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Re: High C/S rates, Infant mortality (was macrosomia)From: Braun, R. Daniel (rbraun@iupui.edu)Wed Feb 18 04:25:03 2004
That was a resident research project that did not get published, but it confirmed some other published studies showing that: If the mother was a para 1 or greater, the most accurate method of estimeting fetal weight was to ask her. It was more accurate than US and any phjysician(Staff, resident, interne or even medical student)'s estimate. Glen, What year did you graduate? Dan R. Daniel Braun, MD "If everyone likes you, you're doing something wrong." Kinky Friedman I believe a self-righteous liberal or conservative with a cause is more dangerous than a Hell's Angel with an attitude. Andy Rooney -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Elrod Glen Maj 3 MDG/SGOB Sent: Tuesday, February 17, 2004 4:45 PM To: Multiple recipients of list OB-GYN-L Subject: Re: High C/S rates, Infant mortality (was macrosomia) U/S is far from perfect, but palpation is also not always a perfect science either I think Dr Braun could correct me if I am wrong, but during my medical school days at IU, they did a study looking at ultrasound estimation of weight, OB guess of weight and mom's guess of weight and statistically speaking they were all the same. So when mom's ask me how much the baby weighs, I politely tell them...your guess is as good as mine. Glen D. Glen Elrod, Maj, USAF, MC Medical Director Women's Health Center Elmendorf AFB, AK 99506 -----Original Message----- From: Sandi [mailto:sandib2@juno.com] Sent: Sunday, February 15, 2004 9:25 AM To: Multiple recipients of list OB-GYN-L Subject: High C/S rates, Infant mortality (was macrosomia) Dr. Modugno, I could not agree with you more! So, how do we make changes? #7: Social inductions... is it possible to refuse to do them? I have informed consent for everything and I think a woman who must read and initial every paragraph of an informed consent on the risks of social induction just might think this isn't such a good idea. In regard to inductions for suspected macrosomia, U/S is far from perfect, but palpation is also not always a perfect science either. As with Dr. Siegel's case, it's a no win situation if you don't induce and there is a catastrophic outcome from a vaginal delivery or if you C/S for a 7 pounder. In this sue happy country I still believe it is best to err on the side of caution. #6: How do the OB's/hospitals classify active labor? Mine is 4 cms. with contractions 5 mins. apart for at least 2 hours. If you don't meet both parameters, I go home. My patients are educated about this throughout the 3rd trimester and most don't call me until they have met the contraction parameter. I am firm with them about this. If I hung out with a woman not in active labor I would also be tempted to "fiddle" around to get things moving along. Tell the nurses to send them home or better speak with the patient yourself. I know an OB that encourages the patients to call her prior to going to the hospital so that she can do a phone triage and stop the patient from going in for irritable uterine contractions. #5: Epidural... do any of you find it possible to be able to reduce the use of epidurals in your practice? Women love the idea of pain free labor. Again, informed consent acknowledging the increase in the rate of C/S for FTP and other side effects related to epidural. You also have to tackle the nurses at the hospital. Nurses are big supporters of epidurals and I have witnessed them cajoling patients into making that decision. It should be patient choice, and if they choose it, then they should know the risks. Give them the responsibility for their choices. #4: What can be done to increase the knowledge in the use of forceps and vacuum? Does ACOG offer refresher courses at their annual meetings? #3: Even my patients become impatient. Again, I am very firm with them about waiting until their body is ready. I also lightly strip everyone (with informed consent, of course) at the 40 wga visit and then again at 40+4. I haven't had anyone go past 41 wga in several years. Again, being firm about waiting is the best bet. #2: In regard to Friedman's curve, as long as it is the accepted standard of care, we are obligated to use it. Has someone attempted to take a new look at this with a study? With good monitoring, a patient should be able to labor as long as it takes (within reason) to have a NSVD. Another problem with this is your #6, once they are admitted the "curve" begins. Send them home ;o) #1: The saddest reason of all, but totally understandable. Many of the people at yesterdays One Voice rally just could not understand the ramifications of liability. They are the women who have had C/S and want VBAC. They say they won't sue, and maybe they wouldn't, but they are the minority. Putting the responsibility for their care in their hands is my credo. It is their body and their baby. My patients are hammered with this throughout pregnancy. I am not in their home making sure they aren't drinking/smoking/drugging and making sure they eat right, therefore it is their responsibility. I even have an informed consent for this ;o) I also have an advantage that unfortunately most of you don't... Time. Because I only deliver around 50 babies a year I am able to spend more time with my patients. 60 mins. for an initial visit and 15-30 mins. for return PNV's. I think the time element makes a big difference when it comes to liability. I have a patient in my practice right now that was only touched by her OB during her pap and her delivery. The office nurse palpated, measured fundal height and listened to FHT's. This is not good OB care if you ask me. The patient needs that "touch" and familiarity. I would be terrified that I missed something (IGUR, macrosomia) if I allowed my assistant or students do this without me following up. I'd like to add another reason myself... #8: Continuous fetal monitoring. Being stuck in a lying down position, not using gravity to do the work greatly increases the risk of C/S. It also increases pain, so then you get an epidural and so on. Do any of the OB's on this list allow for intermittent monitoring? My midwifery law requires intermittent monitoring of q 30 mins. in active labor, q 15 mins. in transition and q 5 mins. during 2nd stage. Is this possible in a hospital setting? In regard to the foreign countries, I know nothing about Korea, but I do know that there are several S. American countries with women who demand C/S to prevent vaginal stretching. A hospital in S. Florida that serves a large S. American population has a >50% C/S rate. Sad, in my humble opinion. How do the OB's on this list feel about on demand C/S? In regard to worldwide infant mortality rates, I've been saying for years that the WHO needs to standardize the paramaters worldwide. If a country is not using these parameters, they should not be included. If you got this far... thanks! Sincerely, Sandi Positive changes can be made by a single person if done slowly and thoughtfully! a message dated 2/14/2004 6:14:03 PM Eastern Standard Time, -- sandib2@juno.com writes: After Tort Reform we need to look at why our C/S rate is so high and why 27 other countries have lower infant mortality rates and lower C/S rates than us. Stepping off my soapbox and donning flame proof suit... Sincerely, Sandi
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