Re: EFM 800 pound gorilla
From: art fougner, md (evsono@pipeline.com)
Tue Jul 10 09:39:02 2007
Garry
I hereby dub thee the Bard of Parker.
Art
At Mon, 9 Jul 2007, Garry E. Siegel, M.D. wrote:
>
>Admitted on Thursday and still pregnant Sunday?
>
>For no other reason, that cries out for a section and is the 800 pound
>gorilla in the room.
>
>Garry
>
>At Mon, 9 Jul 2007, D. Ashley Hill wrote:
>>
>>I have a couple of thoughts:
>>
>>1. It sounds like the nursing staff utilized the chain of command
>>appropriately, as long as they did not verbalize their disagreement with
>>the attending physician in front of the patient or family. The chain of
>>command, while uncomfortable (and a real pain if you're the chief), has
>>been life-saving and probably is not used enough.
>>
>>2. According to the "new" EFM guidelines (reviewed in CLINICAL
>>MANAGEMENT GUIDELINES FOR OBSTETRICIAN—GYNECOLOGISTS NUMBER 70, DECEMBER
>>2005) minimal variability is less than/equal to 5 beats per minute. I
>>agree it can be challenging to see an otherwise normal tracing (accels
>>with scalp stim, no periodic decels, negative contraction stress test)
>>with minimal variability. Was she on meds like magnesium sulfate or
>>narcotic analgesics? If she had an epidural, was the BP normal? A scalp
>>pH, often not available even in larger US hospitals, might answer the
>>question. We don't use fetal pulse oximetry any longer and ACOG does
>>not support that modality. However, as others have said, with a
>>positive scalp stim the baby should not be hypoxic.
>>
>>3. As chief, unfortunately, you have to take a stand. When I am in
>>this position I talk with the patient, explain that it looks like the
>>baby is ok but that reasonable people might disagree (after all, the
>>intraobserver correlation with expert EFM review is only something like
>>30%), and that you do not have any better way to assess fetal
>>well-being. If she wants to decrease risk to the baby but increase risk
>>to herself, then she should consider a cesarean. If she is willing to
>>take the (probably small) risk of continued labor, then that's her
>>decision. Regardless of her decision, by taking a stand one way or the
>>other you will disappoint (or anger) half the audience, but it's better
>>to be respected than liked. Best wishes. Hopefully all was uneventful.
>>
>>Ashley
>>
>>At Mon, 9 Jul 2007, Richard D. Kaplan wrote:
>>
>>snip.. That physician reviewed all the previous tracings and felt that
>>the
>>>minimal variability and minimal accels (10x10 with scalp stim.) were not
>>>significantly different from the previous 48 hours. No periodic decels were
>>>ever present.
>>
>>--
>>D. Ashley Hill, MD
>>Associate Director
>>Department of Obstetrics and Gynecology
>>Florida Hospital Family Practice Residency
>>Medical Director, Loch Haven Ob/Gyn Group
>>Division Director, Dept. of Ob/Gyn, Florida Hospital Orlando
>>Orlando, Florida
>>
>--
>Garry E. Siegel, M.D.
>Private Practice
>Roswell, GA
>
--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
