was no difference in the length of labor in a 2008 randomized trial that actually showed a shorter second stage of labor in the intermittent group, but other similar outcomes Again, probably just an unexpected and random difference. And then finally, a larger 2020 trial that found no difference in the mode of birth or UTI symptoms or other outcomes of interest, like we’ve been discussing.
Antonia: 13:08
Okay, so basically you’re saying the bulk of the data says there’s no difference or perhaps a trend towards shorter delivery time or more vaginal deliveries, but maybe that’s just related to how much the patients are being moved and repositioned for these intermittent caths.
Howard: 13:25
Yeah, maybe, or again, just random differences in small studies that were underpowered to see anything. But the question is, if doing some intervention has the same effect as not doing the intervention, then I think our preset philosophically should be to not do the intervention. We shouldn’t do invasive procedures or even non-invasive interventions on patients if we don’t have good quality data that says that that thing benefits the patient, and I think that’s the case here.
Antonia: 13:54
Yeah, and on that same note, you were talking about bladder drainage for your surgery patients. I saw a research letter in the Green Journal for November 2024 that was challenging the use of even one-time bladder drainage by straight cath for patients undergoing minor gynecologic surgeries, because they showed in their little study they did that even just straight catheterization one time led to a greater risk of UTIs and no decrease in the risk of urinary retention.
Howard: 14:24
Yeah, and UTIs specifically symptomatic or significant UTIs such a hard outcome to find that maybe these studies are underpowered. There’s a 2015 abstract in the Green Journal where they randomized 200 women to straight cath or no straight cath and then assessed bacteria and urinary pain and they didn’t find a difference. But yeah, I don’t normally do this. I have the OR team have my patient void before they come back, especially if this is a short procedure Think all the DNCs and diagnostic lapse and salpingectomies and those sorts of things. So if you’re doing a procedure that takes 10 or 15 minutes or less, there’s really no reason to introduce a catheter when there’s clearly no benefit potentially some harm. And if you’re doing a laparoscopic case, you may need the bladder drained before you do the surgery, but they can pee right before they come back. Anyway, I think this is going to be another one of those episodes where we respond to a listener comment with the whole rest of the episode. That’s fun though I think. So let’s get into that and see how much time we take up.
Antonia: 15:26
Yeah, yeah, I was looking forward to this. So yeah, we mentioned in our prior episode we had a listener question we wanted to give some proper time to address, so we saved an article for that topic and we actually have a couple questions around this, so let’s get into it. So one of our listener friends writes very straightforwardly she says I remember listening to a recent discussion on the podcast about manual rotation in the setting of persistent OP or occiput posterior, but unfortunately now I can’t find which episode it was in and I was hoping to listen again. Can you help me find this Signed rotating and Rota. So I need that tagline up. That’s good.
Antonia: 16:07
Funny Anyway, so that’s an easy question. It’s back in season one, episode six, where we discussed micro skills in obstetrics. But we didn’t really go into much detail about the technique or the idea of rotation for persistent posterior presentations. We mainly just said it’s a good thing to have in your skill set. So let’s talk about this a little bit more now.
Howard: 16:32
Yeah, and made the claim loosely that you might save yourself a section once or twice a year if you were doing that. So the micro skills list in that episode were all things that don’t affect your practice that much on an everyday basis, but maybe every now and again you have a patient who, if you don’t have that skill set they’re going to get a cesarean. They might not have needed, but because we do them so infrequently these sorts of things, then it’s hard to maintain our skill set.
Howard: 16:58
We may not be comfortable with them and after a while folks just give up on doing them altogether and or don’t do them well or I don’t want to say aggressively, but not with full gusto, because they don’t feel confident doing it. So this includes things like external cephalic version, for example, or breach extraction of a second twin, or operative deliveries, for that matter, vacuum and forceps deliveries, and certainly it includes things like manual rotation.
Antonia: 17:22
Yeah, so there was a maintenance of certification article from this past cycle and it was from June 2022 in the Gray Journal and it was a systematic review and meta-analysis of randomized controlled trials relating to manual rotation of occiput posterior or transverse positions posterior or transverse positions and they ultimately identified seven studies they thought were appropriate, involving a total of 1,400 women, and about half of those were assigned to manual rotation and the other half were not. They were the control group and they found from this review that manual rotation was associated with a higher rate of spontaneous vaginal delivery. But when they stratified it, they found that statistical significance persisted only for occiput posterior, not for transverse. They also found an overall lower rate of episiotomy, so I think that does suggest that this is a useful technique, wouldn’t you say?
Howard: 18:21
Yeah, and they looked at a lot of other results too that might be of interest, like neonatal outcomes, rates of shoulder dystocia, nicu admissions, those sorts of things, and they didn’t see any differences. So take some solace that this is a safe thing to do when you do it correctly and that in a lot of folks, especially if you’re learning to do this, you might want some reassurance that this is a safe thing to do. But yeah, the first question always is does it work? Was it worth doing to begin with? And at first blush, yeah, it appears to be. It’s worth doing because it’s not associated with any demonstrated risks in these studies compared to not doing it, and it does save at least some subset of women a cesarean delivery they would have otherwise received.
Howard: 19:02
But I think this can also be a reminder that a systematic review or a meta-analysis like this one that analyzes prior trials is again only as good as those individual trials. And in a unit that already has a high rate of cesarean, you may not see much of a difference in the C-section rate if you implement a program of manual rotation, and that’s because these are such a small fraction of all the cesareans and many unnecessary cesareans that happen in most places. You also might see less effect on the opposite extreme if the cesarean rate is already quite low and maybe it’s customary to give patients even several hours to push, which if you’re in the OP position you might need. In other words, if you allow a primigravity patient four hours or longer in some cases to push, then a lot of those patients are going to be successful at pushing out the occiput posterior baby, even if you don’t rotate it, and so you may not see an implementation effect there in those kinds of centers either.
Antonia: 20:05
Yeah. So there’s some other factors at play that could balance this out or maybe dilute out the value of doing this. If you do a C-section on everybody who hasn’t delivered a baby in an hour or two, then maybe rotating babies could save some of your patients a trip to the OR, but it would be a drop in the bucket If that’s your practice. You probably have a lot of other things to work on to optimize your cesarean rate than the manual rotation. So all of this is to say we should look at some of the individual trials and put them into context.
Howard: 20:37
Yeah, that reminds me of what we’ve commented before about the ARRIVE trial, where yeah you might lower your cesarean rate if your cesarean rate’s already three times as high as it should be, but if you don’t have that high of a cesarean rate, the ARRIVE trial at least in terms of lowering your risk of cesarean and or not increasing it probably doesn’t apply to your practice, so you have to think about that.
Howard: 20:57
So let’s see how the data looks from some of the individual trials, and I think the challenge here is looking at your own practice setting and your own individual rates and experiences and then seeing which trials suit you. And that’s the failure of some of these systematic reviews is they take studies that aren’t really analyzable together and they put them together. So one of those was a retrospective trial published in 2011 that had 731 patients who underwent manual rotation, compared to over 2,500 who did not. In this trial, which was done in the United States, they found a significantly lower rate of cesarean and lower rate of severe perineal lacerations, along with fewer hemorrhages and less chorionitis in the group that received manual rotation. In fact, the number of rotations needed to prevent one cesarean delivery was just four, which a number needed to treat a four is wonderful. They did find a higher risk of cervical laceration in the patients who had rotations, but overall they concluded that it was a fantastic thing to do.
Antonia: 21:56
All right. Well, the context here is this was a study done by people who really are advocates for a lower cesarean rate, like we all should be right, but maybe not everyone is, and they are likely very good at doing manual rotations, given that their trial included several hundred of them, and there were some pretty big names in OBGYN on the author lines, including Aaron Cauhey and some others, and this was from the MFM department at UC San Francisco, and that might look different. It probably looks different than a trial done in a facility or setting with higher cesarean rates maybe a smaller community setting, for example and frankly, that has people that maybe aren’t trying quite as hard to turn babies when they say they’re trying, but they just go through the motions just to at least say they tried.
Howard: 22:48
You see that with external cephalic versions a lot where the effort is minimal because there’s not a lot of desire to succeed. But yeah, and that’s my point about looking at the individual studies, this trial may not apply to your hospital, your setting or attitude, and we, unfortunately, are being beat over the head with these sorts of systematic reviews and meta-analysis because they’re easy to write and publish. You actually see courses now where we’ll teach you in a weekend to throw together systematic reviews, and you see authors now who’ve done little real research where they’ve published 70 or 80 systematic reviews and meta-analysis to build their CVs. You can even hire people to do them for you. Essentially, we should talk about this problem with systematic reviews and meta-analysis in more detail in another episode. But again, remember, a systematic review of five garbage studies and one good study is not a fair thing to do. The one good study will trump those. So you do have to look at these individual components of these trials.
Howard: 23:41
There was a randomized controlled trial published in the Gray Journal in 2021, where the authors randomized 257 women in France at four hospitals to either prophylactic manual rotation of an occiput posterior head or to no trial of that, and they found that operative vaginal deliveries and cesarean deliveries were significantly less common in the intervention group. They reduced their rate of operative vaginal deliveries from 41.2% to 29.4%, and the patients also had a significantly shorter duration of the second stage of labor if they underwent a manual rotation. And, of course, they found no safety differences or neonatal outcome differences between the two groups.
Antonia: 24:17
So another very positive study for manual rotation, but there are also trials that show no difference, right?
Howard: 24:24
Of course, yeah, and that’s how we get to this interesting systematic review that they put on our MOC list, which, still overall, did show a lower rate of cesareans, again among occiput posterior patients only. So we’re focusing our conversation really on occiput posterior patients and not occiput transverse patients. Here there’s a trial published in the American Journal of Obstetrics and Gynecology, mfm, in 2022, called the TURNOUT trial, and this was a smaller study, but 80 women were assigned to manual rotation and 80 women to some sham procedure, and they basically found that 40 and 41 women in the two groups they got an operative delivery anyway, despite undergoing an attempt at manual rotation in one half of them.
Antonia: 25:06
Okay. So that’s an example maybe of if you have a really high rate of operative deliveries like 50% of every OP person then maybe trying the procedure doesn’t do much.
Howard: 25:19
Right, exactly, and we talked about this phenomenon in the last episode too where the people in the extremes of performance don’t necessarily benefit from interventional changes. So remember, in the last episode we talk about Norwegians not benefiting from adopting modern labor curves, but folks on the other end in the United States, who had high cesarean delivery rates, did but recall. The meta-analysis said there was no benefit. Interestingly, though, in this turnout trial which didn’t meet a planned enrollment of 416 patients and so of course that’s how you may find a type 2 error, which this very well may be they did find that among the more experienced doctors there was a reduction in the rate of operative deliveries from 63 to 51% still a high rate of operative deliveries, but I should point out that most of these operative deliveries were not cesareans. In fact, there were only six cesareans in the rotation group and seven in the control group, but over 40% of the patients had forceps or vacuums in the two groups.
Antonia: 26:14
So it sounds like the technique matters and, yeah, that rate is really high and maybe it shows that those obstetricians there really seem to favor operative deliveries, vaginal or C-section. That study was in Australia. In the US many of those operative vaginal deliveries could have become cesareans instead, and then you would have had a study like the previous one, which then showed a significant reduction in the rate of cesarean.
Howard: 26:45
Exactly so. The point is you have to look at the individual studies here and decide if this is in a practice setting in a patient population like yours, and does the data apply to you and your facility and your patients? I suspect for most US-based obstetricians manual rotation will result in fewer cesarean and operative vaginal deliveries, with a shorter length of the second stage of labor and perhaps then less hemorrhage and less chorio.
Antonia: 27:09
Okay, so let’s talk about technique. We should note that manual rotation of the occiput, posterior or transverse head really became for most of us a replacement for the technically more challenging and potentially more risky forceps rotation Usually that’s Keelan’s. I’ve seen some other names like there’s something called the left forceps or the Scanzoni maneuver, where you use any other kind of conventional forceps, so where we have less and less experience doing rotational forceps, which I actually never was shown in residency, so I don’t do that. I was never got to be part of one of those deliveries.
Howard: 27:47
Even though you do a lot of forceps.
Antonia: 27:49
I do a lot of forceps, yeah, but not rotations. That’s like a whole separate thing.
Howard: 27:53
And that’s typical of our generation.
Antonia: 27:55
Yeah, so we do, maybe a manual rotation and then just forceps. Well then, with the decreasing overall experience with forceps overall, and especially with rotational forceps. Well then, with the decreasing overall experience with forceps overall, and especially with rotational forceps, a lot of those deliveries have just been replaced with cesareans over time and somehow it seems that cesareans have even eclipsed just the manual rotation technique, which is safer, objectively and easier than doing an unscheduled cesarean with a deeply impacted fetal head and the occipital posterior position. There’s just a historical truth that you can’t dispute here. We’ve had the rate of cesareans go from 5% in the early 70s to nearly 34% in the US, and the decline in forceps use and manual rotations is definitely a part of it. It’s not the whole story, obviously, but the question now is how do people learn lost art? How do they start doing something they’ve never done before, that was never taught very well to them?
Howard: 28:55
Yeah, those are all good points. We talked about the fetal pillow recently and people looking for the assistance to do these very difficult cesareans where the patient has been complete and pushing and there’s a deeply impacted head, and the solution to a lot of those is to pull the baby out, not push it back in and go do a cesarean. But folks have lost confidence in not just manual rotation but in operative deliveries in general. So you do see obstetricians who just don’t do operative vaginal deliveries and they’ve replaced essentially all of those deliveries potentially with a cesarean. And then even among the folks that’s what you’re saying even among the folks who do operative deliveries, well, we’re not doing rotational operative deliveries. So we replaced the manual rotation aspect if you’re not doing that probably with a cesarean. So, yes, those are many of the small reasons that add up to that much larger rate of cesarean without a concomitant improvement in neonatal outcomes. That’s the other important part about that is that we’ve not seen babies at term doing really any better since the 1970s, even though the cesarean rate has gone up significantly. So let’s talk about how to do manual rotation.
Howard: 30:08
There’s a couple of prerequisites. The first thing is you need to have a fully dilated cervix and you need to have confirmed the rotation or position of the fetal head. Now you don’t need an ultrasound to do this. I personally almost always do this now with an ultrasound If I’m going to do this. I didn’t always, but you know you’ve got a swollen head, you’ve got a lot of cap it. It’s tough. It’s tough even for very experienced people to always know with a high degree of certainty how that fetal head is rotated. But certainly if you feel confident with your digital exam, there’s not a lot of cap it and you know the position, then that’s fine. You’re not obligated to do the ultrasound.
Howard: 30:44
The ultrasound could be transabdominal and transvaginal. We talked before about using the angle of progression technique and some of those, and I’ve really incorporated more of that trans I should say translabial ultrasound or trans perineal ultrasound into my practice. And when the head is deeply in the pelvis you can see a lot more sometimes. But you don’t necessarily have to do that. You can do a transabdominal ultrasound and confirm the rotation of the head, look for where the eye sockets are, look for the rotation with the falx cerebri, and you can do the same thing with a translabial ultrasound and you may also do the angle of progression and practice that while you’re doing that, you just put a glove over the abdominal ultrasound probe and hold it between the labia and again looking for some of the same landmarks.
Howard: 31:30
It’s a different view, obviously, but something that you can practice and become more familiar with. You can even have somebody ultrasound you while you’re doing the rotation, transabdominally, and it’s pretty cool and we’ll put a link to a video of just that where somebody’s done this later on. But anyway, when you do the rotation, the timing of it at least, is something that people will argue about. So some folks think that you should do it as soon as you know that they’re completely dilated but rotated incorrectly, and others say, well, let them push for 30 to 60 minutes before you try to do it, and that’s because many of these will rotate spontaneously in just that short interval of time, and so waiting 30 minutes or so is typically the approach I’ve taken. But you’ll also just see that many patients are making great progress and maybe they don’t need to be rotated and they’ll push out their six pound, 12 ounce OP baby just fine, and you don’t need to do anything.
Antonia: 32:23
Yeah, and we were talking earlier about just how moving patients around, for example for intermittent catheterization, seems to help shorten their labors, possibly. So maybe if they’ve pushed for 30 minutes in one position there hasn’t been much progress in the rotation or descent, then maybe you could give them another 30 minutes, change up the positions a bit and have a few more that’ll rotate in the correct position without any further intervention. And then if someone still remains OP and is not close to delivery of an OP baby after those 30 to 60 minutes, then you’ve got this trick up your sleeve that we’re about to go over.
Howard: 33:01
Yeah. So 30 to 60 minutes and maybe that’s the difference too in some of these rotation studies is when you’re doing it completely prophylactically, before they’ve even pushed, maybe the effect washes out. But if you reserve it for the group of patients who’ve pushed for a little bit and not made progress and not rotated spontaneously, maybe you see a statistically significant outcome and we can do a whole episode sometime about pushing positions. You see a statistically significant outcome and we can do a whole episode sometime about pushing positions. Is it changing the position or is it just being patient? I think that for a lot of people it’s like pit breaks. We should talk about that sometime. You’re not really doing anything. You’re just maybe generating patients and giving a patient some time that an impatient provider might not have given them. But yeah, I think we’re both in the 30 to 60 minute camp before you try this and not just doing it because you discovered that the baby was OP.
Howard: 33:49
Okay, well, there’s basically two techniques for doing this. So there’s the fingers only technique or the digital rotation technique, which involves putting your fingers along the raised edge of the parietal bone while you gently de-station the fetal head and apply rotational pressure and then some flexion as it rotates around and comes back into the pelvis. I personally don’t like to do this technique. I remember, as an intern, an upper level resident telling me that, and I don’t know, it always felt weird to me to put pressure along the edge of the parietal bone like that. And so why wouldn’t you just hold the head in your hand and do it? That way? Just felt safer to me, so comfort level wise, and in my view this probably only really works for the easy cases, like you’re not going to put a tremendous amount of pressure and so maybe you’re being successful with the patients who might not have needed it. But I don’t know. I can just, like I said, I can be, can remember being a resident and just thinking this is weird. So that’s just my opinion and my own preference.
Antonia: 34:45
Unfortunately, it seems to be that I would get requested to evaluate way longer than after 30 to 60 minutes of pushing the head is really wedged. And that’s when they finally say what if maybe this baby is OP and we need help? And when there’s a lot of molding and swelling and the head is really wedged in there there’s just nowhere to get around. And so if I can tell this baby’s OP, I’ll just feel for whatever leverage I have and a lot of times it’ll be the edge of an overlapping skull suture and then I’ll just work to push against that with a couple fingertips and give counter pressure on the opposite side with my thumb, not going super hard of course, and that’ll work some sometimes, not always, but I think this may be the primary method that’s taught in training programs, possibly because it could be viewed as less aggressive and just a gentle little attempt. As if there’s some harm. We showed there’s no demonstrated harm, but it’s as if there’s a fear that putting your whole hand around and really actually turning the head might over rotate the neck or something like that. So maybe that could be what happens with some of these trials that don’t show huge benefits, where you’re getting this fingers only more.
Antonia: 36:17
Half-hearted effort, because they don’t necessarily always break down exactly how they put their hands on. And then half-hearted effort. Half-hearted effort, because they don’t necessarily always break down exactly how they put their hands on. And then half-hearted effort, half-hearted result. But then there is also the true whole hand technique. So why don’t you go a little more into that?
Howard: 36:34
Yeah, and that’s definitely what. When you read expert opinion pieces or our textbooks, that’s what’s recommended. They mentioned the finger technique in passing, but the whole hand technique is typically what’s recommended, and this is where my colleagues with smaller hands have an edge up on me.
Antonia: 36:51
Yeah, so I guess I shouldn’t have an excuse to only use my fingertips. If I can fit my whole hand in, then I’ll do that Well but no joke.
Howard: 37:00
There’s been many times in my career, for a variety of reasons, where I’ve called in.
Howard: 37:04
Well, I’m not being sexist, but it’s always one of my female colleagues who has smaller hands than I do and they can just do things with those smaller hands that hopefully none of them are mad about me calling them for help, but it does make a difference and, like you said, it can be difficult to get your hand in there.
Howard: 37:19
Anyway, here’s how you do it. If you’re rotating from the right occiput posterior, then normally you’d use your left hand, and if you’re rotating from the left occiput posterior, then you would normally use your right hand. So for right occiput posterior, you slide your left hand in with your palm up and you’re going to hold the occiput in the palm of your hand, so that your hand has the palm up and the head on the hand and your fingers are holding the posterior parietal bone and your thumb is on the anterior or left parietal bone. So fingers on the right posterior side, thumb on the left anterior side, and then you simultaneously flex the head to make the diameter that the head is occupying smaller, and then you push the head up just a little bit, you de-station it just a little bit so that there’s enough room to rotate, and then in this case you would pronate your hand. So this is again your left hand. You’d pronate your hand to rotate the head counterclockwise and you do the mirror image of that, obviously for the left occiput, posterior head.
Antonia: 38:25
I was just mining the motions. So yeah, de-stationing the head is not the same as disengaging the head. You’re not pushing it all the way up to the fundus like out of the pelvis and causing cord prolapse or other issues. You’re just pushing it up just maybe a few centimeters at the most just to get a little bit more room. And if you’re really just right hand dominant and you feel like you can’t do these kinds of things with your non-dominant hand, you can also use your right hand in a contralateral way where you start pronated and flex and de-station and then you do the rotation by supinating your hand. I think a lot of people who are right-handed maybe they’re not comfortable doing something that requires this much dexterity with their left hand.
Howard: 39:13
Were you making a pun with the word dexterity?
Antonia: 39:15
Not intentionally, but I wasn’t trying to be sinister either.
Howard: 39:20
Okay, we’re losing listeners with the. Latin puns, anyway. Yeah, so you could do it with your right hand, and we have a video showing that. And that’s actually called. Well, there’s two techniques. The video doesn’t show this, but there’s a technique called the Holland Maneuver and I think that thinking about the symmetry and just the mechanics of using your left hand for ROPs and your right hand for LOPs works much better and it’s all about how you pronate and go in the right direction at the end, but you can obviously use either hand.
Antonia: 39:51
And then the key is, after you’ve done all of these things, flex D station, rotate.
Antonia: 40:00
Don’t lose your progress and let the baby just rotate right back. You keep your hand there where the baby has rotated to some OA position. It doesn’t have to be direct OA, it could just be ROP to ROA, for example. And for the next maybe one or two contractions or one or two pushes, keep your hand there as the head comes back down and then, once you feel like it’s not going to rotate anymore on its own back to the wrong position, then just immediately resume pushing. Don’t start taking a big break there, and ideally if they had been pushing for just a little bit of time before you started this, like maybe the 30 to 60 minutes then just having that little bit of molding from the pushing could make this rotation that much easier. But like I mentioned before, when there’s a ton of swelling and maybe there could be a little bit of cephalopelvic disproportion, and if they’ve already been pushing for two plus hours, it’s a little bit more of a hail Mary to call us at that point and say can you do a manual rotation now?
Howard: 41:04
Yeah, and this is why it’s important for residents and stuff who are listening. This is why it’s important to think about and, every time you check a patient, to think about the rotation is it occiput posterior, is it transverse, is it asynclitic, is it flexed correctly? Because a lot of these things are correctable. I remember one time many years ago of coming on to shift and inheriting a patient who had been pushing for right at three hours and basically told you, take her to the OR. She’s pushed for three hours and no bueno. And I went in and assessed her and of course it was ROP and I flipped it and she it just slid out. It just slid right out, right. So if you’ve ever done that and you ever seen that effect, it’s just so much easier for a patient to deliver a baby when it’s turned correctly. And that’s not just the occiput posteriors. Again, that does include asynclitics and things like that too. So practice knowing the rotation of these fetal heads and learn the skills to do this. And, like I said, you can use an ultrasound if you want to have confidence in doing it, in fact. So I’ll put a link to a couple of videos and maybe put these on the Instagram too. So there’s a really cool video on YouTube from the ISUOG where they show again that transabdominal ultrasound in real time while the fetal head’s being rotated. I joined that group and I’m a member just to see a lot of the great videos that they have, and a lot of them are videos of labor management using ultrasound.
Howard: 42:29
So there’s a lot of advocates now for increased use of ultrasound doing forceps, placement and operative deliveries and lots of things. The last time I did forceps I don’t do as many as you do, but I a hundred percent brought the ultrasound in there to understand exactly where the rotation was. You just feel a lot more confident with your placements and things like that. So these are great skills to practice and great opportunities for residents to learn that. And ultrasound will definitely make you more confident. And learning things like angular progression and stuff like that too will make you more confident about deciding which patients who’ve pushed for a while should get a trial of operative delivery versus.
Howard: 43:07
Maybe they just need a section and I’ll put another link to and I don’t know if this person was an attending or a resident chief resident maybe but some great teaching in the call room, obviously on a call night shot with a phone and it makes me proud of seeing this kind of resident teaching and the next generation of physicians. But they just have a mannequin on the call room bed demonstrating the techniques we’ve been talking about. Now the person doing the video does just recommend using a dominant hand. She’s right-handed, but in this case she did an LOP fetus, so you can see the technique for that and then you can do the mirror image of that with your left hand. Or she talks about how to use your right hand for both.
Antonia: 43:46
Yeah, and in that video she recommends putting a pillow to tilt the mom’s pelvis a little bit so that because she’s starting pronated and so that helps her get her hand fully around the baby’s head in the correct way. So if you are using the holland maneuver or ipsilateral hand for the ipsilateral rotation, then she she mentioned, as you said, she prefers to use her dominant hand for strength and I could understand that. I don’t have the biggest biceps either. So it’s not that she’s saying Holland technique per se, but she figured out a similar way to make it work and that’s totally fine because she makes it work.
Howard: 44:32
Yeah, and more power to her. I don’t think you need necessarily a lot of strength to do this, but again, if you’re more comfortable with your dominant hand, then she shows you a way to make it work.
Antonia: 44:42
There’s a few other visuals I want to bring up too, just to give some variety. There’s a video. I think there’s some residents at UConn and they talk about manual rotation. About halfway through Then they switched to talking about rotational forceps, one of the ones that’s similar to Key Lens, and I think listeners can take it or leave it. I’m not going to go into rotational forceps, but the first half where they just talk about the manual rotation. They have some really great visuals with the mannequin doll. And then there’s another link. If you just need a single picture you can look at quickly, rather than a whole video. You’re probably going to roll your eyes, but I think the OBG management journal has a really great illustrator.
Howard: 45:24
They do.
Antonia: 45:25
Yeah, and there’s a link to a PDF. They wrote an article about manual rotation and you can take it or leave it. As for the article, but if you just look at that picture it shows really nicely how to how the hand is positioned for that whole hand technique. And then, finally, I’ll just bring up the scans only maneuver again, it’s the rotation with regular forceps, so maybe Simpsons or Lucarts, that are talking planes.
Antonia: 45:53
Yeah, they have that pelvic curve. I have a colleague that does this, so this could be a technique that might actually be more accessible for some people to learn if they really want to learn it, and if you have colleagues out there that could train you up. You pretty much just have to alter the angle of your forceps so that you don’t do damage to the maternal pelvic organs with that internal pelvic curve, so you can look into that option. This is another one of those articles you’d roll your eyes at, but they talk about scansony and they have some visuals, too, of what it means to alter the angle.
Howard: 46:30
Yeah, and the scansony obviously is something that I don’t know. Many people under the age of 60 that are doing it. There are definitely people out there trying to preserve this as a technique. So if you’re fortunate enough to work with some place where you can get enough volume of that, then that’s the way you keep the art alive. I don’t think if you’ve not been trained to do this and you read about how to do a Scanzoni that you should be trying to do it on your own, and definitely not.
Howard: 46:55
And that’s the beauty of manual rotation we probably accomplish about the same thing. So, okay, well, great things to look at We’ll put some of those on the Instagram too and great visuals to explain what we’ve tried to poorly describe with our language.
Antonia: 47:07
And I want to just go back to position changes again. So these sorts of things are commonly done around the country. There’s programs like spinning babies and other similar things. So that video of the call room demonstration about the manual rotation where she said put a pillow under the pelvis to tilt her Originally I thought it was one of those things like, oh, you tilt the mom and then that’ll help the baby tilt even more and then you don’t have to work as hard at rotating. But it’s not that. So what about these different interventions that nursing often will do? And they’re advocated also by doulas and midwives where they might say, oh, the baby’s OP, we’re going to put her in the fire hydrant position for a little while and then reassess.
Howard: 47:54
Yeah, so I broke out my old labor progress handbook written by Penny Simpkin and Ruth Anchetta and these are midwives and this is a book that I read quite intently when I was a resident and I think people used to call me the man midwife and in that book they have a section about interventions to reposition the OP fetus and they do mention manual rotation but they don’t discuss it because they say that’s beyond the scope of what they do, or at least beyond the book. So they’re focusing more on these other sorts of interventions that you’re talking about. So their main recommendation is observation. Again, a lot of them are going to turn on their own. And then in terms of actions, they recommend a hands and knees position for the mother, but also at least discuss having her do lunges, abdominal lifting or knee chest position or just being upright as ways of encouraging rotation of the fetal head.
Antonia: 48:49
And I think that the primary intervention that most resources will talk about for Maybe they’ll also use the peanut- ball or all kinds of position changes, and they’re not just to provide comfort to the mother, which they do, but they’re also meant to speed the progress of labor or to potentially put the fetus in a more favorable position, and they are fairly standard. On most units I’ve worked on, including where I work now and actually where I delivered my second baby, they did some of these things on me just because we didn’t have any issues with OP. But they were like, can we try some of these positions? And I said, sure, and I thought it was funny because they did some positions. So it’s after I got an epidural and they seemed like they were disappointed and almost apologizing that it didn’t immediately make me go from five centimeters to fully dilated. I’m like, oh, bummer. So that’s a tangent. We still had a great outcome and it didn’t take long. But I don’t know. They must have been assuming this would work, just like in one second, which I don’t think.
Howard: 50:20
that’s the point here yeah, and again, we could do a whole episode about these different sorts of positions and the peanuts and all those sorts of things. They are ubiquitous, as you said, and maybe perhaps they buy time and changing positions has some merits, but in terms of the evidence basis for a lot of these randomized controlled trials, there is a lot lacking. So there are trials specifically about this topic and hands and knees posturing, for example, for occiput posterior babies, and so there was a systematic review of these trials, published again in the American Journal of Obstetrics and Gynecology, mfm, back in 2021. They found five studies that met their inclusion criteria, and essentially these studies divided patients into a hands and knees position, with about 1,700 total in that arm, versus a control group, which I guess were patients who weren’t deliberately put in the hands and knees position, with about the same number of patients in the control arm, and they found that both groups had exactly the same rate of occiput anterior positioning by the time they reached the second stage of labor, which was 81.2%. So a lot turned on their own, and they also found that there was no difference in the position of the fetal head immediately after the intervention.
Howard: 51:35
So, in other words, what if it had changed, but it moved back. So they wanted to make sure they captured that as well. They did a subgroup analysis of just patients who had ultrasound confirmed fetal head rotation right after the intervention and found that immediately after the hands and knees position there was more occiput anterior babies, and it was barely statistically significant. But the effect didn’t persist, and so by the time they were delivering or pushing there was no difference, and none of the secondary outcomes were any different too, including things like length of labor where they measured that. In other words, they found that hands and knees at least made no difference in fetal head rotation.
Antonia: 52:12
It is interesting, though, that maybe it could make a short-term difference in just a small fraction of people, like maybe, even if they do rotate temporarily, that could help with descent. I’m imagining that this baby’s position, when the mom gets on her hands and knees and this OP baby is basically looking down at the floor that I understand the theory that it would just make more sense for the baby to flop where their back is heavier, but apparently that doesn’t happen that much. But maybe, if it even happens, sometimes it could descend a bit. They rotate right back when she gets on her back, but I don’t know, it didn’t seem to be very groundbreaking, is, I think, what you’re saying here?
Howard: 52:53
There’s a lot of assumptions about what these positions do, but I don’t know it didn’t seem to be very groundbreaking is what you’re saying here? There’s a lot of assumptions about what these positions do on the size and shape of the pelvis that are probably not founded in science. That well Remember.
Howard: 53:10
We talked about that with breach delivery and the effect of these position changes actually made the pelvis less favorable, but maybe just changing it and moving the elasticity around made a difference. I think there’s also this phenomenon that whenever something is likely to end up the right way, a lot of things get credit for that happening.
Howard: 53:25
So, the Webster technique that chiropractors do for preventing breach fetuses at term, starting at 30 or 32 weeks. Well gosh, 97% of babies are cephalic at term. So if you start when it’s 50-50, in almost every pregnancy that you do the Webster technique on verts and that’s the case here 80 plus percent were occiput anterior, regardless of which arm they were in. So if you practice these things anecdotally you’re going to see outcomes that feel compelling. But I do think that things anecdotally you’re going to see outcomes that feel compelling. But I do think that what you’re saying they looked at that, as in this study. And again, of the five studies they looked at, only two of them use ultrasound to diagnose a fetal position. And if you look at the individual numbers of those smaller two studies, one of the arms, for example, only had five patients in it that were occiput anterior. And so these are just examples of like subset analysis from two very small studies in the group and probably just random outlying data because the sample sizes are too small to power for it.
Howard: 54:24
The largest trial here had over 2,500 patients and they employed a series of interventions leading up to the onset of labor.
Howard: 54:31
That included pelvic rocking twice per day in the hands and knees position to try to change the position before labor started, and they found that that was not effective.
Howard: 54:39
Another trial in Spain actually did the intervention during active labor and they compared hands and knees position to just having the patient in lateral decubitus position and they found no difference immediately after the intervention or at birth. The authors concluded that time alone seems to be the thing that affects rotation from OP to OA and not this hands and knees intervention, and that seems to be about right and there’s really no theoretic reason why it would move the fetus and, frankly, if it did, it might move it from OA to OP just as often. Like even if you were stimulating movement, how do you control it? I do have an increasing number of patients these days ask me at 38, 39 weeks whether the fetus is OP or OA, and I realize that’s because the birth blogs are telling them to do knee chest rocking if the doctor tells them it’s OP, and so that’s exactly what these studies looked at, and also during it, during labor, and they found no differences.
Antonia: 55:33
Well, just as you said before, potentially buying time could be the thing that these accomplish. But I could come up with some theories of why gravity changing the maternal pelvic tone maybe that’s enough to just nudge the baby to passively roll one way or another in the uterus or to stimulate the baby somehow to actively turn themselves. But obviously it’s so non-specific, like how do you know in one specific mom with this specific build and baby and all kinds of other maybe neurologic things that we can’t possibly know, how is it going to impact that specific one and how do you generalize? So the spinning babies is a workshop, in case people don’t know. A lot of nurses do it and it’s like a package deal. You learn about all of these different positions and it is more than just decubitus or just hands and knees positions, and I think it would be difficult, if not impossible, to break down each individual position or each specific combination of positions or even to compare using the whole package versus not, because there’s just all kinds of confounders.
Howard: 56:52
Yeah, and I’ve reviewed their literature from time to time and to date there still are no trials showing, for example, a lower rate of cesarean. So that’s a whole other topic that we could go into, certainly a whole discussion on. And I would warn people just that this is a workshop from a commercial company that’s selling a product and again there’s no RCTs that show that these techniques are effective. It could be an interesting question again of just if movement in general versus allowing them to lay there with their epidural and not move for six hours, if that makes a difference. But I suppose, as you said, these positions they’re not necessarily risky.
Howard: 57:29
They probably they may help decrease DVT risk, if nothing else like let’s, you know, move people around and that sort of thing. But I won’t do another Adam’s ruin. Adam ruins everything.
Antonia: 57:38
Is that?
Howard: 57:38
that guy’s name is. Howard ruins everything, so we can talk about spending baby some other time.
Antonia: 57:43
Yeah, yeah, I wouldn’t want to dump all over it. I do have some issues with how much the product costs, like the it’s a fad and my nurses do it too.
Howard: 57:52
Everybody does it. Like I said, when I was a resident, I read the Simpkin and Encheta handbook. It’s essentially the same thing, and I did these things. I would identify rotations and I would go in and do them.
Antonia: 58:02
Let’s do one more quick listener comment. So we had another comment referring to a previous episode where we discussed cesarean scar niches and the techniques for closing the uterus at the time of cesarean and the effect on future niche development or placenta accreta. We had a listener ask us whether there could be increased post-operative pain or adhesions that come along with closing the uterine serosa as opposed to not closing it, and really I could not find any evidence anywhere for or against this. Frankly, especially specifically relating to cesareans or uterine procedures. Another one of our very dear friends of this podcast who has some experience in this area, also wanted to point out that preventing placenta accreta isn’t the only outcome of interest and it might not be the only reason that we want to repair the C-section a certain way if we think that it would affect the development of a niche or if even going back to repair a niche later on.
Howard: 59:07
Yeah, exactly. So yes, our friend Francisco has done some work in recognizing these niches as a cause of abnormal uterine bleeding in particular, and I’ll put a link to a systematic review and meta-analysis from Fertility and Sterility back from 2022 that looks at nine studies on this topic and concludes that there is a strong and consistent association between patients who have cesarean scar defects and abnormal uterine bleeding and that there’s a fairly unique bleeding pattern associated with this, where you see prolonged bleeding and perhaps abnormal discharge along with a pattern of intermenstrual spotting.
Antonia: 59:41
And there’s also a paper in JAMA Network, open from 2023, where a consensus meeting was held and a disorder called cesarean scar disorder was defined as having a uterine niche, along with one primary or two secondary symptoms. The primary symptoms included post-menstrual spotting, pain during any uterine bleeding, having technical issues with embryo transfer, with the catheter insertion, or having secondary, unexplained infertility and, along with that, having intrauterine fluid like unexplained intrauterine fluid. And then the secondary symptoms included dyspareunia, abnormal discharge, chronic pelvic pain, avoidance of sexual intercourse, having malodorous blood loss, having also just plain secondary, unexplained infertility and having secondary infertility despite having reproductive technology techniques done. Another one was negative self-image and another was discomfort during participation in leisure activities.
Howard: 1:00:56
Right. So basically, if you have a niche and you have symptoms, then you have cesarean scar disorder, and for folks wishing to preserve or enhance their fertility, repair of these niches might be beneficial in alleviating the symptoms, though obviously those symptoms could be due to lots of other things too. You might have the niche just coincidentally. So that’s a different direction than discussing repairing niches purely for the prevention of invasive placental disorders or, as you said, optimizing the best technique for preventing them when you repair your cesarean. It’s not just about future placenta accreta spectrum disorders, and so we’ll see over time if the literature bears out the benefit and safety in subsequent pregnancies from repairing these niches or settles on some more firm guidance about how to prevent them, to begin with, various cesarean closure techniques.
Antonia: 1:01:43
All right, well, a big thanks to Francisco for bringing that point up.
Howard: 1:01:48
Yeah, and we’ll put these videos up on the Instagram and we’ll be back in a couple of weeks with something even more exciting.
Antonia: 1:01:57
All right.
Announcer: 1:02:01
Thanks for listening. Find us online at thinkingaboutobgyn.com. Be sure to subscribe. Look for new episodes every two weeks.
