Re: Ob: PP hemorrhage in a VBAC--why do we VBAC, anyway :)?
From: art fougner, md (evsono@pipeline.com)
Fri Jun 8 07:41:39 2007
Does anyone know what the sensitivity and specificity of Uterine
Exploration for Scar Integrity actually is?
Art
At Thu, 7 Jun 2007, Garry E. Siegel, M.D. wrote:
>
>Good question and comment, and I was raised to do so, also, and still
>do. However, I explore every uterus after delivery if possible (i.e. if
>hurts/no epidural, I likely don't do it--if they are comfy, I do).
>
>I am certain that the CNM did NOT explore it.
>
>Garry
>
>At Thu, 7 Jun 2007, Marie Harkins wrote:
>>
>>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
>>>>
>>> --
>>> Garry E. Siegel, M.D.
>>> Private Practice
>>> Roswell, GA
>>
>--
>Garry E. Siegel, M.D.
>Private Practice
>Roswell, GA
>
--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
