Clinical Pearls

OB/GYN News, June 15, 2001 by Bruce L. Flamm

Most of us spend more time in clinic than the operating room, so office tips are frequently helpful in our day-to-day practice.

Here are a few that you may find useful in the clinic.

* Think ahead and make a friend.

If a prenatal patient says her husband plans to have a vasectomy after her baby is born, a light bulb should go on in your head. Be sure to tell her that if she winds up having a cesarean section, she could undergo sterilization during the same operation. If she's interested in this option, make sure you have her sign the appropriate consent forms.

If she ends up having a cesarean, as about one out of four women do, you can simply tie her tubes during the operation. If the consent has not been signed, your hands will be tied but her tubes won't be. This simple plan will keep many husbands from undergoing unnecessary surgery After the cesarean be sure to remind the lucky husband that, thanks to your foresight, he won't be having scrotal surgery Doctor, you just made a friend!

* Beware of the 'heparin hematoma.'

My partner Dr. Barry Standley one of the hardest working obstetricians in the United States, offers this pearl of wisdom from personal experience.

If your obstetric patient requires subcutaneous heparin during her pregnancy, have her inject it in her thighs rather than her abdomen. Otherwise, if a cesarean is required, high tissue levels of heparin in the abdominal wall can make for a messy operation and a wound that falls apart.

* Sit down and stay a while.

Twenty-three years ago Blucher Taylor, a wise obstetrician in North Carolina, taught me this Southern pearl.

When he made rounds at the hospital he would always sit on his patient's bed. He probably spent no more time in the room than other doctors, but the perception was that he did. When a doctor walks in and walks out without sitting down it may seem to the patient that the doctor spent less time in the room than he or she actually did.

I don't recall hearing about this subject for more than 2 decades until another prudent doctor, Kirk Keegan of the University of California, Irvine, recently mentioned that he always sits down when he sees a patient in the clinic.

* Another view the TOP syndrome.

A previous column of mine dealt with the TOP (Torments of Pregnancy) syndrome that often causes patients to demand induction of labor. Dr. Damien Moore of Orange County Calif., offers some physiologic explanations that his patients find reassuring.

He explains that symphysial and sacroiliac pain in the third trimester is nature's way of expanding the birth canal so the baby will fit through easier. He further notes that edema reflects an increase in the body's reservoir of fluid in preparation for dehydration during lab or as well as blood loss at the time of birth.

Although a physiologist might argue about the accuracy of both explanations, they do convey in simple terms the general notion that these symptoms are almost universal and may in fact, be beneficial.

DR. BRUCE L. FLAMM is area research chairman and a practicing ob.gyn. at the Kaiser Permanente Medical Center in Riverside, Calif.