Re: ality OB
From: Anna Meenan, MD (annam@uic.edu)
Tue Jun 14 08:57:42 2005
And what makes you think a doula wouldn't have done crap? All the doula
studies show lower c-section rates. Sorry, I'm at home and my files are
in the office.
--
Anna Meenan, MD
At Tue, 14 Jun 2005, David Rivera wrote:
>
>YO ANNA, the epidural was in for 20 minutes before I decided on a Cesarean. She was OP from the beginning. A doula wouldn't have done crap. All this happened within a matter of a few hours. She would have had a section if she'd come in three days later and would have had one if I'd induced her two days before the ultrasound, as someone suggested.
>
>So are you so wedded to doing things by the book that patients have absolutely no say in their care? So what is wrong with an elective Cesarean in the first place???
>
>That is largely my beef with you. Vaginal delivery and wasting time: Good. C section: Bad. There is higher morbidity in women who've had a long labor and a section v those who have an elective section without labor. There is no significant cost difference with a section when you factor in the time, intensity of care and other stuff. (I can get you the citation by Steve Clark).
>
>Elective Cesaerans were pioneered by Yuppie women who didn't have the time for labor, and often requested by female OB/GYNs
>
>"Anna Meenan, MD" <annam@uic.edu> wrote:
>You didn't tell us the whole story at the beginning. It would have made
>a big difference to know that her mother had had c-sections and was
>talking c-section from the beginning. I could have predicted how this
>would have ended up. That being said, however, there are plenty on this
>list who will argue (and maybe already have---I haven't read the rest of
>today's posts yet), that a c-cection was not inevitable. A doula and a
>midwife would have been a huge help here. She was making excellent
>progress at the beginning, and who's to say that the epidural didn't
>contribute to her being OP? Was she ambulated? Was she allowed to labor
>in a tub? Did she have constant one-on-one attendance with a doula who
>continually reinforced that she was making excellent progress? Would she
>have done better if she had gone into spontaneous labor a couple of days
>later? I have seen a ton of these types end in vaginal deliveries also.
>And lets not forget that, the more c-sections we do, the more mothers we
>will have talking their daughters into needing c-sections down the road.
>
>Anna Meenan, MD
>
>At Mon, 13 Jun 2005, David Rivera wrote:
>>
>>"Anna Meenan, MD" 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?
>>*************************
>>
>>*************************
>>*************************
>>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
