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Rivera
Sent: Monday, June 13, 2005 1:59 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: ality OB
"Anna Meenan, MD" <annam@uic.edu> wrote:
Told you what i do with everyone. Why would this lady be any different?
NST/AFI twice-weekly, induce at 41 weeks if cervix ripe, 41.5-42 weeks
if cervix not ripe. I don't start inductions in the middle of the night
if they are elective, just because less staff around, etc.
Anna Meenan, MD
C'mon Davey, what's the punch line?
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=20
Here's "THE REST OF THE STORY."
Don't call me Davey-reminds me of Davey and Goliath. And don't call me
Shirley, either. But you can call me a cab,
This is more about art v science, flexibility and individual judgment v
dogma, and ultimately "treating the whole patient." There was no
disaster averted. I just didn't think she would deliver vaginally based
on her pubic arch, the size of the baby, her age and a distinct sense of
deja vu.
My first choice was elective section but I decided on the old college
try since I wasn't sure who would be second guessing me. Her pubic arch
was a tad on the narrow side, which added to my gut feeling about labor
being a bad idea.
There are several mitigating factors: Solo call in a rural hospital
with a small OB staff (2 nurses per shift), variable quality of
pediatric care, CNRA lives 30 minutes away, and a large indigent
population with the usual psychosocial problems. No in-house
anesthesia, no residents, no other OBs AND, Anna, no FPs doing
deliveries. I prefer to do things in broad daylight with maximum
ability to control the situation when my resources are that limited
rather than shuckin' and jivin' in the middle of the night.
She came in with her mother, her grandmother, her sister (who is
pregnant and due in Janaury) and her aunt. She figured this would be a
cakewalk; a few contractions and she'd have a baby by noon. I got the
horrified look when I told her first labors can take 18 hours or more.
I did a tubal ligation and asked anesthesia to see her before he left.
I later found out the scrub tech pulled everything for a Cesarean before
she left.
Pitocin started around 0930. With the first contraction she cried and
said, "Mommy I want to go home." The CRNA talked to her about
epidurals. . Her mother started going on about she had a cesarean with
both her kids and if she needed a section it had to be under general
because grandma had a spinal and was paralyzed for several years and
would sue anyone who tried to do a spinal for a cesarean.
She got to 5cm by 11am, screaming the entire time. She didn't want an
epidural but we finally talked her into one at 1pm, (which she thinks
didn't do anything, but she was much calmer after it kicked in). The
mother bitched out the poor CRNA because he told the patient he'd have
to go home when she said she couldn't hold still. After he got the
epidural in, he walked out and showed the mother the Tuohy needle,
explaining he really didn't want this to break in her back because she
was bucking like a bronco.
She was still 5cm at 1pm. The baby showed good reactivity, some
drifting of the baseline into the 100s, but still good short-term
variability. Her mother was saying "Why didn't they (meaning me) just
do a section after the ultrasound. Why can't you just do one now?" I
gave her the standard lame excuse about the Cesarean police along with
an anecdotal story of a teenager who pushed out an 11lb 4 oz baby in 20
minutes. I told her we'd decide at 2pm, but I decided at 1:30 pm since
I knew that's what I shoulda done in the first place.
. Her mother was ecstatic that I decided to section her and we did it
under general. The kid was OP with a nuchal chord x2. The CRNA said I
was so fast he did his first propofol/nitrous/oxygen Cesarean. The kid
was OP (no surprise) and had a smoker's cord (scrawny, little.Wharton's,
and long) around the neck twice but house APGAR scores. EBL 200cc.
One of the seasoned OB nurses (mid 50s) said, "I figured she was going
to be a section when she walked in. Three years ago she would have had
to go through a long labor just to prove she needed a section. I'm glad
we did this"
Everyone be happy with baby out; mom actually thanked CRNA. She looks
dandy yesterday morning and will likely go home this morning.
Sometimes discretion is the better part of valor. I've seen many
instances where going "by the book" led to a bad outcome. The Book is a
guide; one has to learn judgment.
My suggestion is to offer the sister for an elective section at 39 weeks
DAR
