Manual Rotation Research Articles

Delivery Mode After Manual Rotation of Occiput Posterior Fetal Positions: A Randomized Controlled Trial.

To evaluate whether manual rotation of fetuses in occiput posterior positions at full dilation increases the rate of spontaneous vaginal delivery. In an open, single-center, randomized controlled trial, patients with a term, singleton gestation, epidural analgesia, and ultrasonogram-confirmed occiput posterior position at the start of the second stage of labor were randomized to either manual rotation or expectant management. Our primary endpoint was the rate of spontaneous vaginal delivery. Secondary endpoints were operative vaginal delivery, cesarean delivery, and maternal and neonatal morbidity. Analyses were based on an intention-to-treat method. A sample size of 107 patients per group (n=214) was planned to detect a 20% increase in the percent of patients with a spontaneous vaginal delivery (assuming 60% without manual rotation vs 80% with manual rotation) with 90% power and alpha of 0.05. Between February 2017 and January 2020, 236 patients were randomized to either manual rotation (n=117) or expectant management (n=119). The success rate of the manual rotation maneuver, defined by conversion to an anterior position as confirmed by ultrasonogram, was 68%. The rate of the primary endpoint did not differ between the groups (58.1% in manual rotation group vs 59.7% in expectant management group (risk difference -1.6; 95% CI -14.1 to 11.0). Manual rotation did not decrease the rate of operative vaginal delivery (29.9% in manual rotation group vs 33.6% in expectant management group (risk difference -3.7; 95% CI -16.6 to 8.2) nor the rate of cesarean delivery (12.0% in manual rotation group vs 6.7% in expectant management group (risk difference 5.3; 95% CI -2.2 to 12.6). Maternal and neonatal morbidity was also similar across the two groups. Manual rotation of occiput posterior positions at the start of second stage of labor does not increase the rate of vaginal delivery without instrumental assistance. ClinicalTrials.gov, NCT03009435.

Electronic Point Spread Function Rotation Using a Three-Row Transducer for ARFI-Based Elastic Anisotropy Assessment: In Silico and Experimental Demonstration.

Degree of anisotropy (DoA) of mechanical properties has been assessed as the ratio of acoustic radiation force impulse (ARFI)-induced peak displacements (PDs) achieved using spatially asymmetric point spread functions (PSFs) that are rotated 90° to each other. Such PSF rotation has been achieved by manually rotating a linear array transducer, but manual rotation is cumbersome and prone to misalignment errors and higher variability in measurements. The purpose of this work is to evaluate the feasibility of electronic PSF rotation using a three-row transducer, which will reduce variability in DoA assessment. A Siemens 9L4, with 3×192 elements, was simulated in Field II to generate spatially asymmetric ARFI PSFs that were electronically rotated 63° from each other. Then, using the finite element method (FEM), PD due to the ARFI excitation PSFs in 42 elastic, incompressible, transversely isotropic (TI) materials with shear moduli ratios of 1.0-6.0 were modeled. Finally, the ratio of PDs achieved using the two rotated PSFs was evaluated to assess elastic DoA. DoA increased with increasing shear moduli ratios and distinguished materials with 17% or greater difference in shear moduli ratios (Wilcoxon, ). Experimentally, the ratio of PDs achieved using ARFI PSF rotated 63° from each other distinguished the biceps femoris muscle from two pigs, which had median shear moduli ratios of 4.25 and 3.15 as assessed by shear wave elasticity imaging (SWEI). These results suggest that ARFI-based DoA assessment can be achieved without manual transducer rotation using a three-row transducer capable of electronically rotating PSFs by 63°. It is expected that electronic PSF rotation will facilitate data acquisitions and improve the reproducibility of elastic anisotropy assessments.

A randomized controlled trial of prophylactic early manual rotation of the occiput posterior fetus at the beginning of the second stage vs expectant management

Women whose fetuses are in the occiput posterior head position at the time of delivery are known to have longer second stages of labor and more complicated deliveries including more operative deliveries (cesarean, forceps, or vacuum-assisted delivery) and more third- and fourth-degree lacerations than those whose fetuses are in the occiput anterior position. We hypothesized that rotating the fetus at the start of the second stage might decrease these complications. At Utah Valley Regional Medical Center, we randomized term (37 weeks or beyond), nulliparous patients with epidurals and a singleton fetus in the occiput posterior position to either attempted early manual rotation to occiput anterior or to a control group managed expectantly. The control group could later be rotated if indicated by the clinical setting. The primary outcome was the length of the second stage of labor. Dichotomous outcomes were compared utilizing the chi-square test, and continuous outcomes were compared utilizing the Student t test or Wilcoxon rank sum test.The sample size estimate was for 64 patients to be randomized (32 in each group) to show a difference of 36 minutes of pushing time between the 2 groups. We randomized 65 patients (33 to early manual rotation and 32 to control). When we examined a variety of baseline obstetrical characteristics, we found no statistically different values for the 2 groups. The early manual rotation group had a shorter median second stage of labor (65 minutes vs 82 minutes; P=.04). Early manual rotation of the occiput posterior fetus led to a shorter second stage of labor in this small randomized trial. Future larger randomized trials are needed to validate these findings.

3 Prophylactic Manual Rotation of Persistent Occiput Posterior to decrease operative Delivery: a Multicentric Randomized Trial

Persistent occiput posterior (POP) positions are the commonest malpresentations of the fetal head during labor and are associated with prolonged second stage of labor, cesarean, instrumental deliveries, obstetrical anal sphincter injuries, postpartum hemorrhage and chorioamnionitis. Manual rotation is one of several strategies described to deal with POP. The literature suggests that manual rotation of POP could decrease operative deliveries but no randomized study has confirmed these findings. The aim of this study was to determine if the trial of prophylactic manual rotation during the early second stage of labor is associated with a decrease risk of operative deliveries (instrumental and/or cesarean deliveries). This study was a prospective, randomized, controlled trial conducted in four French hospitals. Women with singleton term pregnancy and POP position confirmed by ultrasound at early second stage of labor and with epidural analgesia were eligible and randomized (1:1) to either receive the trial of prophylactic manual rotation of POP position (intervention group) or no trial of prophylactic manual rotation (standard group). The primary outcome was operative deliveries (instrumental and/or cesarean deliveries). From December 2015 to December 2019, 257 women were randomized: 126 assigned to the intervention group and 131 to the standard group. The groups did not differ in baseline characteristics. Operative delivery was significantly less frequent in the intervention (I) group compared to the standard (S) group (29.4 vs. 41.2%, p=.047, Differentiel (I-S) [95% confidence interval, CI] = -11.8 [-15.7;-7.9]; relative risk [95% CI] = 0.71 [0.51-1.00]). Women in the intervention group were more likely to have a significant shorter second stage of labor and have a neonate with a significant higher Apgar score at 5 minutes. The were no differences in other secondary outcomes. Trial of prophylactic manual rotation of persistent POP positions during the early second stage of labor is associated with a decrease risk of operative delivery.

Persistent occiput posterior position outcomes following manual rotation: a randomized controlled trial

Persistent occiput posterior position in labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation from the occiput posterior position to the occiput anterior position in the second stage of labor is considered a safe and easy to perform procedure that in observational studies has shown promise as a method for preventing operative deliveries. This study aimed to determine the efficacy of prophylactic manual rotation in the management of occiput posterior position for preventing operative delivery. The hypothesis was that among women who are at least 37 weeks pregnant and whose baby is in the occiput posterior position early in the second stage of labor, manual rotation will reduce the rate of operative delivery compared with the "sham" rotation. A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 4 tertiary hospitals was conducted in Australia. A total of 254 nulliparous and parous women with a term pregnancy and a baby in the occiput posterior position in the second stage of labor were randomly assigned to receive either a prophylactic manual rotation (n=127) or a sham rotation (n=127). The primary outcome was operative delivery (cesarean, forceps, or vacuum delivery). Secondary outcomes were cesarean delivery, combined maternal mortality and serious morbidity, and combined perinatal mortality and serious morbidity. Analysis was by intention to treat. Proportions were compared using chi-square tests adjusted for stratification variables using the Mantel-Haenszel method or the Fisher exact test. Planned subgroup analyses by operator experience and by manual rotation technique (digital or whole-hand rotation) were performed. Operative delivery occurred in 79 of 127 women (62%) assigned to prophylactic manual rotation and 90 of 127 women (71%) assigned to sham rotation (common risk difference, 12; 95% confidence interval,-1.7 to 26; P=.09). Among more experienced operators or investigators, operative delivery occurred in 46 of 74 women (62%) assigned to manual rotation and 52 of 71 women (73%) assigned to a sham rotation (common risk difference, 18; 95% confidence interval,-0.5 to 36; P=.07). Cesarean delivery occurred in 22 of 127 women (17%) in both groups. Instrumental delivery (forceps or vacuum) occurred in 57 of 127 women (45%) assigned to prophylactic manual rotation and 68 of 127 women (54%) assigned to sham rotation (common risk difference, 10; 95% confidence interval,-3.1 to 22; P=.14). There was no significant difference in the combined maternal and perinatal outcomes. Prophylactic manual rotation did not result in a reduction in the rate of operative delivery. Given manual rotation was associated with a nonsignificant reduction in operative delivery, more randomized trials are needed, as our trial might have been underpowered. In addition, further research is required to further explore the potential impact of operator or investigator experience.

The Curricular Practical Training Rotation Problem Formulation and the Assessment of Rotation Strategies

This study addresses the curricular practical training rotation problem, which is a type of staff assignment problem. Many educational institutions require theoretical knowledge to be complemented by practical training. Although the details of the implementation differ from institution to institution, it is necessary to prepare a rotation plan that determines how long the trainees will practice in which unit in which training period. Because of the complexity of the problem and humanistic reasons, the manual rotation plan can not reach the optimal level that satisfies all stakeholders and takes time. This study defines a general Curricular Practical Training Rotation Planning Problem specific to the curriculum-based trainee assignment process carried out in a university department and proposes an integer mathematical model for its solution. It is one of the important contributions of this study. It also provides a methodological approach to identify the most appropriate rotation strategy that will satisfy stakeholders. The methodological approach followed is a structure that can be adapted to different perspectives. The study has the potential to guide practitioners and researchers in the field and to lead a rich literature that will be formed with different side constraints and purposes to the problem.

Performance of Generator Translation and Rotation Motion on Vertical Direction for Sea Wave Power Plant

The generator has been used in the sea wave power plant to converting mechanical energy into electrical energy. Generator for sea wave power plant depends on the motion as translation and rotation. For position of trust force direction is horizontal and vertical motion. Generator translation and rotation consists of several components such as rotor, stator, frame holder of generator, shaft, piston and etc. In previous study, the generator translation and rotation motion in horizontal direction was used for sea wave power plant [1]. The results show that the performance of generator is depend on the stiffness of frame holder of generator, number of coil (pole) and magnet, material of pole and magnet and etc. The design frame holder of generator translation and rotation motion in horizontal direction is less rigid (stable) and precision, thus affecting the performance of the generator. To overcome problem in the frame holder of generator translation and rotation in horizontal direction, frame holder of generator vertical direction mechanism are used in this research and performance of generator is output like output voltage and power of generator. Input power of generator by using manual process (rotated by hand) and rotation speed of thrust force of generator is 100 rpm to 200 rpm and using load by lamp 16.6 ohm (12 w). Generator holder design made with 900 inclination conditions in order to straight or perpendicular to the motion generator components. By applied separate of experimental of generator translation and rotation motion obtained the results of experimental tests voltage generator without the load for generator translation motion is 42.7 volts at 200 rpm and for the generator rotation motion of 77.4 volts. By applied load, the maximum value of output voltage generator becomes decrease is 31.14 volt for generator translation and generator rotation is 36.82 volt.

Short statured primigravidae: Options for the obstetric management from a survey of UK obstetricians

ObjectiveTo assess the current antenatal and intrapartum management options for primigravid women of short stature with a clinically large fetus by a survey of UK Obstetricians. Study designAn online survey comprised of 15 questions including the options on timing and mode of delivery, counselling about the risk of long-term pelvic floor morbidity following spontaneous vaginal and instrumental deliveries, choice of instruments and the role of episiotomy. The survey was sent to the participants as a part of Royal College of Obstetricians and Gynaecologists (RCOG) Newsletter between September 2017 to October 2018. The scenario described was of a primigravid short stature woman (i.e. height of 160 cm or less) who presents with a clinically large fetus at 38 weeks gestation. Results424 Obstetricians participated in the survey. The participation ratio cannot be identified as the survey was emailed as a part of the RCOG Newsletter.Sixty five percent respondents stated that they would scan for estimated fetal weight, 48 % would offer induction of labour at 40 weeks and 14 % would offer an elective/planned caesarean section (CS) at 39–40 weeks. Fifty nine percent would discuss all these risks: obstructed labour, shoulder dystocia, instrumental delivery and obstetric anal sphincter injury (OASI). 73 % would not discuss the long-term risks of urinary and/or faecal incontinence and pelvic organ prolapse.In the presence of failure to progress in the second stage of labour, 69 % would attempt a rotational instrumental delivery and 5% would offer a caesarean section. Manual rotation and ‘straight’ forceps application were the most frequent type of rotational delivery, followed by Ventouse and Kiellands forceps. Thirty four percent stated that they do not routinely perform an episiotomy in this scenario. Seventy three percent stated that their choice of instrument was not based on the long-term risk of urinary and faecal incontinence. ConclusionThe results suggest that 40 % of the respondents would not discuss all of the complications after vaginal delivery in women of short stature. The most common delivery option would be vaginal delivery.

Chronic and Acute Low Back Pain and Its Relationship to the Sacral X-Axis, Leg Length Changes, Sciatica, Abdominal Pain, Idiopathic Scoliosis, and Incontinence

Several interactive pelvic axes occur during activities of weight-bearing and ambulation. Flexion and extension of the symmetrical innominates occur on the sacral x-axis with weight-bearing. Normal asymmetric innominate rotation occurs on the innominate axis at the pubic symphysis during weight-bearing with normal ambulation. Oblique sacral movement occurs on an oblique sacral axis concurrent with asymmetric innominate movement. Acute and chronic low back pain is commonly caused by a bilateral symmetrical or oblique anterior innominate rotation on the sacrum on an acetabular axis, usually while lifting, bending, lowering, shoveling, sweeping, a pendulous abdomen, during pregnancy, or with a postural forward head. The innominates are caused to sublux slightly cephalad and laterally on the sacral x-axis at the posterior inferior iliac spine (PIIS). This is a measurable movement that puts a rotational shear on the bilateral sacral x-axis and separates the sacral origins of both the gluteus maximus and the piriformis from their ileal origins resulting in pain across the mid-buttocks into the trochanter, down the tensor fascia lata into the lateral knee causing piriformis syndrome, pain across the buttock from the PIIS to the trochanter, a sciatic neuritis or a pseudosciatica. In all probability, true sciatica is probably not from the disc but rather caused where the sciatic nerve exits just below or sometimes through the compromised piriformis. A specific abdominal pain may also accompany acute or chronic low back pain as may an idiopathic scoliosis. An associated posterior movement of the ischial tuberosities can approximate the distal sacrum, loosen muscles of the pelvic floor, decrease kinetic tension on the sacrotuberous ligaments, and cause some degree of incontinence. Dysfunction is all initiated at the sacral x-axes. This is corrected effectively simply with a manual bilateral posterior innominate rotation that reverses all and various symptoms leaving the patient free of pain. Many areas of dysfunction are described, but not all.

Automated Spectrophotometer Control System

The spectrophotometric method is widely used for the qualitative and quantitative analysis of substances, in the study of the structure and composition of various compounds. The article solved the actual problem of spectrophotometers measuring process automating. The structure of the spectrophotometer control unit based on the Arduino Uno hardware platform has been proposed, a stepper motor driver scheme, providing replacement of the manual rotation system of the spectrophotometer diffraction grating to a system using modern stepper motors has been developed. It made it possible to increase the measurement efficiency by reducing the measurement time and improving the metrological characteristics of the spectrophotometer (the limiting absolute error in setting the wavelength is reduced from ± 0.5 nm to ± 0.3 nm).

Azhar dome physioclasis: A new surgical technique of treating patients with late presenting blount's disease

Introduction: Surgical treatment of patients with multi-planar deformity secondary to Late Presenting Blount disease (LPBD). Is there a new method for acute deformity correction of tibial deformity in patients with LPBD? The new method entailed acute deformity correction of the deformity by manual rotation of the deformed limb relative to the CORA in the physis itself. Patients and Methods: A prospective case study performed on two patients. First patient was eleven years old boy with LPBD and bilateral affection. Patient's height was 127cm, and weight was 60 kg; with BMI was 37.2 kg/m2. Both sides were done, left sided correction preceded the right side by 6 weeks. The second patient was twelve years old female. Her height was 145cm, and weight was 67kg with BMI 31.8 kg/ m2. Results: Acute correction of the varus, procurvatum and internal rotation was achieved intraoperatively with corrected mechanical axis. Average follow up was 20 months. No complications encountered in either limb. Conclusion: “Dome Physioclasis” is a new novel surgical technique that allows acute tibial multi-plane deformity correction in patients with LPBD. This method is suitable for selected cases where patients complain from severe deformity and near skeletal maturity. Future more experience in the technique may improve its understanding.

Successful management of a supralevator intraperitoneal puerperal hematoma with angiographic embolization

Puerperal hematomas are rare, yet often life threatening, complications following vaginal deliveries. The etiology remains broad; however, early recognition is vital in preventing postpartum hemorrhage and maternal death. Our case illustrates treatment of a supralevator hematoma with angiographic embolization following a spontaneous vaginal delivery in a young woman. Her labor course was complicated by persistent occiput posterior presentation that failed spontaneous and manual rotation.

A retrospective case series evaluating the outcome of implants with low primary stability.

There is a need of more studies on whether low primary implant stability would negatively influence the success of implant therapy. Therefore, this retrospective study analyses outcomes of implants placed with low primary stability and factors that may be related to implant failures. This retrospective study included 156 patients, restored with 169 implants that presented manual rotation within an observed follow-up time of a minimum of 34days and a maximum of 9.28years. Descriptive statistics, survival analyses (life tables and Kaplan-Meier estimates) and radiographic assessment based on marginal bone level measurements were performed. This original study was adherent to STROBE guidelines. Seven implants failed in seven patients, rendering cumulative survival rates of 94.74% (95% CI: 89.11-97.50) and 94.33% (95% CI: 88.30-97.30) at implant and patient levels, respectively. Kaplan-Meier estimates showed implant loss was found only in advanced surgery group (7 implant loss in 82 implants) when compared with simple surgery group (no implant loss in 87 implants; p=0.005). Within the limitations of this retrospective study, implant placement with low primary stability might not negatively affect either the survival rates or marginal bone level changes of implants provided that a protected and unloaded healing is guaranteed.

Vibration analysis for large-scale wind turbine blade bearing fault detection with an empirical wavelet thresholding method

Blade bearings, also termed pitch bearings, are joint components of wind turbines, which can slowly pitch blades at desired angles to optimize electrical energy output. The failure of blade bearings can heavily reduce energy production, so blade bearing fault diagnosis is vitally important to prevent costly repair and unexpected failure. However, the main difficulties in diagnosing low-speed blade bearings are that the weak fault vibration signals are masked by many noise disturbances and the effective vibration data is very limited. To address these problems, this paper firstly deals with a naturally damaged large-scale and low-speed blade bearing which was in operation on a wind farm for over 15 years. Two case studies are conducted to collect the vibration data under the manual rotation condition and the motor driving condition. Then, a method called the empirical wavelet thresholding is applied to remove heavy noise and extract weak fault signals. The diagnostic results show that the proposed method can be an effective tool to diagnose naturally damaged large-scale wind turbine blade bearings.

Rotation manuelle des variétés postérieures : état des lieux de la littérature en 2019

ObjectiveThe aim of our study was to evaluate the safety and the benefits of manual rotation in the management of Occiput-posterior positions in 2019. MethodsA systematic review of literature was performed using the MEDLINE and COCHRANE LIBRARY databases, in order to identify articles concerning maternal and neonatal outcomes after a manual rotation, through January 2019. Information on study characteristics (review, author, year of publication), population, objectives and main neonatal and maternal outcomes were extracted. ResultsA total of 51 articles were identified and 12 articles were selected for the systematic review. The rate of successful manual rotation were about 47 to 90%. There were more success if systematic manual rotation, multiparity, engagement, spontaneous labour and maternal age<35. The 2nd stage of labour was shorter after an attempt of manual rotation. The randomised controlled trials did not find any statistical difference concerning operative deliveries or neonatal and maternal outcomes. ConclusionThe manual rotation is an obstetrical manoeuvre which must be regulated and only practiced by trained operators. Currently, the state of science is not sufficient to recommend the manual rotation as a systematic practice in 2019.

Republication de : Variétés postérieures au cours du travail : mécanique obstétricale, diagnostic et prise en charge

Persistant occiput posterior (OP) positions are the commonest malpresentations of the fetal head during labor and their diagnosis remains challenging. They are associated to prolonged second stage of labor, prolonged expulsive efforts, labor augmentation, cesarean sections and instrumental deliveries. On the maternal side, severe perineal tears, post-partum hemorrhage or chorioamnionitis are more frequent. Currently, prevention of persistent OP positions is based on the maintain of precise maternal positions. Several positions have been evaluated but only lateral position on the same side of the fetal spine has proved its effectiveness. Fetal head rotation can also be achieved with extraction instruments though none has ever been evaluated by a randomized controlled trial. Obstetrical forceps seem more efficient than vacuum but are associated with severe perineal tears. Evaluation of rotation with Thierry's spatulas is scarce. Last, manual rotation is of routine use in many wards. This management is associated with a twofold reduction of operative delivery rate and rare adverse outcomes but has never been evaluated through randomized control trial.

Physiologic widening of the medial clear space: What's normal?

BackgroundLiterature has validated the use of stress radiographs for evaluation of ankle stability. However, to our knowledge no study has reported the amount of physiological widening that occurs with manual external rotation stress test in uninjured ankles. The purpose of this study was to assess the amount of medial clear space widening that occurs with a manual external rotation stress test in uninjured ankles. MethodsA cohort of adult patients undergoing operative fixation of unstable ankle fractures were prospectively enrolled to have their contralateral ankle undergo manual external rotation stress examination. Fluoroscopic images of the unaffected ankle were performed in the OR. A non-stressed mortise view and manual external rotation stress view were obtained with a standardized marker to correct for magnification differences. The images were de-identified, presented in a randomized order and reviewers who were blinded. Each reviewer measured the medial clear space. ResultsThirty fluoroscopic images on fifteen patients were obtained. The mean medial clear space on the non-stressed mortise view was 3.1 mm (SD-0.69; Range 1.9 to 4.2, 95% CI [2.75, 3.45]) versus a mean of 3.2 mm (SD-0.71; Range 2.0 to 4.7, 95% CI [2.94, 3.66]) in the stressed mortise view group. Inter-rater reliability was excellent between all observers for medial clear space (ICC-0.88; CI [0.78, 0.94]). ConclusionsOur results support the previous literature and allow us to advocate for ankle fractures with >5 mm medial clear space after external rotational stress to be considered unstable. Additionally, ankles with a medial clear space between 4 and 5 mm, instability should be considered only if lateral shift is > 2 mm on stress examination. Our data shows that no physiologically healthy ankles widened beyond these established cut-offs before or after the manual external rotation stress.

Bilateral Anterior Innominate Osteotomy for Bladder Exstrophy.

Bladder exstrophy is a congenital condition that affects the genitourinary and musculoskeletal systems, and less commonly affects the intestinal system, with cloacal exstrophy. This condition results from abnormal migration of the mesenchyme, between the endoderm and ectoderm, leading to anterior rupture of the cloacal membrane. Numerous osseous morphologic changes are observed in bladder exstrophy. Rotational anomalies include external rotation of the posterior part of the pelvis and iliac wings, on average 12°, and acetabular retroversion1-3. Although various osteotomy types have been described for initial bladder exstrophy closure, the anterior approach has demonstrated positive outcomes in improving daytime continence, gait, and correction of the diastasis4. Thus, the anterior iliac osteotomy provides an effective method to help close the pelvic ring and decrease stress on the anterior abdominal wall during exstrophy closure. In addition, this technique promotes continence by reconfiguring, and thereby restoring, the fibrous symphyseal bar and pelvic floor musculature5. The steps of the procedure include (1) preoperative planning, (2) patient positioning, (3) incision, (4) identification of the lateral femoral cutaneous nerve, (5) subperiosteal dissection of the iliac wing, (6) guide pin placement and anterior osteotomy, (7) posterior hinge osteotomy (for cloacal exstrophy and for patients ≥2 years old), (8) external fixator pin placement, (9) anterior internal fixation of the pubic symphysis (for cloacal exstrophy and for patients ≥2 years old), and (10) resumption of the urologic procedure followed by wound closure and application of external fixator. Numerous previous techniques for osteotomies in bladder exstrophy have been developed, starting with Shultz in 1958, who recognized the importance of bringing the pubic bones together for gait correction in exstrophy repair6. O'Phelan was the first, to our knowledge, to document outcomes of this bilateral posterior osteotomy technique to reduce tension from the externally rotated iliac bones and widened pubic symphysis in a 2-stage bladder exstrophy closure7. Other approaches have included an oblique iliac wing osteotomy and pubic ramotomy, described by Frey and Cohen in 19898. However, the latter approach inadequately restores the pelvic osseous relations except in female newborns who would have a small diastasis after manual rotation of the pelvis. This procedure has several advantages over the prior conventional posterior approach. These include better approximation and improved mobility of the pubic rami at the time of closure, prevention of vertical migration of the hemipelvis, direct visual placement of an external fixator and adjustment postoperatively, and no requirement for turning the patient during the operation. In addition, this procedure allows for adjunctive posterior osteotomy from the anterior approach to provide adequate closure in those with cloacal exstrophy, prior failed closure, or extreme diastasis of >6 cm9.

Outcomes of operative vaginal delivery managed by residents under supervision and attending obstetricians: a prospective cross-sectional study

To assess both severe maternal and neonatal mortality and morbidity after attempted operative vaginal deliveries by residents under supervision and by attending obstetricians. Secondary analysis of a 5-year prospective study with cross-sectional analysis including 2192 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. Obstetricians who attempted or performed an operative vaginal delivery were classified into 2 groups according to their level of experience: attending obstetricians (who had 5 years or more of experience) and obstetric residents (who had less than 5 years of experience) under the supervision of an attending obstetrician. We used multivariate logistic regression and propensity score methods to compare outcomes associated with attending obstetricians and obstetric residents. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesareans, postpartum hemorrhage >1500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, or maternal death; severe neonatal morbidity was defined as a 5-minute Apgar score <7, umbilical artery pH <7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, or neonatal death. High prepregnancy body mass index, high dose of oxytocin, manual rotation, persistent occiput posterior or transverse positions, operating room delivery, midpelvic delivery, forceps, and spatulas were significantly more frequent in deliveries managed by attending obstetricians than residents whereas a second-stage pushing phase longer than 30 minutes was significantly more frequent in deliveries managed by residents. The rate of severe maternal morbidity was 7.8% (115/1475) for residents vs 9.9% (48/484) for attending obstetricians; for severe neonatal morbidity, the rates were 8.3% (123/1475) vs 15.1% (73/484), respectively. In the univariate, multivariable, and sensitivity analyses, attempted operative vaginal delivery managed by a resident was significantly and inversely associated with severe neonatal but not maternal morbidity. After propensity score matching, delivery managed by a resident was not significantly associated with severe maternal morbidity (adjusted odds ratio, 0.74; 95% confidence interval, 0.39-1.38) and was no longer associated with neonatal morbidity (adjusted odds ratio, 0.51; 95% confidence interval, 0.25-1.04). Management of attempted operative vaginal deliveries by residents under the supervision of attending obstetricians, compared with by the attending obstetricians themselves, does not appear to be associated with either maternal or neonatal morbidity. These reassuring results support the continued use of residency programs for training in operative vaginal deliveries under the supervision of attending obstetricians.

Ankle gravity stress view in the seated position: A technical tip

The ankle gravity stress view (GSV) is often utilized to elucidate instability in patients with an apparent, isolated lateral malleolus fracture. While this has been demonstrated to have advantages over the manual external rotation stress test, positioning in the lateral decubitus position can be difficult, uncomfortable and time-intensive. We report a simple and safe technique that allows one to obtain a gravity stress view of the ankle with the patient seated.