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Re: VBACs (long) From: Garry E. Siegel, M.D. (garrys@mindspring.com) Sat Apr 9 21:03:40 2005 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Garry E. Siegel, M.D.: "Re: OB: CT pelvimetry" Previous message: Garry E. Siegel, M.D.: "Re: Assessing pelvis" In reply to: RModugno@aol.com: "Re: VBACs (long)" Next in thread: R. Daniel Braun: "Re: VBACs (long)" Robert: What you tell patients is what we tell them, too. We don't induce or ripen VBACs, with rare exception (prior successful VBAC, favorable cervix needing delivery, and never any cervidil or cytotec). Your comment about responsibility is spot on. The CNMs are not as adept in dissecting out the circumstances of the original section, reviewing the op note (if detail is present aside from the actual surgical technique), and they are not as well versed in the differences among VBAC candidates based on the reason for the first section. In other words, and you well know this, 70% of VBACs are successful, no doubt. However, the odds you would quote my second case (sectioned at full dilatation) have to be less than those you would quote someone who had a section for a laboring breech at 6 cm. In fact, part of our requirement to have an MD see the patient is to let them hear, straight up, face to face, what we think their situation is. Logistically, we have not chosen to have the MDs screen the VBACs beforehand, i.e. the patient and her record is interviewed before acceptance, but I suppose that we could do that. It is fortunate that most of the patients who have a poor chance at success will listen to reason, and I've found it useful to say my peace in a non-threatening, very matter of fact, business-like fashion, and to tell the patient that there is no rush to make decisions, but it is obvious that you should have a repeat section. It is hard for the patients to understand that when success if very unlikely, that there are tremendous advantages to a scheduled section, and potential disadvantages to an unsuccessful laboring VBAC. Hell, many of them will agree to a repeat section but want to wait for labor to do it! Garry At Sat, 9 Apr 2005, RModugno@aol.com wrote: > >In a message dated 4/9/2005 2:22:10 PM Eastern Standard Time, >eramirezt@coqui.net writes: > >Any thoughts on these cases welcome. >> >>Garry >> >>-- >>Garry E. Siegel, M.D. >>Private Practice >>Roswell, GA > >Garry, you could be in a 12 MD, 50 CNM practic, but ultimately, the >responsibility & liability falls on the MD's shoulders, as you know. I would suggest >coming to a practice policy agreement in your collaborative practice >regarding VBAC.All docs and CNMs should be in agreement regarding the management of >the individual patient.. If the patient's expectations are IYHO unreasonable - >then you have the right to ask the patient to take her business elsewhere. >Ideally this situation should be dealt with sooner than later. > >Our approach to VBAC's (unencumbered by any data): >1) We tell the patient that the medical literature (usually coming from >large academic institutions with many layers of interns, residents, fellows and >attendings) is that VBAC's are successful in 70% of cases. >2) We will NOT cervical ripen/induce a patient at 41 weeks or beyond with an >unripe cervix with previous C/S. >3) We tell the patient the greatest chance of having a successful VBAC is a >previous successful VBAC. >4) The bottom line: Easy VBAC, easy repeat section. Gosh, I must be getting >old! > >Robert Modugno MD MBA FACOG >Marietta, GA -- Garry E. Siegel, M.D. Private Practice Roswell, GA Next message: Garry E. Siegel, M.D.: "Re: OB: CT pelvimetry" Previous message: Garry E. Siegel, M.D.: "Re: Assessing pelvis" In reply to: RModugno@aol.com: "Re: VBACs (long)" Next in thread: R. Daniel Braun: "Re: VBACs (long)"

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