Re: Ob: PP hemorrhage in a VBAC--why do we VBAC, anyway :)?
From: FRANCES WREN (fwren@shaw.ca)
Fri Jun 8 03:03:50 2007
I used to do this all the time after VBAC.
I do not do it any longer routinely.
however if I have had an "iffy" VBAC...and a fair amount of bleeding I will do it .
I sometimes wonder however unless there is a big tear one might not recognise it anyways.
>----- Original Message -----
From: Marie Harkins <mharkins@twcny.rr.com>
Date: Thursday, June 7, 2007 4:34 pm
Subject: Re: Ob: PP hemorrhage in a VBAC--why do we VBAC, anyway :)?
> When I first started to work in obstetrics (mid 80's) the hospital
>
> policy for VBAC included manual exploration of the uterus after
> delivery. Some of the older docs did it then, no one does it now.
>
> Do any of you still do this, or did you do it at one time? Do you
>
> think it would have made a difference in this case?
>
> Marie Harkins, CNM
> Ithaca, NY
>
> On Jun 7, 2007, at 4:24 PM, Garry E. Siegel, M.D. wrote:
>
> > The case was straightforward; I just posted it this way to generate
> > discussion.
> >
> > She is thin, and I reopened her low transverse skin incision in a
> > Maylard/semi-Maylard fashion (that's how I do sections) and
> didn't
> > take
> > the inferior epigastrics and had tons of room. I also did the
> case in
> > Allen stirrups, in case I needed vaginal access (i.e. to see if the
> > bleeding had stopped).
> >
> > Upon opening the perioteum, I expected a hemoperitoneum, yet she
>
> > didn't
> > have it. However, you could see clot underneath her bladder
> flap, and
> > the clot--easily 500 to 1000 ml.--was concealed under the
> bladder flap
> > and kept coming out vaginally (the vagina was full of clots, as
> was
> > the
> > firm uterus). The clot was from a low transverse rupture,
> > obviously of
> > the old incision, easily palpable and then visualized. The clot had
> > nicely dissected the bladder way off the incision, and I could
> easily> access the pelvic planes necessary to safely access the
> uterus and see
> > the ureters easily. The left half on the incision was mush,
> this was
> > her fourth (and they planned no more), so it was an easy
> decision
> > to do
> > a TAH. As is often the case, the lower uterine segment and
> vagina
> > were
> > ballooned and distorted, but I could define the cervix and actually
> > grasp the vaginal portion of the cervix through the rupture so
> that I
> > could preserve the upper vagina easily.
> >
> > She got 8 units in total, and looked great this AM.
> >
> > Garry
> >
> > At Thu, 07 Jun 2007, rmodugno@aol.com wrote:
> >>
> >> Hmm... Why is he asking this?
> >>
> >> Did a laparotomy - found the uterine incision intact with a
> posterior>> blowout through the uterine vessels?
> >>
> >> Robert Modugno MD MBA FACOG
> >> Sylva, NC
> >>
> >> -----Original Message-----
> >> From: Garry E. Siegel, M.D. <garrys@mindspring.com>
> >> To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
> >> Sent: Wed, 6 Jun 2007 7:21 pm
> >> Subject: Ob: PP hemorrhage in a VBAC--why do we VBAC, anyway :)?
> >>
> >> 37 YO P 4004 at term
> >> #1 Term LTC/S, breech, document
> >> #2 and #3--VBACs, uneventful, our CNMs, 9 to 10 pound babies
> >>
> >> This deliver--SROM, irreg ctx., augmented. While the CNM was
> >> caring for
> >> her, I stopped in a followed her a bit. Clincal EFW 4200 g
> >>
> >> Dilatation was protracted for a multip., and she had a couple
> of
> >> runs of
> >> hyperstimulation (meaning tachysystole with bradycardia) that
> >> resolved
> >> with the old Pit on/Pit off/flip sides.
> >>
> >> She progressed to complete dilation, and started with big
> variables.>> After pushing around 5 to 10 minutes, heart tones
> were jumbled
> >> (FSE) and
> >> unreadable, and I watched the CNM with the head crowning, and
> simply>> whispered to her (she is a newby but a goody) to make an
> >> episiotomy, and
> >> have her push even between contractions and "get the baby out."
>
> >> The baby
> >> came out, all well.
> >>
> >> PP she hemorrhaged, and it was assumed by the CNMs/L and D
> nurses
> >> to be
> >> atonic--methergine, more pit, hemabate.
> >>
> >> When she got hypotensive, I got the call.
> >>
> >> Room exam--firm fundus 2 fingers below, no lacerations, lots of
> BRB.>> Belly soft, no complaint of shoulder pain, FWIW.
> >>
> >> Hct. 23 (was 37), quick CT showed fluid in upper abdomen, clot in
> >> pelvis, ?hematoma of uterus--we went from the CT scanner across
>
> >> the hall
> >> to the theater.
> >>
> >> What did I do and what did I find?
> >>
> >> Garry
> >>
> >> --
> >> Garry E. Siegel, M.D.
> >> Private Practice
> >> Roswell, GA
> >>
> _____________________________________________________________________
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> >
> > --
> > Garry E. Siegel, M.D.
> > Private Practice
> > Roswell, GA
>
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