Re: OB: Twin delivery/availablity of anesthesiologist--long
From: Efrain Ramirez MD (eramirez@icepr.com)
Thu Dec 31 16:22:26 1998
Gary,problem is that the 30 minutes rule does not apply....immediate
delivery means "something" below 30 minutes...there is a "Holy Grail" of
17 minutes wandering in no man's land...living difficult times.
At Wed, 30 Dec 1998, Garry E. Siegel, M.D. wrote:
>
>This past weekend, I had a 36 week vertex/vertex twin delivery
>complicated by a cord prolapse of twin 2. Briefly, after the first
>delivered vaginally, vertex, I ruptured #2, whose tracing had been a bit
>off (variables and 165s), and in the process of vacuuming, a cord
>prolapsed. Long story short, a quick attempt at a vaginal delivery
>vertex didn't fly, and I could push up the head, get one foot, but I
>couldn't get it down to complete an internal podalic version. Thus, I
>did about as stat of a section as possible.
>
>Normally, I have been delivering twins under epidural, in the C/S room,
>with enough nursing people/OR crew such that a section could be started
>immediately. In the past, I've had the MD anesthesiologist or CRNA *in
>the room*, and usually, they've had nothing to do. More recently, I've
>been comfortable with one of them in the house. With this delivery,
>they were in the house but not in the room, as I didn't ask the MD
>anesthesiologist to be there. When the poop hit the fan, he arrived
>promptly, but it took him around 3 to 5 minutes to hook up his monitors,
>get his drugs, and sleep her. These 3 to 5 minutes could have been
>saved had he been in the room.
>
>So. . .
>I'm kicking myself for not insisting on their presence, and I have
>little doubt that he would have been there if asked. When I discussed
>this with the other MD anesthesiologists (we have 5), one of them, a
>stickler for detail, studies, and cost effectiveness, wondered about
>references, and the ACOG 30 minute rule. Furthermore, in our place, if
>there is an after hours case, the MD anesthesiologist might be the only
>guy in house, and if a section came along, he's calling in another MD or
>CRNA, ie "we can start the section in 30 minutes." Obviously, if he's in
>a case, and I've got twins delivering, I'm going to want a body in the
>room, not just in the house.
>
>so. . .
>
>Here is what the 11/97 ACOG educational bulletin says:
>
>"Appropriate, experienced pediatric and anesthesia personnel should be
>notified and available at delivery."
>
>Williams 20th edition says (page 885):
>
>"An experienced anesthesiologist should be immediately available in the
>event that an intrauterine manipulation or cesarean delivery is
>necessary."
>
>What do ya'll do? Do you agree that I am justified in asking for an MD
>anesthesiologist or at least an CRNA in the room?
>
>Garry
>
>--
>Garry E. Siegel, M.D., FACOG
>Private Practice
>Roswell, Ga.
>
--
Efrain Ramirez MD FACOG
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