Re: Malpractice questionairre
From: Elrod, Darryl G Maj 48 MDOS/SGOBO (Darryl.elrod@LAKENHEATH.AF.MIL)
Thu Jun 28 03:38:39 2007
No Ef, he's talking to me. I have to justify what I do or don't do. I
do appreciate the link to the article. In fact, that looks like a good
list of the circumstances I would collect gases (except the thyroid
disease) and I'll use it in my discussion.
Thanks,
Glen
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Efrain
Ramirez
Sent: Wednesday, June 27, 2007 10:54 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: Malpractice questionairre
Dan.. first I don't understand your statement "I would suggest you
state what you really do" .. I told you what I do - I do umbilical cord
gases analysis to all my deliveries - I don't see no reason for not
doing until a baby has a low APGAR score - why do them at that moment??
- who is it going to help? (if it is $$ - and I don't care the zillions
they cost - if it is going to get me and my family out of a malpractice
claim)...
Through the years of doing them I have found not one case of regret - I
have informed neonatologists of low pH, low bicarb on GBS patients (I
think there is an article linking the 2 with severity of the disease?)
Besides, read the following- carefully, without passionate feelings -
with the most opened minded approach..
Un abrazo,
Ef
I know you will live long enough to see it become the standard of care
:)
Acidemia and Cerebral Palsy
Both the International Cerebral Palsy Task Force and the American
College of Obstetricians and Gynecologists' Task Force on Neonatal
Encepha-lopathy and Cerebral Palsy have published criteria to define an
acute intrapartum event as sufficient to cause cerebral palsy (2, 11).
Among the essential criteria cited by both task forces is evidence of
metabolic acidosis in fetal umbilical cord arterial blood obtained at
delivery (pH less than 7 and base deficit greater than or equal to 12
mmol/L) (see box). Additionally, the National Collaborating Center for
Women's and Children's Health, commissioned by the National Institute
for Clinical Excellence, has recommended that umbilical artery pH be
performed after all cesarean deliveries for suspected fetal compromise,
to allow review of fetal well-being and to guide ongoing care of the
infant (12).
Conclusion
Umbilical cord arterial blood acid-base and gas assessment remains the
most objective determination of the fetal metabolic condition at the
moment of birth. Thresholds have been established below which it is
unlikely that an intrapartum asphyxial insult will have resulted in
neurologic injury to the infant. Additionally, most infants born with
umbilical arterial metabolic acidemia at a level consistent with causing
a neurologic injury will, in fact, develop normally.
Physicians should attempt to obtain venous and arterial cord blood
samples in the following situations:
* Cesarean delivery for fetal compromise
* Low 5-minute Apgar score
* Severe growth restriction
* Abnormal fetal heart rate tracing
* Maternal thyroid disease
* Intrapartum fever
* Multifetal gestations
At Wed, 27 Jun 2007, R. Daniel Braun wrote:
>
>I would suggest that you state what you really do. If you are ever
going to
>get them, I would do it if the 5 minute apgar is 6 or less. This is
exactly
>what I did, when I was still delivering. I would collect a cord segment
on
>all deliveries and set it on the table. When I heard the 5 minute
apgar, if
>it was 6 or less, I would send them down to the lab for gasses.\
>However in my opinion, that is also worthless as is any Apgar score
done
>these days. I have not seen a correctly done Apgar score for over 20
years.
>An Apgar score is a procedure that is DONE at 1 and 5 minutes. It
includes
>putting a catheter in the babies nostril to elicit a reflex response
e.g.
>cough/sneeze=2, grimace =1, no response=0.When you ask the peds at 8
minutes
>what were the Agar scores and the response is "I don't know, I will
have to
>think about it when I get around to it and let you know" then you know
that
>they didn't do it.
>They usually tell you, we were too busy to do it at the appropriate
times.
>OK, then report Apgar NOT DONE. Don't make up some false value 30
minutes
>later that will become a significant issue in a court of law 4-10 years
down
>the line.
>
>Dan
>
>On 6/27/07, Elrod, Darryl G Maj 48 MDOS/SGOBO <
>Darryl.elrod@lakenheath.af.mil> wrote:
>>
>> So Garry and Dan,
>>
>> What would you tell the malpractice carrier? I do exactly the same
as
>> Garry. Floppy baby, bad strip, etc I will collect the cord for
possible
>> sample. If baby has looked great and comes out screaming, I don't.
>>
>> Like Dan said, this could come back to haunt me later, I suppose.
>>
>> Glen
>>
>> -----Original Message-----
>> From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
Garry
>> E. Siegel, M.D.
>> Sent: Tuesday, June 26, 2007 6:17 PM
>> To: Multiple recipients of list OB-GYN-L
>> Subject: Re: Malpractice questionairre
>>
>> Dan:
>>
>> Don't hold your thoughts back. . .
>>
>> Garry
>>
>> FWIW, if the apgars are good, I don't do them. If the apgars aren't,
or
>> the tracing was funny/meconium or maybe things don't seem right, then
I
>> do them--not very often, though.
>>
>> Garry
>>
>> At Tue, 26 Jun 2007, R. Daniel Braun wrote:
>> >
>> >All cord gases do is cover the insurance comany's ass at the expense
pf
>> the
>> >patient. They are of no value to the mother or the newborn and are a
>> waste
>> >of money.
>> >I can say that since I am now retired and don't have to purchase
>> Malpractice
>> >insurance any longer.
>> >
>> >Dan
>> >
>> >On 6/26/07, Elrod, Darryl G Maj 48 MDOS/SGOBO <
>> >Darryl.elrod@lakenheath.af.mil> wrote:
>> >>
>> >> Joe,
>> >>
>> >> Yeah! I know. There are a bunch of questions all like that.
>> >> Thankfully, most I 'do' the right thing and don't have to explain
>> >> myself. It just got me questioning if on this one I SHOULD be
>> >> collecting a sample of cord for gases on each and every delivery.
>> Did I
>> >> miss some new policy statement that makes it standard of care? Of
>> >> course the malpractice carrier will be the first ones to pick up
on
>> this
>> >> for sure.
>> >>
>> >> Glen
>> >>
>> >> -----Original Message-----
>> >> From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
Joe
>> >> Sent: Tuesday, June 26, 2007 1:34 AM
>> >> To: Multiple recipients of list OB-GYN-L
>> >> Subject: Re: Malpractice questionairre
>> >>
>> >> Elrod, Darryl G Maj 48 MDOS/SGOBO wrote:
>> >> > I am filling out my first malpractice questionnaire. It read
>> through
>> >> a
>> >> > list of questions and if you pick the 'wrong' answer (ie Do you
>> apply
>> >> > fundal pressure for relief of shoulder dystocia? If YES, then
>> >> explain)
>> >> > they make you explain the answers.
>> >> >
>> >> > One of the questions is 'Do you routinely collect cord blood at
ALL
>> >> > deliveries' If NO, then explain.
>> >> >
>> >> > Somehow, because I was trained that way, just doesn't seem
salient.
>> >> > What do you all do with regard to cord blood collection at
delivery
>> >> and why?
>> >> >
>> >> > Thanks,
>> >> >
>> >> > Glen
>> >> >
>> >> Is this for your own insurance carrier? From legal point of view
>> >> whatever you put in print may come back to haunt you. Joe C
>> >>
>> >--
>> >R. Daniel Braun, MD FACOG(L) CMT
>> >Professor Emeritus
>> >Dept. of Obstetrics and Gynecology
>> >Indiana U. School of Medicine
>> >
>> >R. Daniel Braun
>> >
>> > "Science without Religion is LAME; Religion without Science
is
>> BLIND"
>> > Einstein 1941
>> >
>>
>> --
>> Garry E. Siegel, M.D.
>> Private Practice
>> Roswell, GA
>>
>--
>R. Daniel Braun, MD FACOG(L) CMT
>Professor Emeritus
>Dept. of Obstetrics and Gynecology
>Indiana U. School of Medicine
>
>R. Daniel Braun
>
> "Science without Religion is LAME; Religion without Science is
BLIND"
> Einstein 1941
>
--
" The greatest obstacle to knowledge is not ignorance,
it is the illusion of knowledge." Daniel J. Boorstin - Historian
