OB-GYN-L Messages for August, 2006: Re: Ob: Arrest of dilatation

Re: Ob: Arrest of dilatation

From: Garry E. Siegel, M.D.

garrys@mindspring.com

Thu Aug 3 22:47:54 2006

My practice chooses not to participate in homebirth in any fashion. You are quite correct--we are getting patients with, in my opinion, somewhat unrealistic expectations of what will happen in labor. That said, our CNMs prepare them as much as the patients will allow. I am AMAZED at how many patients simply will not accept the clear fact that they have a complication of pregnancy--be it glucose intolerance, or pre-eclampsia--especially if the MD says it directly and clearly (as opposed to the L and D nurse or CNM).

One of the "staples vs. sutures" CNM primigravidas had one abnormal value on a 3 hour GTT, which does not make a diagnosis of GDM, yet when faced with a macrosomic fetus and polyhydramnios at 34 weeks, she was treated as if she had GDM though that horse was out of the barn. Her 2 hour sugars were abnormal 1/3 of the time. When I said these things to the couple while laboring, the husband said--"Wait, she doesn't have diabetes." I said, well, maybe not, but something has caused a big baby and too much fluid, and her sugars were up 1/3 of the time ("They were?"). He was happy when I said that we don't know if the abnormal glucose metabolism (a softer way of saying it, I suppose) caused a big baby, or "that's just the way you guys make babies" caused it. He was thankful that I acknowledged the latter, though it made no difference. Incredible, as the bottom line was the same--9 pounds 12 ounces weren't going to come out vaginally at a rate of 2 cm/day.

You made the comment that delaying a section causes no harm. You are wrong in two ways: First, as Dan pointed out, her risk of complication is greatly increased the longer she labors, and she became febrile, requiring treatment with antibiotics for Mom, and maybe the baby. Thus, statistically as well as anecdotally, delaying the necessary section is a mistake.

In terms of home birth, this patient got an epidural long before I was involved, and, in my experienced opinion, would not have been able to labor without one.

Walk a mile in my shoes--see someone have serious postop. endometritis requiring triple antibiotics for a few days, and then get antibiotic colitis, or a wound infection. See a baby get lines and IV antibiotics and extend the hosptial stay and not go home with Mom, as well as be at risk for more serious illnesses.

Garry

At Thu, 3 Aug 2006, Jamie wrote: >
>It sounds like you are getting quite a few patients who would be happier
>with homebirth, but are perhaps uncomfortable with not being able to
>have an attended one legally. If I'm not mistaken, direct entry
>midwifery is illegal in GA, so the choices are hospital, UC, or illegal
>midwife. This particular patient, if she attempted a home birth, might
>have transferred anyway at some point, but waiting until the c/s was
>necessary did not harm her or the child. Perhaps supporting legalized
>midwife assisted homebirth for those women so inclined is the answer to
>this problem. It's not really reasonable to expect that hospital
>obstetrics will change much until the liability situation changes, so
>women who don't want that kind of birth should have another legal, safe
>option.
>
>At Wed, 2 Aug 2006, Garry E. Siegel, M.D. wrote:
>>
>>Sue:
>>
>>What's the solution?
>>
>>I think we would agree that induction with pre-eclampsia at term is
>>warranted, and if she's not progressing, she's not progressing.
>>
>>Her reticence to proceed to a section allowed a fever to develop, and
>>she didn't progress, got antibiotics, and still had a section.
>>
>>Dan, this patient did not have an assessment of her pelvis before
>>induction.
>>
>>Listers, would you expect a CNM or MD to have done so?
>>
>>Dan, had I personally assessed her pelvis in the office, and told her
>>that it was not good, and that the chance of success was poor, I think
>>she would have looked at me like I was crazy, and then asked why not
>>try. I have not been successful convincing/selling/arguing/cajoling
>>patients who are not accepting of honestly given advice and direction,
>>and, you know, they don't always do what you want/tell them to do.
>>
>>Garry
>>
>>At Wed, 2 Aug 2006, Stmidwife@aol.com wrote:
>>>
>>>Respectfully, that is why they are going to a midwife for midwifery as
>>>opposed to an Obstetrician to participate in the Obstetrics of 2006.
>>>
>>>Sue
>>>
>>>In a message dated 8/2/2006 4:19:37 P.M. Pacific Standard Time,
>>>ob-gyn-l@obgyn.net writes:
>>>
>>>You're on the mark, but I truly think that the CNMs are pretty
>>>supportive and frankly attract those patients who are dissatisfied
>>>elsewhere, and are unrealistic about hospital based Obstetrics in 2006.
>>>
>>>Garry
>>
>>--
>>Garry E. Siegel, M.D.
>>Private Practice
>>Roswell, GA
>>
>--
>JFields, RN, BSN
>

-- Garry E. Siegel, M.D. Private Practice Roswell, GA

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