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Re: OB: OA vs. OPFrom: Garry Siegel (garrys@mindspring.com)Sat Dec 30 21:37:54 2000
At Sat, 30 Dec 2000, O'Grady, Patrick MD wrote: > Thanks for the great educational comments, Dr. O'Grady. For those of you who have not read his books on forceps and vacuums, they are musts. A few comments about the cases I've recently posted: 1. In the prolapsed arm/VBAC case, my partner ruptured membranes in early labor (3 cm) to stimulate progress. I think that most Ob docs would have done the same. While this doesn't make it right (maybe the best intervention is no intervention), just because he got an unexpected outcome doesn't mean it was wrong. I assume that he felt that the vertex was presenting and low enough to proceed. 2. Forceps versus vacuum--when a multip can't push out a baby, and it is OP, then that is telling me that: a. her epidural is dosed to much--not the case here b. the baby is bigger than we think c. a vacuum is a waste of time in my hands 3. Easy C/S versus tough vaginal delivery--Dr. Miller's comments are well thought out, and retrospectively, who wouldn't rather have done a section as opposed to a difficult vaginal birth with a less than perfect outcome. However, in my place, I could deliver this baby with a non reassuring tracing faster vaginally than with a section. As someone pointed out, it would not have been an easy section, as the vertex was low enough to deliver vaginally. Those are the sections with lacerations and extensions of the incision, atony, etc. Dr. Miller's comments about our lower threshold to do a section, and prevention of long term ill effects of vaginal childbirth are germane; however, it is not yet standard to avoid attainable vaginal birth by doing a section. That said, I absolutely agree that one rarely regrets, or gets sued for doing a section. OTOH, had I sectioned her, gotten lacerations, atony, etc., and had to transfuse her, then I perhaps would have been "wrong" to have sectioned her. As Dr. O'Grady said, the best way is what works for the Ob; while I may overestimate my forceps skills, in this case, the baby was deliverable vaginally. I do not agree with Dr. Miller that rotations that were ok 10 years ago are now not ok. 4. Fetal distress--I do not use this term in the chart, but still use it in discussions with nurses, colleagues, for ease and familiarilty. 5. Apgars in the forceps case--7 at one minute, 8 at five minutes. Since they were normal, I chose not to send a gas (Geff's comments have me thinking a lot about when I send gasses, and with normal Apgars, sometimes I don't). I'm enjoying these threads. Garry
-- Garry E. Siegel, M.D., F.A.C.O.G. Roswell, GA Private Practice
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