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Cesarean section delays-longFrom: Arthurfree@aol.comSat Mar 9 14:12:41 1996
In a message dated 96-03-02 10:36:10 EST, Dr. Copeland writes:
> such a facility must have the "(c)apability to perform cesarean delivery Dr. Copeland, This is a very valid point, and a well thought out guideline. I must admit that I've hesitated in replying largely to see what the group did with the "remote home births vs moving to the city (Australia) string, and the home birth string that degenerated into more smoke than substance. There is some similarity, since when the remote GP's referred to in Australia are unable to provide obstetric services, for whatever reason, the patients in that reason are left several hours by car from the nearest obstetric provider. We do the absolute best we can, in rural America, to take the best care of our patients possible. This includes transferring to a perinatal center, in utero, if possible when higher risk situations are recognized early. Prenatal care for high risk pregnancies is likewise performed in perinatal centers. We've made a qualitative decision, that our population of mothers is best served by having obstetric care available locally rather than all requiring over an hour on the road in labor (that hour is to the nearest hospital with obstetricians on staff, not the center). The understanding that we cannot provide the acuity of care available in urban centers is explicit. In spite of all this foresight, we wind up delivering at least as many of the patients that have been referred out due to risk as we ship out in labor. Two recent examples are a term abruption who appeared in the emergency room (thankfully with reasonable heart tones) and a breech -breech set of twins ruptured and eight cm dilated. They simply do not have the wherewithal to actually move to the city for a month surrounding the EDC. We constantly work to obtain and maintain the tools necessary to take good care of our patients and having anesthesia availble within a thirty minute drive is actually an improvement from what we had four years ago. Hence my comment that we keep the instruments pulled for a section, and someday I will have to proceed without my anesthetist. Yesterday, we stabilized seven victims of a two car crash in our emergency department within a ninety minute period. It took every physician in town, and the patients on the floor had minimal monitoring for a while, but we did reasonably well - a five year old with massive head trauma was the only immediate fatality. Would these patients have done better in a level one trauma center? Absolutely. But these unfortunates did not have their accident in Des Moines. Did we do well? The very best we could with what (and who) was available. Our local hundred or so deliveries a year is not nearly enough to attract obstetricians to the area, and even if we did, having limited specialists on staff would dilute the number of providers who could take general medical/ER call. I am a family physician, do my best to stay abreast of current ob practice, and do sections because to do less would be akin to agreeing to box with my hands tied behind my back. I am, by necessity, a jack of all trades, and our current legal climate demands I appear a master of all as well. I guess the only incongruity I see with this guideline (that I agree is reasonable, a worthy goal, and can be protective in cases where more rapid intervention was really necessary) is that it can be used to hang me for providing necessary local care, when a poor outcome caused by the loss of local services would only be unfortunate fate . . . Arthur Freeland, MD Centerville, Iowa population 6500
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