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Re: OB: Family in the LDR etc. - Devil's Advocate (long)From: Dr Don Miller (DrMiller@aol.com)Sat Dec 30 09:05:07 2000
Actually, in the context of peer review of bad outcomes rather than a support group discussion, I think this entire episode should be a lesson for all that if you're tempted to use Kiellands, do rotations, etc. at +2 station, even for fetal distress, DON'T DO IT! Do an "easy" C/S (especially if you already have an epidural) if you can't make the feeling to do SOMETHING go away. My guess is that the patient's mother was not at all suprised by the racial makeup of the child. I'm sure she knew who her daughter "dated". My guess is that the mother heard a lot of grunting, saw a lot of pulling and sweat, and saw a newborn come out covered with blood, bruised, maybe a little or a lot depressed, and with an asymmetric facial cry, with worried looks on the faces of the nursing staff. That's enough to make anyone concerned and possible angry. Then the patient's mother saw what was supposed to be an easy delivery for a multip, turn into a "vaginal C/S" that is always orders of magnitude more difficult than a regular one. My difficult vault tears were ALWAYS after forceps I wish I would have never done, but somehow felt the urge to do ten minutes earlier. BTW, what IS the outcome and prognosis of large vaginal vault tears? I don't know, I've never seen any good data and I don't know what I could truthfully tell the mother. All I know is that you can superficially, sometimes with great difficulty, put the two edges back together, but there is likely to be severe damage to the underlying tissue, fascia, and supports that may not be apparent for decades. I mean, that's what the entire discussion is about concerning even delivering vaginally versus an elective C/S. "Fetal distress" is certainly a subjective and a prejudicial term (in fact, ACOG recommends that the term be abandoned completely for something like "non-reassuring heart rate pattern"). We always need to reflect on cases with bad outcomes for which the justification for action was fetal distress (and never call it that again). What were the 5 minute Apgars? the cord pHs? Was her epidural just redosed with a subsequent bradycardia? Would ten minutes have made a difference? Bottom Line - If you didn't do it ten years ago, put away the Kiellands now. No one will ever sue you for NOT doing a Kiellands at +2, but they will sue you for NOT doing a C/S. All IMHO.
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