David,
thank you for your thoughts. You have indeed hit upon the very issue we think is most
pertinent with
this senior registrar.
Firstly, I just want to clarify that in no way do I trivialise his concerns. I
wholeheartedly
understand his desire for a 'safe' delivery of the 2nd twin and always at the back of
my thinking
as in every midwives' action) safe practise resides. But in his concern he removes
(and removed)
so many rights of the labouring woman, and it is her lack of choice that concerns me.
The point about decreased experience is interesting. We are a small low risk unit, and
this
registrar has come from a large high risk one. So not only does he see very little
'drama' but he
also sees 1/4 of the numbers he did at St. Elsewheres. This set of twins was his first
delivered at
our hospital and he had been there for 6 months by then. I am convinced that his
desire to intervene
stems from a lack of confidence stemming from a lack of experience. ( Our NVD rates
btw have dropped
from 73% this time last year to 62%).
Also, the use of the epidural to allow for any necessary procedures is compounded by
the fact that
he wanted an epidural in labour ward, and THEN transfer to OT for delivery as well.
Clearly, this
was defeating the best use of the epidural.
I find the whole issue very interesting, specifically because he is just a registrar
and thus, part
of the new breed of obstetricians. I find it very scary. I will take your range of
options on board
as we continue to discuss this. Thank you.
Robin.
----- Original Message -----
From: "David Simon" <[EMAIL PROTECTED]>
To: "ozmid" <[EMAIL PROTECTED]>
Sent: Saturday, August 18, 2001 9:56 AM
Subject: second twin
> 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
>
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