Management of the entrapped second twin: the benefits of sublingual glyceryl trinitrate.

Abstract

EDITORIAL COMMENT: The complications of manipulative delivery are dear to the heart of every obstetrician. Problems such as head entrapment with breech delivery at Caesarean section, uterine inversion and difficult manual removal are all extremely unpleasant situations that may be assisted by the use of glyceryl trinitrate. This paper emphasizes the use of glyceryl trinitrate in another situation where uterine relaxation may be beneficial, namely malpresentation of a second twin in the presence of a uterine fusion abnormality and a constriction ring in the second stage. Obviously general anaesthesia would be an alternative, but all modern obstetricians are faced with an extreme reluctance of anaesthetists to give general anaesthetics in labour ward. It was unusual in this case to bring the baby down into the pelvis cephalically rather than perform an internal version and breech extraction. This manoeuvre was obviously felt to be the most appropriate improvisation at the time. There seems nothing inherently wrong with guiding the head down past the constriction ring into the vagina and then applying forceps. One can imagine that it may have been less traumatic than an internal version and breech extraction which may have risked the head being trapped above the constriction ring with the body‐below should uterine relaxation have been incomplete. The statements made about the dilution necessary for intravenous administration of glyceryl trinitrate and the relevant safety of the sublingual application are important to bring to the attention of obstetricians. We agree with the authors statement that glyceryl trinitrate needs to be on hand before delivery if it is to be used in the emergency situations described in this paper. It seems to the Editorial Board that the most likely use of the technique described would be at Caesarean section under epidural analgesia with oligohydramnios and a growth‐retarded fetus presenting by the breech when there is a poorly formed lower uterine segment.