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Re: Postdates,Neonatal DeathFrom: ainsron (ainsron@sbcglobal.net)Tue Aug 2 18:20:53 2005
My patients often ask for inductions and I have no problem inducing patients if they request it for a variety of nebulous social reasons when the cervix is ripe and they are past 38 weeks. I have no problem inducing patients for medical reasons at any point whether or not the cervix is ripe. It is another issue for me to recommend induction to all my patients at 38-40 weeks for my convenience - either because I am going out of town, off call for the weekend or to manage my office more efficiently. Like you, avoiding a death or complications on a neonate is the ultimate goal we share and strive for. Without doing the volume of elective inductions you describe, I've not had a serious complication from meconium aspiration or post dates. Ronald E. Ainsworth, MD, FACOG -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Richard Chudacoff, MD Sent: Tuesday, August 02, 2005 3:27 PM To: Multiple recipients of list OB-GYN-L Subject: Re: Postdates,Neonatal Death Avoiding just one would be enough for me. Beside, how do you get your patients NOT to ask for an induction before 40 weeks? Richard Chudacoff, MD This message is confidential, intended only for the named recipient(s) and may contain information that is privileged or exempt from disclosure under applicable law. If you are not the intended recipient(s), you are notified that the dissemination, distribution or copying of the messages is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at either the e-mail address or telephone number above and delete this e-mail from your computer. _____ From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of ainsron Sent: Tuesday, August 02, 2005 5:20 PM To: Multiple recipients of list OB-GYN-L Subject: Re: Postdates,Neonatal Death That's the point, three weeks before delivery would have been 38 weeks. Is that when we should be delivering all of our patients? Seems like a slippery slope to me. How many deliveries does one have to induce to prevent one complication from meconium aspiration, not to mention one death due to the same? If Richard's rationale is correct, it should be the standard of care - and it isn't, not according to what I read. If you passed that idea by most of the Ivory Towers of medicine, I doubt it would get a serious look, let alone the IRB approving it as a pilot study. Ronald E. Ainsworth, MD, FACOG -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of R. Daniel Braun Sent: Tuesday, August 02, 2005 11:38 AM To: Multiple recipients of list OB-GYN-L Subject: Re: Postdates,Neonatal Death Delivery prior to passage of Meconium would have prevented it. By the description of the stained placenta and cord it probably happened sometime between 2 days and 3 weeks before delivvery. It takes a while for those phagfocytes to gobble up the Mec and after 3 weeks it begins to turn brown and yellow. Dan On 8/2/05, ainsron <ainsron@sbcglobal.net> wrote: How exactly would delivery at 39 weeks have prevented this unfortunate neonatal death? With Apgars 8/9, labor management and timing of the decision for C/S sounds perfect to me. I wonder what the pH was? The question is, what was the cause of pulmonary hemorrhage - meconium aspiration? Was the baby adequately suctioned by the neonatologist? Ronald E. Ainsworth, MD, FACOG -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Richard Chudacoff, MD Sent: Tuesday, August 02, 2005 6:40 AM To: Multiple recipients of list OB-GYN-L Subject: Re: Postdates,Neonatal Death This happens. If anyone can find me any literature that supports pregnancy after 40 weeks I'd change my practice. However, situations like this reinforce my belief of 39 week inductions. Richard Chudacoff, MD This message is confidential, intended only for the named recipient(s) and may contain information that is privileged or exempt from disclosure under applicable law. If you are not the intended recipient(s), you are notified that the dissemination, distribution or copying of the messages is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at either the e-mail address or telephone number above and delete this e-mail from your computer. _____ From: ob-gyn-l@obgyn.net [mailto: ob-gyn-l@obgyn.net <mailto:ob-gyn-l@obgyn.net> ] On Behalf Of Ingrid Gold Sent: Monday, August 01, 2005 8:55 PM To: Multiple recipients of list OB-GYN-L Subject: Postdates,Neonatal Death As I'm sure most of you remember, I'm in a group practice. 2 CNM's, 2 OB's, almost all patients are shared, most are monolingual spanish. Last week, on Monday I think I sent a woman over from the office to be induced, indication postdates. She was 41 1/7, with good dates, G4 P3 (all NSVD), no previous problems (spanish only). She was being induced without incident (I was not on call) when the strip got bad and the midwife called the OB. They waited about 1 1/2 hours before deciding that she ought to have a cesarean. As is standard at our hospital, a neonatologist was present for the ceserean. Apgars were 8 & 9. Thick meconium was present at delivery, it had not been noted earlier, even though membranes were ruptured, and internal leads placed. The baby and placenta were heavily stained. At 1 hour the baby had a pulmonary hemmorhage and was transported from our level I facility to a level III, 3 miles away (by helicopter of course). About 4 hours later resuscitative attempts were stopped and the baby was pronounced dead. The next day, Tuesday, after office hours I went to L & D, planning to see the parents and express my sorrow. I was warned by both the OB nurse and the OB there not to go into the patient room, that she was in a blaming mode, and I'd be a perfect scapegoat. I followed their advice. One of the questions she'd asked was why I had waited to have her induced, and not sent her in a week earlier. I had seen her for her last 4 prenatal visits. Until now our practice has done NST's at 41 weeks, and induction at 42 weeks. I had a hard time deciding to send her in "so early", but without insurance she'd have to pay for the NST (but not the delivery, FES). I actually gave her the option and she chose induction.She was 2-3 cm, 80%, -2 when I sent her in. Complicating my timing were that they had just brought the baby over from the other hospital, a priest was there, and so were the organ donation people (who she refused to see). I went home without seeing her that day. The next day I was on call, and had 6 deliveries. (a record for me in one day, and with only 2 OB nurses). I did not stop in and see them. Then I had four days off, and went out of town (it was great to escape the 115 degrees in Phoenix, and go to the top of Sandia mountain in Albuquerque where it was 66). She came to the office today. I didn't realize she was there until she was gone. The MA said she was accepting, not blaming, and doing well given the circumstances. Your comments please.
--
R. Daniel Braun
Kinky for Governor
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