Re: VBACs (long)

From: Efrain Ramirez (eramirezt@coqui.net)
Sat Apr 9 13:20:28 2005

We happen to be in a more or less situation as you are – many years ago we were, maybe, the most outspoken Ob-Gyn’s in the VBAC issue – our institution was backing the idea – we even made the font page of the most popular newspaper .. well - everybody knows the story of the VBAC issue – we rapidly became the only ones offering such a service – the “last stronghold” and many referrals were seen each month – and it became quiet of a challenge – many of the patients were very nice, intelligent and understanding but others were confrontational- to say the least .. in my case it was “fun” –because I had a chance to review the history of VBAC – I was “brought up” with the dictum “of once a C/S always a C/S” – then the change of heart occurred – and then another change of heart when the politics and economics of our science came into place –

I vividly remember one patient who wanted to have a VBAC home delivery – I was suppose to be a 24/7 back-up if something went wrong – I told her that such a scenario was impossible – tears swelled her eyes – “Are you sad” I asked – “No, I am angry” she replied – “Why”? I inquired in a surprising manner. “Because I thought you were a good doctor – your are as bad as everybody else I met” or something of that sort – I calmly replied - “Well – your reaction is very common in patients who are immersed in a cult or in an egoistic personal crusade … I am very sorry I can not be of help to you .. adiós – y que Dios te bendiga” She really was furious – I never knew what happened to her….

Little by little I came to realize that VBAC’s are not worth the time and effort – and the liabilty is so great - we still get a few referrals though!

Having said that:

#1- repeat C/S #2- repeat C/S

Good luck!!

Ef

At Sat, 9 Apr 2005, Garry E. Siegel, M.D. wrote: >
>Our practice (2, soon to be 3 MD, 2 CNM) gets a good number of VBAC
>patients seeking our CNMs. We're supportive of VBAC, but the patients
>that they see run the entire spectrum--from "routine" VBACs (Breech 1st
>time) to those whose prior Ob/Gyns have said "no VBAC" for good reason,
>and they seek out alternatives. In general, we don't find ourselves
>disagreeing with the other docs much, and we have decided to have any
>VBAC CNM patient be seen by one of our MDs at one of the first visits
>(we get some later transfers, too) to go over the circumstances of their
>first section, op note if available, etc.
>
>While our CNMs are good, there are many times at which I delve into the
>details of the first section and/or review the op note, and basically
>find that the patient is a really poor VBAC candidate. I find myself
>letting the air out of some of these people's balloons, in that they
>sought out our CNM practice to VBAC (street gossip, internet gossip,
>etc.), yet they really find that traditional obstetric thinking is
>present. These discussions can be long, sometimes very enjoyable, and
>sometimes contentious when the patient simply won't accept my opinion,
>even when it is a no-brainer.
>
>What would you do with these cases?
>
>#1
>37 YO P1001, from India, induced/ripened at 42 weeks. Got to 7 cm., and
>had LTC/S for distress for a 5 pound 14 ounce baby. I just met her at
>38 weeks (solid date, late transfer), and her fundal height was 35. My
>interpretation of the last pregnancy was that she certainly may have had
>an IUGR baby, and I thus had a similar concern here, and had a nice
>conversation with her and told her so. MFM scan done shows 38 week BPD,
>35 week HC, 34.7 week AC, and 38 week femur, with the comment that the
>AC was 5th percentile, and to consider delivering by 39 weeks.
>
>#2
>33 YO P1001, Oriental, prior LTC/S who was induced at 41 weeks (she's
>not exactly sure why, but she went to the MD office and was sent
>straight over to L and D ?heartbeat). The patient is now 33 weeks, 5
>feet tall maybe, and around 100 pounds pre-pregancy and has quite narrow
>hips (simple just to look at her). She progressed to full dilation, and
>pushed (according to her, not specified in the op note) for 30 minutes
>and had a section for distress. HOWEVER, the op note says the diagnoses
>were arrest of descent and chorioamnionitis, and the baby was 6-14
>ounces.
>
>Any thoughts on these cases welcome.
>
>Garry
>
>--
>Garry E. Siegel, M.D.
>Private Practice
>Roswell, GA
>

--
 I think I will do nothing for a long time but listen,
 And accrue what I hear into myself...and let sounds
 contribute toward me.


                                    ~walt whitman~



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