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Re: Two questions for the ListFrom: ainsron (ainsron@sbcglobal.net)Thu Jul 7 12:53:35 2005
Ronald E. Ainsworth, MD, FACOG First question; 21 y.o. patient came in with complaints of irritative vaginal discharge. She recently relocated to this community. When asked about history, she said that prior to moving here she had laser of her vulvar area for reasons she didn't know. I got the medical records and she had biopsy proven carcinoma in situ of the vulva, which was laser vaporized. Now am I off base in thinking that she was inappropriately or inaccurately treated. My approach to vulvar lesions of this magnitude has been excision to assure there is no invasive disease, as well as to assure the margins are clear. Give me some insight here. I tend to excise also. DiSai states that surgical excision "has been the mainstay of therapy... but laser in the management of VIN has evolved into treatment of choice by many, particularly for multi-focal, extensive disease." The important caveat is that greater expertise is necessary before using laser, in order to R/O invasive disease before proceeding. Second, our nursing administration has asserted that whenever a patient is started on pitocin, they are continuously monitored period, no exceptions. Their justification sited is nursing association standards that mandate such monitoring. My understanding has been that variations on monitoring, including intermittent auscultation, depending upon the stage of labor, is all acceptable from ACOG. They say "it is being done this way everywhere". Maybe I am being sensitive here, but I object to a nursing standard taking precedence over ACOG standards. The ACOG recommendation is that auscultation or fetal monitoring are equivalent and if auscultation is used in low-risk patients it should be: every 30 minutes in first stage and 15 minutes in second stage; in high risk patients (and they consider patients on pitocin to be high-risk), it should be: q15 minutes in the first stage and 5 minutes in second stage. That is per ACOG Guidelines for Perinatal Care, 5th ed. http://www.acog.org/publications/guidelinesForPerinatalCare/
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