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Re: OR fetal monitoringFrom: mark decker (mdecker@nconnect.net)Fri May 31 22:00:11 1996
There is a widespread fear of the perceived legal risk associated >with vaginal breech birth. I have heard many physicians say that they would >like to do them, but don't because of the risk of malpractice litigation. > Such a shame that our ability to offer choices to birthing women is limited >by these sorts of factors. > >Cheri Van Hoover, CNM >Kaiser Hospital >Redwood City, CA > thanks for the response. it is too bad. the newer data does not support increased risk. trouble is if you get an injury you are suspected as being at fault. similar to a cp kid..with little muscle tone needing a vacuum or a forceps delivery because with little to no tone they seem to not come down right and need some help. viola..a cp kid..must been the vacuum or the forceps. typically they have borderline fhts..not a lot of variability but no lates,,nothing acute..just chronic low grade hypoxia pounding on them week after week. you get a bad kid and you usually win these I here <85% doc win rate>..but what a cost to prove you were right. years of uncertainty and MONTHS in a trial. I do most of my breeches vaginally because that's how I was trained..and it is common to do them vaginally in wisconsin. I feel comfortable with them...and I give a lot of informed consent and I present all my breech and other "operative" or interventionist activities as a risk issue such that it is clear that bad outcomes do occur "normally" as a result of good choices..that nothing is garunteed to go ok but that I am trying to decrease the risk of an injury..not absolutely prevent it. I get my share of ureteral inuuries. 3 so far out of 7-8 years of private practice with 700-800 cases minimum done, I have found them at the time of the injury twice and one I discovered a week later after a laparoscopy..<urine leaked through a necrosis injury after a cautery burn of a bleeding area during the surgery> the burn site was a few centimeters from the ureter> obviously related. straight up with all the patients and no suite so far on these. went to trial on a case where I traced the ureter out on a laparotmy and it was fine at the end of the case..not tied off etc. six months later she came in with pain and a cystic mass on the right side <I had removed the ovary and lysed a hundred adhesions..damn close..it was a two hour case...> when I did a pelvic there was a cystic right on the side wall along the ureteral path so I did an ivp in the work up..kidney gone. on reviewing this case I discovered that the day I was operating on her she had two active law suits in process already...and I had only seen her as a consult for pelvic pain..did her surgery for ovarian cyst pain..and the adhesions..done the oophrectomy. so I had no rapport with her. took five years to get to go to court and present the case..facts etc. she had evidence of old endo on the ovarian tissue I removed..and it turned out she went to surgery again for pelvic pain 2 months before trial..and had large implants of endo removed by a general surgeon..the implants were on the right sidewall. not to get intpo huge detail.. but I only had to spend 3 days in court and won decisively. I could not imagine 3 or more months in trial with an injured baby as is often the case with cp kids and I imagine..brachial plexus injuries. sorry went on too long.. but it does do a number on your family and yourself..and takes forever to sort through..and no matter how pricipled the practice choices you can get bad outcomes with good medicine and there is no garuntee you will win a case you should win. I have that battle..not to let the lawyers practice medicine for me. as a consequence I let them guide my dictating much to the pain and agony of transcription..I dictate informed consent up the butt. and I have laid out detailed risk discusions and options discusions. <btw in wisconsin it is a significant misdeameanor...fine and jail time not set yet to my knowldege..if a physician does not DOCUMENT IN THE CHART..ALL..yes ALL the reasonable options of treatment. not enough to state you covered them..you must list them in the record or you are a criminal in the eyes of the legislature. > went off again.. I will quit.. I have had one or two vaginal breeches come out a little slower than I like <about 3-4 minutes to get through all the mechanisms and I had fleeting thoughts that I was gonna get a grey hair or two out of it> but I do quite a few of them on my patients and as a consultant and if they come down they usually come out. only one transient nerve injury that was mild and cleared up over two weeks. btrw the one significant nerve injury occured on an easy vaginal delivery with no unusual traction or any head turnong. that one took three months to get to normal and still can't figure out why it occured. goes to show you can't figure it all out. Mark -- mark decker md major surgery is done on me obgyn - avid biker minor surgery I do one someone else. midwest usa I need to remember that. <perspective>.
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