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Re: routine intrapartum labsFrom: Efrain Ramirez (eramirez@icepr.com)Sat May 27 15:16:45 2000
At Sat, 27 May 2000, Geffrey Klein, MD wrote: > >At 9:13 PM -0500 on 5/26/00, maggiecnm wrote: > >>What is this group's opinion of routine cord gases for all infants >>regardless of Apgars? I am in a new hospital where this is standard >>practice and have been chastised by several MDs for not getting them, >>even when the babies are pink and screaming with excellent apgars. In >>my previous hospitals, we only got them if the apgars were poor or after >>a difficult delivery. >>Also, is there any reason to get a CBC and diff on every intrapartum >>patient? When I asked about this, no one could remember when they had >>actually changed their management based on the CBC, and most of them are >>just filed in the chart and not looked at. > >Per ACOG CO 138: > >Immediately after delivery of the neonate, a segment of umbilical >cord should be doubly clamped,divided, and placed on the delivery >table pending assignment of the 5-minute Apgar score. Values from the >umbilical artery provide the most accurate information regarding >fetal and newborn acid-base status. A clamped segment of cord is >stable for pH and blood gas assessment for at least 60 minutes, and a >cord blood sample in a syringe flushed with heparin is stable for up >to 60 minutes. If the 5-minute Apgar score is satisfactory and the >infant appears stable and vigorous, the segment of umbilical cord can >be discarded. If a serious abnormality that arose in the delivery >process or a problem with the neonate's condition or both persist at >or beyond the first 5 minutes, blood can be drawn from the cord >segment and sent to a laboratory for blood gas analysis. It should >be noted that, occasionally, it may be difficult to obtain an >adequate cord arterial blood sample. > >-- >_________________________ > >_________________________ >My Conclusions: > >1) cord gas is defensive medicine and NEVER alters the management of >mom or baby >2) cord gas can be used to help exonerate a doc by excluding >intrapartum asphyxia as the cause of a poor outcome >3) in a vigorous infant, a cord gas can only hurt the doc by >suggesting metabolic acidemia when the baby is fine >4) cord gasses cost money to perform > >So.. *** WARNING.. MY OPINION FOLLOWS **** > >If a doc insists on performing cord gasses at EVERY delivery, he is >spending the patient's money on a test that will not be used to help >manage her case. However, if for medicolegal purposes, the doc >really feels that this is a helpful thing to do,even though it is >not, then he should pay for the test himself... > >______ > >As for the issue of CBC. We get that on admission because of the >high incidence of anemia in pregnant patients. It is a good baseline >measurement and has on occasion made me aware of severe anemia that I >was not expecting. A platelet count is usually requested by >anesthesia prior to administering an epidural. On occasion, the >first clue that a patient has HELLP syndrome is gleaned by the >admission CBC.. > >-- >_______________________ >Geffrey H. Klein, MD >_______________________ >geffrey.klein@obgyn.net >200 Medical Center Blvd Suite 103 >Webster, TX 77598 >(281) 332 6723 > >http://www.geffreyklein.com > IMHO-you are wrong--it is not defensive medicine - at least the way I see it. I do my best to do just good medicine -- not defensive medicine. To me it is an objective data of the fetus's condition - as with BP, temperature (besides touching a patient and asking her how she feels you must get some data don't you??) . We do pH and if below 7.15 or so - then the whole thing - about 20 bucks - too much? ACOG has changed its mind so many times - we all do!! - remember herpes cultures - how about VBAC's ?? Do you do now early repair of 4th degree dehiscence - years ago it was heresy- - ACOG is not the Pope - My belief is that in the future, cord gases will become a standard of care - as with the APGAR score - to quantify your clinical impression - before the apgar scores - the baby was Ok - or a bit depressed -- right? You must at least admit that it is not a stupid idea and there are articles out there supporting such approach. Your conclusions are too dogmatic -in my opinion. As for the CBC - I agree with you that you must need to objectively quantify your clinical impression -I don't think it is wise just to ask her if she feels weak and pull out her lower eyelid.
-- "The things you learn after you know everything are the important ones"
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