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Date: Sat, 30 Dec 1995 12:56:22 -0600
Reply-To: ob-gyn-l@listserv.bcm.tmc.edu
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From: rowan@pavilion.co.uk (R J Connell)
To: gklein@ICSI.Net
Subject: Replies after a long Christmas break!!
X-Comment: List for the discussion of obstetrics and gynecology
Status:
Well a Merry (belated) Christmas and Happy New Year.
I've just got back from my girlfriend's parents' Irish Christmas, which was my first and absolutely fantastic.
I've just spent 3 hours going through 450 messages.... and I thought nobody loved me!!!
I'm sorry for not acknowledging authors...
1 Many of us have mentioned "trial of labour" with primip breeches (Prof Walker and Jason). This is indeed a term known to me, but what do you MEAN?
2 I am not impressed with any instrumentation for bottoms. Surely if a "trial of labour" is taking place, my understanding being good progress in labour, then this is NOT agood idea.
3 I would electively section all primip breech. Yes I have had the misfortune to watch a baby die with a "stuck" head, (not me as the accoucher). I have also had three primip breech vaginal deliveries in the last 6 months as the ladies arrived essentially fully dilated and I would state that it was lovely (but very stressful).
4 Estimated fetal weight and pelvimetry.
Surely if one thinks pelvimetry is useless then why bother with EFW? It makes a mockery. If the sonographers state the weight to be 3.5kg (with a 20% error!!!) and you've not botherred with pelvimetry what is the point? are you 100% confident she does not have a small pelvis?
In my "own" practice (as long as I make consultant) I will "never" do either. One has a gut feeling even as a student that a baby is big/normal or small????
I have seen "big baby" and "small pelvis" deliver normally and the converse end with an impacted head and obstructed labour.
5 Why bother with a generous episiotomy electively for breech. These last three were intact, and it takes a second to perform one if needed (and they are needed occassionally) and anyway performing too early just means that the ladies bleed!
6 Who cares with rates of caesareans? If its indicated it should be done? If my rate was 50% and I was "sure" of my correct management with "all" my deliveries I would sleep well.
7 Talk to patients, talk to their husbands and find time to talk to them a day or two after and then at the postnatal visit. Dads usually have a great deal of trauma especially after an "emergency" C/S where there is little time for explanation, but a kind word after the op before you write your notes and a day or so later saves everyone. If they are or you are unhappy with any of the management ask them to see YOU at six weeks.
8 Epidurals, well I would have one "if I were a girlie, just like my dear papa" (Monty Python).
My most beuatifully experienced delivery was a lady who had a large ing hernia who was to have an elective instrumental delivery (primip). She had a combined spinal epidural (mobile epidural) and this was always fully functioning. She had oxytocin and the baby was never "distressed" (whatever that means!!!!!!!!!). We (she and I) delivered the baby with a few pushes and me steering the baby around the curves and everything was intact and the baby's second christian name is Rowan!! She was fully conversant throughout and she, her husband, the midwife and me shared a truly wonderful experience. So I love epidurals.
9 I find it horrendous that in this day and age people can say without pain you can't get in touch with your body etc what utter crap. This neolithic type of attitude may be good for some but it does not fit with most women. Sure some have great "mormal" deliveries without pain relief but the choice should be offered and all types of analgesia should be "instantly" available in my veiw. (cf anaesthesiologists).
10 I have had some great teachers in my (short) time and I have been exposed to a great deal of different types of delivery, of which I am thankful. I would be saddened if I could not do a vag breech etc because of lack of experience.
11 What about a 5th baby (a veritable monster) which is breech. I had to do a c/s on two ladies in a week for 7th baby CEPHALIC because they just got stuck......
12 What is the cut-off for prem vaginal (vertex) deliveries??
13 If the US is so similar to the UK etc why do you have such a high prem delivery rate?? I cannot beleive that your populations are so much more high-risk that some of our (UK) centres. Is it because of too high dependancy on high tech and less on clinical accumen? Too high intervention??
A friend of mine is now a cardiologist in the USA and was excellent in the UK. One of his first "grand rounds" he presented a patient with a complicated heart murmur with mixed valve disease, which he had seen that very morning and diagnosed by auscultation with his stethoscope. His seniors and colleagues were astounded and disbelieving because he had not done an echo...
14 Peanuts. Yes I read in Womans weekly or something while waiting somewhere that allergies- whether peanut or milk etc were DUE to the mother ingesting IT during pregnancy. This is not an alflatoxin metabolite transfer to the fetus story this is EVERY foodstuff. Aha hence my recent allergy to anything FRENCH?? But seriously this was a genuine story carried by a quite weel read glossy which was obviously completely misrepresenting something that the author probably overheard.
15 Funnels / bladders / placentae etc.
Well when I started scanning I was told that a full bladder distorts everything so to get an "accurate" look at the internal os the lady must urinate. As you know when scanning even gynae scans the internal os is a bit of a ..... but empty the bladder and THEN try to find a funnel!
16 Platelets. Dr Letsky (haem) at Queen Charlotte's always told me it was platelet function that mattered. Platelet counts drop in pregnancy. They become bigger and therefore fool our automated coulter counters and she
>80,000 is "very happy" as long as the function is normal. Get the
haematologists to look under a scope and manually count them if in doubt or do it yourself????
17 I must buy House of God, and read it.
18 Finally.
I must re-iterate the point that lay-people must be excluded from our list. Points raised are (hopefully) controversial and whilst we have had one or two worthwhile additions to our chat, we risk becoming staid and boring in case one of our patients or potential patients read it. I was appauled by the carry-on witnessed with the "vagismus" lady. This is not a forum for patients and anyone not a medical professional must be struck off. In a similar way that we are mentioning the difficultied with an open internet page, the same is true with this forum.
I enjoy being controversial and hearing all your views. We may not practice in ways that we may want to, because of "higher" pressures but our views are so important. By suffocating this by allowing lawyers, patients etc in on this we will never progress. In the past all the great progressive strides were taken by people trying out their ideas. I feel that litigation worries are stifling progress in all branches of medicine and if in a small way we can reduce that by this closed forum the better for all.
Happy New Year to you all
Rowan Connell
Rowan Connell London and Brighton
(I say no to-oo... Bordeaux.
Chablis.... tastes like pee;
No more...the Piat d'Or...
ad infinitum...
Good to see "they" have decided to stop earlier.)
rowan@pavilion.co.uk
tel 0402-131525
