Avoiding obstetric pitfalls

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

The reason obstetricians pay three times more for malpractice insurance than internists is not because we take care of more complicated patients in the clinic but because we deliver babies.

Most of us have learned that things can go bad very quickly in the labor and delivery suite. Allen's Law, discovered by the famous Yale historian Frederick Lewis Allen, states that "everything is more complicated than it looks to most people." This is often true in obstetrics as is Agnes Allen's Law, which was first proposed by professor Allen's wife: "Almost anything is easier to get into than out of."

Here are some obstetrics pearls aimed at keeping you from getting into situations that are difficult to get out of.

* Remind nurses to check the fetus in the operating room.

When you order a cesarean for a laboring patient you often have your hands full preparing for the surgery Nevertheless, take a moment to be sure the nurses check fetal status in the operating room. In the midst of the commotion involved with getting your patient ready for surgery they may focus only on her and forget about the fetus.

You don't ever want to deliver a depressed baby and then realize that the last recorded fetal heart rate was in the labor room 25 minutes before the surgery began.

* Don't disconnect the monitor in the middle of a deceleration.

This turn of the old aphorism "don't change horses in the middle of a stream" obviously does not apply to a prolonged deceleration or what we formally call a fetal bradycardia. If the fetal heart rate has been down for several minutes, you can t just wait around to see what happens.

In the much more common case where you call a cesarean due to recurrent variable decelerations, ask the nurse to wait a few seconds rather than unplugging the monitor at the bottom of a variable. Otherwise, a tracing that ends with the baby's heart rate down to 70 beats per minute might incorrectly seem to suggest that a crash cesarean had been indicated.

* Consider a fetal scalp electrode before an epidural.

When a patient sits up for an epidural, the external fetal monitor is often displaced and records nothing but squiggles or loss of signal. In some cases, there may be no information on how the fetus is doing for 20 or 30 minutes. Maternal hypotension often occurs with epidural placement, and babies tend not to like the situation.

Therefore, if technically feasible, it may be a good idea to place a fetal scalp electrode before epidural placement, especially in vaginal-birth-after-cesarean patients.

* 1 ain't low.

Some obstetricians believe that an instrumented delivery done at 1 or certainly at 1 to 2 station is a low forceps or low vacuum delivery But the American College of Obstetricians and Gynecologists defines these both as midpelvic procedures. The leading point of the fetal skull must be at least at a 2 station or lower to be classified as low. Stating that you did an easy low vacuum delivery from 1 station is a contradiction that may come back to haunt you. A midpelvic delivery may indeed be indicated but you should know you are doing it.

Send Us Your Clinical Pearls!

Please include your name, affiliation, and phone and fax numbers. Mail to:

Dr. Bruce 1. Flamm

10445 Victoria Ave.

Riverside, CA 92503

Or send them by fax to 909-353-5625 or by e-mail to bruceflamm@aol.com.

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