Jan and Robin
I don't think you should trivialise the concerns of the registrar in regard
to the second twin, but equally, a discussion should be able to take place
without personal attack. Neither the Effective Care statement on elective
caesar vs vaginal birth for twins, nor the various studies on the relative
merits of caesar versus internal version and breech extraction for the
non-vertex second twin is relevant to this debate.
The registrar is concerned about delay in appropriate management if there is
a bradycardia for the second twin. Although there may be no hospital in
Sydney with a policy of twin birth in theatre, this is certainly a topic
that would be discussed in most labour wards. This has become more of an
issue for several reasons over the recent decade or so - 1)decreased
experience amongst registrars/junior consultants due to increased elective
caesar rates for twins, decreased working hours, more trainees to share the
experience around 2) the fact that anaesthetists will no longer give a
"quick GA" in labour ward to allow breech extraction 3)and the inevitable
increasing concern around blame for poor outcomes. There has been a high
profile case in Melbourne surrounding delay in birth of second twin.
Options would be
1) A detailed consent form that recognises the potential for delay in
appropriate management if a complicated manoevre was required for birth of
the second twin in labour ward
2) A discussion with the anaesthetic staff to see whether they would be
happy to put in a spinal in labour ward to allow emergency manoeuvres
3) Place an epidural catheter in labour, but put in no solution unless
needed for second twin
4) Expect only a small chance of problems and explain to the mother that a
very uncomfortable (but perhaps bearable with nitrous) procedure may
possibly be needed.
Jan is right - the chance of problems is small, but especially when there
has been disagreement about options there can lots of "I told you sos" when
things don't turn out well.
David
--
This mailing list is sponsored by ACE Graphics.
Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe.
