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Re: OB-GYN-L digest 4115From: RModugno@aol.comSun Aug 28 14:43:36 2005
In a message dated 8/28/2005 3:24:47 PM Eastern Standard Time, rd.braun@gmail.com writes: Delivery by the most expeditous route. On 8/28/05, _RModugno@aol.com_ (mailto:RModugno@aol.com) <_RModugno@aol.com_ (mailto:RModugno@aol.com) > wrote: In a message dated 8/28/2005 1:18:44 PM Eastern Standard Time, _Hu ladoula1@aol.com_ (mailto:Huladoula1@aol.com) writes: and in another we don't. Who is "we?" In many areas "we' is the malpractice insurer and/or the hospital - both "practicing medicine' without a licence. American obstetricians practice their profession under a veil of fear - fear of malpractice litigation. No LM, CNM, NP, PA, RNC, Doula or consumer of women's healthcare can imagine the shoes in which we walk! So, if an obstetrician perceives that a situation may lead to a lawsuit, increased premiums, cancelling of their liability insurance , premature termination of their career, loss of hospital privileges and personal assets - which pathway do you think they are going to choose? Which would you choose! The consumers can bitch and moan till the cows come home - it just ain't gonna happen in this climate! Her's an example from the real world (happened last night): The patient, a medical student surrounded by her support team of 2 other med students and a law student develops late decelerations on pitocoin. The pitocin is switched off. She has an epidural, is seven centimeters dilated, a primigravida at term with clear amniotic fluid.. Following this incident the baby then develops a baseline tachycardia in the 180s. She is afebrile. There is no apparent "external" cause for this shift from the previous baseline in the 120s. I would expect a "compensatory" tachycardia to resolve within a few minutes.After 15 minutes of watching this tachycardia, it persists. What should I do? Continue to watch? Restart pitocin? There are no further decelerations and naturally reactivity is gone because of the tachycardia. Some seminal event has occured? Now what? Robert Modugno MD MBA FACOG Marietta, GA I talked to the patient, her husband and her "labor coaches". Pointed out that the baseline had risen from the 120's to the 180's - weren't sure why. She did get some brethine, but in my experience this was not a cause of fetal tachycardia which was now persistant, and at seven centimeters and being a primigravida, delivery was not imminent. I recommend a cesarean section. She said to me: "Is it necessary?" Well, was it? Robert Modugno MD MBA FACOG Marietta, GA
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