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VBACs (long)From: Garry E. Siegel, M.D. (garrys@mindspring.com)Sat Apr 9 11:31:43 2005
Our practice (2, soon to be 3 MD, 2 CNM) gets a good number of VBAC patients seeking our CNMs. We're supportive of VBAC, but the patients that they see run the entire spectrum--from "routine" VBACs (Breech 1st time) to those whose prior Ob/Gyns have said "no VBAC" for good reason, and they seek out alternatives. In general, we don't find ourselves disagreeing with the other docs much, and we have decided to have any VBAC CNM patient be seen by one of our MDs at one of the first visits (we get some later transfers, too) to go over the circumstances of their first section, op note if available, etc. While our CNMs are good, there are many times at which I delve into the details of the first section and/or review the op note, and basically find that the patient is a really poor VBAC candidate. I find myself letting the air out of some of these people's balloons, in that they sought out our CNM practice to VBAC (street gossip, internet gossip, etc.), yet they really find that traditional obstetric thinking is present. These discussions can be long, sometimes very enjoyable, and sometimes contentious when the patient simply won't accept my opinion, even when it is a no-brainer. What would you do with these cases? #1 37 YO P1001, from India, induced/ripened at 42 weeks. Got to 7 cm., and had LTC/S for distress for a 5 pound 14 ounce baby. I just met her at 38 weeks (solid date, late transfer), and her fundal height was 35. My interpretation of the last pregnancy was that she certainly may have had an IUGR baby, and I thus had a similar concern here, and had a nice conversation with her and told her so. MFM scan done shows 38 week BPD, 35 week HC, 34.7 week AC, and 38 week femur, with the comment that the AC was 5th percentile, and to consider delivering by 39 weeks. #2 33 YO P1001, Oriental, prior LTC/S who was induced at 41 weeks (she's not exactly sure why, but she went to the MD office and was sent straight over to L and D ?heartbeat). The patient is now 33 weeks, 5 feet tall maybe, and around 100 pounds pre-pregancy and has quite narrow hips (simple just to look at her). She progressed to full dilation, and pushed (according to her, not specified in the op note) for 30 minutes and had a section for distress. HOWEVER, the op note says the diagnoses were arrest of descent and chorioamnionitis, and the baby was 6-14 ounces. Any thoughts on these cases welcome. Garry
-- Garry E. Siegel, M.D. Private Practice Roswell, GA
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