Leukocyte

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I am a Family Medicine intern, and I had one of the most horrific moments of my life this weekend. I was paged by L&D to deliver one of my patients. Everything was going fine, but the baby's head (ROA) just w'ont come out. I decided to use a vaccum. Baby's head finaly came out, and just as a smile was begining to form on my face, the baby's head started turning blue. Very blue. I was freaking out. Told the nurse to page the OB/GYN attending on call, in the mean time I did a episiotomy, and tried the McRobets, Rubin, Woods and Rev. Woods. Again, no luck. I told the mom to gently roll on her hands and knees, and finally I was able to put my finger in and deliver the posterior shoulder. The OB attending finaly came in (just before the baby came out), and told me "You were lucky this time, next time do a c-section". No good job. No pat on the back.

My FM attending told me I did the right thing by not rushing into a c-section. I am a little confused. Is my attending right, or are OB/GYNs in general "c-section happy".:confused:
 

chrisisinnocent

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Well I have often heard that nobody will ever sue you for doing a c section too soon but you will certanly get sued for not doing one or doing one too late.
If that kid had come out with neurological damage or shoulder dystocia it would have been an instant multi million dollar judgement. Oh and the kid and the parents have until he's 21 to sue you. So if little Johnny all of a sudden develops some neurological issue sometime in the future and the mom remembers that "the Dr that delivered you got you stuck and you turned all blue, I bet that's probably why you have seizures now" then it's litigation city.
 
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Leukocyte

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Well I have often heard that nobody will ever sue you for doing a c section too soon but you will certanly get sued for not doing one or doing one too late.
If that kid had come out with neurological damage or shoulder dystocia it would have been an instant multi million dollar judgement. Oh and the kid and the parents have until he's 21 to sue you. So if little Johnny all of a sudden develops some neurological issue sometime in the future and the mom remembers that "the Dr that delivered you got you stuck and you turned all blue, I bet that's probably why you have seizures now" then it's litigation city.
Well the baby did have shoulder dystocia, that is why I did the maneuvers according to the book. "The books" do not tell you to do a c-section when you have shoulder dystocia. You are supposed to go through the maneuvers first. C-section should be a last resort. And what if you do a c-section, and something happens to mom during the surgery. Then what? The lawyer would then come back and say that you should not have jumped into a c-section right away for shoulder dystocia without attempting the manoeuvers.

In residency, attendings keep telling us to NEVER practice "defensive medicine", and to allways practice "good medicine". Wouldn't doing a c-section (without first trying vaccum/forceps and dystocia maneuvers) be considered "defensive medicine",and not "good medicine"?:confused:
 

chrisisinnocent

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Well the baby did have shoulder dystocia, that is why I did the maneuvers according to the book. "The books" do not tell you to do a c-section when you have shoulder dystocia. You are supposed to go through the maneuvers first. C-section should be a last resort. And what if you do a c-section, and something happens to mom during the surgery. Then what? The lawyer would then come back and say that you should not have jumped into a c-section right away for shoulder dystocia without attempting the manoeuvers.

In residency, attending keep telling us to NEVER practice "defensive medicine", and to allways practice "good medicine". Wouldn't doing a c-section (without first trying vaccum/forceps and dystocia maneuvers) be considered "defensive medicine",and not "good medicine"?:confused:
I agree with you on the principle but defensive medicine is practiced all the time. In court you will be judged by 12 people with no medical training not your attendings of fellow physicians. And by shoulder dystocia I meant birth injury secondary to it.
 

BBCatcherVA

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It sounds like you unfortunately met a bad attending. I have always had the Zavanelli maneuver (push the head in and do a C-Section) presented to me as some kind of urban legend. No attending that I have talked to has ever seen or considered doing a C-section for shoulder dystocia because the horse is already out of the barn, so to speak. From a litigation standpoint, I have been instructed that having a shoulder dystocia isn't what is going to get you sued, not knowing what to do when one occurs will. Of course, this may be the type of rhetoric you get in an academic medical center and not in the "real world". To that end, it sounds like you did the right maneuvers and didn't hesitate in performing them. Good for you and the infant. Now if we can only get patients to realize that sometimes bad outcomes occur and they aren't necessarily anyone's fault and that no one is guaranteed smooth passage into this world!
 

goodsamob

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My guess would be that the attending didn't suggest a Zavanelli maneuver. Yes, this is mostly something seen only in textbooks. I would think the attending was refering to the decision to proceed with operative vaginal delivery over c-section. It's difficult to debate that decision without much more information about the case.

The interesting part of the OPs story is that an attending wasn't already in the room. How did an intern get that far into the weeds by themselves? Are you allowed to deliver alone as in intern? That seems odd.

As far as C-section happy, I think that depends in part on how you are trained. In my program, forceps are alive and well. We do them regularly, I dare say daily. (one of our chiefs last year graduated with more FAVDs than anyone else in the country) So, I will be very comfortable as an attending (in just a few days!) with forceps. In many programs forceps are museum showpieces only and vacuums are used with much trepidation. Operative vaginal delivery is a dying art in many programs, and yes, these docs will lean more toward c-section. I would have to say that if you aren't trained well in forceps or vacuums, you best not use them. As you can see, they can land you in a world of trouble.

Rambling post, but the bottom line is that I don't think this story in any way paints ob/gyns as "c-section happy"
 

Flea girl

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It sounds like you unfortunately met a bad attending. I have always had the Zavanelli maneuver (push the head in and do a C-Section) presented to me as some kind of urban legend. No attending that I have talked to has ever seen or considered doing a C-section for shoulder dystocia because the horse is already out of the barn, so to speak. From a litigation standpoint, I have been instructed that having a shoulder dystocia isn't what is going to get you sued, not knowing what to do when one occurs will. Of course, this may be the type of rhetoric you get in an academic medical center and not in the "real world". To that end, it sounds like you did the right maneuvers and didn't hesitate in performing them. Good for you and the infant. Now if we can only get patients to realize that sometimes bad outcomes occur and they aren't necessarily anyone's fault and that no one is guaranteed smooth passage into this world!
Could not resist...One of my repeat c/s this year had a successful zanvanelli 4 yrs ago!!! The MFM attending that did it said that he has done 2....50% mortality rate! Crazy! Seriously, though I am surprised the as a FP intern you delivered without ANY attending in the room or even supervising you doing the vacuum!
 

THP

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I saw a Zavanelli maneuver during my 3rd year rotation.
 

teh t

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when it comes to OB it seems medical/legal drives everything for reasons cited above. yes you may have done the right thing by the books, but in a court there always seems to be some "expert" physician who will contradict the books... and isn't an attending supposed to be there in a timely fashion for all HS deliveries?
 

teh t

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oh yes and there are always plenty of lawyers willing to tell parents it was the doc's fault
 

smq123

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I am a Family Medicine intern, and I had one of the most horrific moments of my life this weekend. I was paged by L&D to deliver one of my patients. Everything was going fine, but the baby's head (ROA) just w'ont come out. I decided to use a vaccum. Baby's head finaly came out, and just as a smile was begining to form on my face, the baby's head started turning blue. Very blue. I was freaking out. Told the nurse to page the OB/GYN attending on call, in the mean time I did a episiotomy, and tried the McRobets, Rubin, Woods and Rev. Woods. Again, no luck. I told the mom to gently roll on her hands and knees, and finally I was able to put my finger in and deliver the posterior shoulder. The OB attending finaly came in (just before the baby came out), and told me "You were lucky this time, next time do a c-section". No good job. No pat on the back.

My FM attending told me I did the right thing by not rushing into a c-section. I am a little confused. Is my attending right, or are OB/GYNs in general "c-section happy".:confused:
Well the baby did have shoulder dystocia, that is why I did the maneuvers according to the book. "The books" do not tell you to do a c-section when you have shoulder dystocia. You are supposed to go through the maneuvers first. C-section should be a last resort.

In residency, attendings keep telling us to NEVER practice "defensive medicine", and to allways practice "good medicine". Wouldn't doing a c-section (without first trying vaccum/forceps and dystocia maneuvers) be considered "defensive medicine",and not "good medicine"?:confused:
* "The books" might tell you to avoid a c-section as long as possible with a shoulder dystocia.

BUT, "The books" also say that a contraindication to a vacuum delivery is operator inexperience (= intern-level). I'm a little unclear as to why an INTERN did not page the OB/gyn attending BEFORE attempting a vacuum delivery.... :confused:

You can't have it both ways - either you're following the "textbook" advice, or you're not.

* This may be just my inexperience talking, but I think that the "best procedure" is the one that you're more comfortable with. Maybe what the OB/gyn attending was not saying that a c-section would ALWAYS be best in this type of a situation, but, when you're an intern, you're better off calling an attending and getting ready to do a c-section, than trying to do a vacuum delivery BY YOURSELF.
 

Trillgirl

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The question is not, "are OB/Gyn c-section happy", the question is why there was no one senior in the DR with you. As an intern, you should never have been alone in ANY delivery. There should have been a Chief Resident (at a minimum) or an Attending present.

It also should have not been your call, as an intern, to do an operative vaginal delivery. You vacuumed your way into the dystocia; there was obviously a reason the baby's head "just wouldn't come out". The attending's comment was probably telling you that doing a last-minute c/s would have been better in this case than choosing the operative delivery and creating a dystocia. You did what you thought was best, no doubt, but someone with more experience should have been the one making the call.
 

nykka3

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The question is not, "are OB/Gyn c-section happy", the question is why there was no one senior in the DR with you. As an intern, you should never have been alone in ANY delivery. There should have been a Chief Resident (at a minimum) or an Attending present.

It also should have not been your call, as an intern, to do an operative vaginal delivery. You vacuumed your way into the dystocia; there was obviously a reason the baby's head "just wouldn't come out". The attending's comment was probably telling you that doing a last-minute c/s would have been better in this case than choosing the operative delivery and creating a dystocia. You did what you thought was best, no doubt, but someone with more experience should have been the one making the call.
TrillG,

I love your signature quote " Just b/c you can reproduce doesn't mean you should". There needs to be some sort of PSA about it.
 

smq123

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I love your signature quote " Just b/c you can reproduce doesn't mean you should". There needs to be some sort of PSA about it.
Seconded. :thumbup:
 

MacGyver

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rule #1 of ob practice:

if you get sued for not performing a c-section, the plaintiffs attorney can ALWAYS find some "expert *****" OB out there who says you should have done the section (especially if they are paid the prevailing expert wage of $100+ dollars per hour, which is way more than they make doing clinical work)

These lawsuits will stop the day greedy "expert *****" OBs stop taking money from trial lawyers to sell out their profession
 

Flea girl

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rule #1 of ob practice:

if you get sued for not performing a c-section, the plaintiffs attorney can ALWAYS find some "expert *****" OB out there who says you should have done the section (especially if they are paid the prevailing expert wage of $100+ dollars per hour, which is way more than they make doing clinical work)

These lawsuits will stop the day greedy "expert *****" OBs stop taking money from trial lawyers to sell out their profession
You think this is just Ob/Gyn that have "experts" that will testify in court for the plaintiffs in lawsuits? Wow, someone needs to wake up and smell the coffee!!
 

Global Disrobal

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Leukocyte,

Thanks for presenting this interesting case for discussion. First of all, no personal attacks, as we are all in training for this exact purpose which is to learn. However, with that said, a few points (some of which have been mentioned above):

1. Your attending (FM) was correct in that you should not have "rushed" to a CS. If the FHT was fine at the time of pushing, ROA position, fetal weight was not judged to be too large, and your assessment was that maternal exhaustion was a factor; or in another scenario you had a variant FHT, then operative vaginal delivery was definitely worth a try.

2. I don't know what factors led the OB Attending to say "next time do a c-section," but I trust that he had his reasons. Was there "turtle sign," or was the baby too big, or other contraindications to operative vaginal delivery?

3. You may want to avoid generalized statements such as "c-section happy," especially in an OB/GYN forum, as many of us take offense. I know alot of us practice evidenced based medicine, use our clinical judgement, and perform a c-section when needed. To be grouped as a whole and called "c-sectio happy" does not help your post and takes away from the great discussion it can lead to.

4. I think the other members are correct in that you should have not been doing a vacuum without an attending or senior resident present. Based on your description, she was ROA without any other need for immediate intervention. Am I correct or was there more to the story?

5. You are clearly mistaking the OB Attending's assertion that you should've done a C-section next time. I am willing to bet you that he is NOT talking about a Zavanelli maneuver after dystocia was diagnosed and unsuccessfully reduced. I think what he was telling you is that when you saw that head not coming down, you should have offered her a Cesarean rather than vacuum, meaning that there is probably other factors he saw with the clinical scenario (i.e. fetal size, labor course).

6. Lastly, don't take the attending's lack of positive feedback personally. We often time get emotional in OB, especially when dealing with potential bad outcomes. Its usually the seasoned clinicians that can turn any event into a learning moment, while the rest of us just take a sigh of relief that it is over. Honestly, if one of my interns had attempted a vacuum without myself in the room, on a non-deceling patient, I would serve their a$$ on a silver platter to them.

Two questions from me:
1. How did the baby do?
2. What would you do differently next time (in same scenario)?

Regards,
GD
 

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Global, you've got me. What is a turtle sign?

Global, one of the things I admire about you is that you always bring the discussions back to a polite level, and you yourself are very polite. That is a wonderful trait. Sincerely, I thank you for it, but you have not understood the attempt to save someone posting here from trouble later in life from attornies.

The editions of Williams Obstetrics which were edited by Jack Pritchard contained this dedication:

"This book is dedicated to the obstetricians who risked their reputations in order that babies might be well born. "

A hard working OB cannot avoid offending people some of the time.

No one called any intern, nor anyone else, stupid.

What was said was if you want to AVOID being called that by an ATTORNEY, get your OB resident in to help you. I think you actually agree with this.
 

Global Disrobal

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Thanks Dejerine.

Your point is well taken and we all do appreciate your input. I just don't want the discussion in this forum to deviate from its original intent. Nonetheless, I do see what you are saying. Thanks for the edit :)
 

Diane L. Evans

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Leukocyte
First,you are crazy for not having an attending in the room.

Second the OB Attd was right you should of call for a consult immediately before you placed the vacuum. While normal vaginal deliveries may be in the scope of your training operative delivery is not and you very well could have a facial paralysis or brachial injury.

Third did you get cord gases? If not why not? This is something that needs to be done with every operative delivery according to ACOG.

Fourth, while you THINK you may of deserved a pat on the back the OB was right you were very foolish to get into such deep trouble without an attending it would have been a huge lawsuit.

Fifth, at all hospitals I know of there is always an OB covering the FP's in case of situations such as these and I understand why the OB was pissed he/she will get named in the lawsuit if there are any bad outcomes sometimes CP can take up to 18 months to diagnose. That is why you get cord gases

Sixth, You need to dictate this case to CYA. Not only may you get written up in residency as performing outside your scope of practice you could also be named as for patient negligance as you obviously are not trained in operative deliveries (as ACOG requires OB to have 45 as a median for competancy prior to graduation)

I would follow up with peds on this child for the next 18 months to make sure this child has a good outcome

In term of dictating. What was the leopolds of the baby? Were there any contraindications was the mom diabetic had an US showing a AC greater HC? Was there fetal compromise before you placed the vacuum? What was your indication for vacuum delivery prolonged second phase? If there was no FHR problems you should of waited for the OB to be present prior to placing the vacuum.What was the position of the head where did you place your vacuum how many pulls did you have over how long of a time. Was the tracing stable during the vacuum? BTW how long did the delivery of head to delivery of baby take? Was the NICU called for the delivery? Did NICU note any cephlohematomas or bruising were clavicles intact. When did you do an episiotomy? If before the vacuum why not?


Thank you for sharing. Perhaps you can share these details with us as all these points need to be considered before doing ANY operative delivery. Next time prior to placing the vacuum call the OB attending.

You are very lucky. Please no one on this forum attempt this as an intern without a OB attending present
 

Faebinder

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Seriously, how can you blame OBGYN for being C-section happy when things like this are still happening?

It's almost like a life sentence of paranoia.... "Is she the one who will get the 20 million dollar verdict from my insurance?"
 

minime

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This case is a tragedy. From everything that I have heard about this case there was absolutely nothing done wrong by the physician. The tracing was good as well as the cord gases. The plaintiff's expert witness was actually kicked out of ACOG for testifying in frivolous cases. In this case they claimed that "head compression" caused the CP. If this were the case then every baby born vaginally would have the same problem. Something needs to be done about this.
 

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There is a lot of good written, peer reviewed support of what you did. I am sorry the attending reacted that way. Dystocias are unpredictable, and ultrasounds are not specific enough to base doing c sections just based on size. I am sure malpractice suits may swing otherwise, but that is the truth when it comes to evidence based medicine.

BTW, you performed a successful Gaskin manuever! Congrats!
 

smq123

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There is a lot of good written, peer reviewed support of what you did. I am sorry the attending reacted that way. Dystocias are unpredictable, and ultrasounds are not specific enough to base doing c sections just based on size. I am sure malpractice suits may swing otherwise, but that is the truth when it comes to evidence based medicine.

BTW, you performed a successful Gaskin manuever! Congrats!
Dystocias are actually common after vacuum deliveries (such as the one described in the OP).
 

minime

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In reply to the above posters on Estimated Fetal Weight by US: ACOG recommends offering C section for EFW >4000g in diabetics and 4500g in non-diabetics.
I am going into my chief year in OBGYN. I personally wouldn't even think about doing obstetrics if that wasn't my sole specialty. It's just too much risk.
 

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In reply to the above posters on Estimated Fetal Weight by US: ACOG recommends offering C section for EFW >4000g in diabetics and 4500g in non-diabetics.
I am going into my chief year in OBGYN. I personally wouldn't even think about doing obstetrics if that wasn't my sole specialty. It's just too much risk.
Do you know why the suggestion is based on weight? I thought head circumference was the limiting factor. Sorry if I'm uneducated on the topic, I'm just starting med school.
 

luvOB

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In reply to the above posters on Estimated Fetal Weight by US: ACOG recommends offering C section for EFW >4000g in diabetics and 4500g in non-diabetics.
I am going into my chief year in OBGYN. I personally wouldn't even think about doing obstetrics if that wasn't my sole specialty. It's just too much risk.
hmm...isn't it 4500g for diabetics and 5000g for non-daibetics? i believe both ACOG and Williams quote these numbers.
 

Global Disrobal

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With respect to the most recent posts, here are the ACOG recommendations (see below). Please be mindful that these are recommendations. In many institutions, including ours here in Washington DC, we often prefer the use of Conway and Langer's cut off of 4250 grams in diabetic mothers. Hope this info helps everyone.

Summary of Recommendations

The ACOG committee provides the following recommendations for the management of fetal macrosomia:

Recommendations based on good and consistent scientific evidence (Level A):

* The diagnosis of fetal macrosomia is imprecise. For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold's maneuvers).

Recommendations based on limited or inconsistent scientific evidence (Level B):

* Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.

* Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000 g in the absence of maternal diabetes.

* With an estimated fetal weight more than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery.

Recommendations based primarily on consensus and expert opinion (Level C):

* Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights of more than 5,000 g in pregnant women without diabetes and more than 4,500 g in pregnant women with diabetes.

* Suspected fetal macrosomia is not a contraindication to attempted vaginal birth after a previous cesarean delivery.