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Twins case part IFrom: Dr. John Provatopoulos B.Sc. M.D.C.M. F.R.S.C. (johnprov@sympatico.ca)Sun Apr 28 07:35:03 2002
This is a bread and butter twins case, I guess some of you will find this boring, but just think its only a matter of time before a multicenter randomised clincal trial is done comparing elective c-section at term for twins Vs. a trial of labour(I tought I heard one was in the works somewhere). I think any such trial will almost certainly mirror the results of the Canadian multicenter term breach trial, that being that overall c-section will be found safer(for the babies). Anyway here goes... I am on call for the hospital and have just finished an easy straightfoward delievery when I get a call from a family Doctor who works in a local hamlet about 80 mi from our center. He would like to transfer a 34 y.o. G3 P2 mom with twins at just under 35 wks , he is afraid mom is going into labour and the local hospital's nursury doesn't feel comfortable taking care of 35 wk twins. Family Doctor says Mom is 4cm dialated,80 % eff. stx -1 and contractiong every 4 minutes. Mom had an ultrasound on that day which shows twins are vertex/vertex, there are two sacs(thank God!), twins are apropriate for 34-35 wks but twin B is about 20 % smaller than Twin A. Mom's last labour had a first stage of 3 hrs and a second stage of less than 20 min for an 7 lbs baby. It's just before midnight and he's going to send mom over by air ambulance, it sounds like he is not convinced mom is in active labour, he doesn't ask about tocolysis and I do not tell him he must start tocolysis . Mom and Dad get to our hospital just after 1 am , I say hello to them very pleasant and reasnable couple. Almost by instinct the D.R. staff have straped on the EFM. EFM shows very nice tracing for both twins and contractions every 3-4 min. I examine patient the results are about the same as family doctors last exam, I palpate a couple of contractions and they are not to impressive, mom says she can feel them but not painfull. D.R. staff ask about calling in the anaesthist for epidural, I tell staff I don't think mom is in active labour yet. I ponder giving Mom some betamethasone (celestone),but instead tell Mom to try and get some sleep because that's what I plan to do! So here is the Question for part II, its 2.5 wks latter and sitting on my hands seems to have caused Mom and twins no ill effects. So should I book an elective c-section at 38 wks, book an elective induction on quiet day where I plan to have anaesthist and pediatrician present, or should I throw all caution to the wind and just hope anaesthist and peds are readily available when Mom goes into labour ? Take care, John
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