The art of delivery

Those final weeks of a pregnancy sometimes seem to drag for some soon-to-be Mums.

“I’m over it, can’t you do something?” is not an uncommon request. Back & hip pain, reflux, swollen legs, waddling gait, can’t sleep…..and that’s just me

Now without opening an argument about expectant management versus induction of labour (today), would I be doing anything bad by relieving my patient of these problems and delivery their babe as soon as they get to term. Are these real medical indication. Will the mother be at risk by continuing the pregnancy? Or do these request fall under the heading of social inductions? Along with requests for inductions because my husband will be flying off to work, war or a week surfing with his mates, there’s  a lamb sale on next week or it has to be tonight there’s a full moon you know!

Or, I just want to plan a big fishing trip and don’t want to be stuck in hospital and miss the tuna!

By way of definition, a pregnancy is considered “at term” after 37  weeks , but is less than 42 weeks of gestational age.

A 2010 commentary by Fleischman et al (http://www.leapfroggroup.org/media/file/ACOGRethinkingDefinitionofTermPregnancy.pdf) argued for a redefinition of a term pregnancy based upon outcomes. Early term babies those born between 37 and 38+6 weeks had a higher rates of mortality and morbidity than those born after 39 weeks. The numbers showed that mortality was half at the later gestation. In the US this was 0.66 per 1,000 live births at 37 weeks compared to 0.33 per 1,000 live births. Small numbers, I know. Studies of babies born by caesarean section at 37 and 29 weeks shows increased rates of respiratory problems, albiet short lived and the need for NUCU admission.

A 2009 study by Toita et al (http://www.nejm.org/doi/full/10.1056/NEJMoa0803267) also found higher rates of neonatal sepsis and hypoglyacemia associated with delivery at 37 to 38 weeks.

As a member of RANZCOG, I get a copy of the Australian New Zealand Journal of Obstetrics and Gynecological or the Red Journal. Occasionally there are is a paper in it which is interesting to a Rural GP Obstetrician.

April’s had a paper by pyschologist Dr Monique Robinson,  (the et al includes Fiona Stanely from http://www.childhealthresearch.org.au/).  They looked at behaviour of children born at 37 week  compared with those born later weeks. Using data from 2900 pregnancies in Western Australia, they compared scores on the Child Behaviour Checklist. They found that children born at 37 weeks had a increased risk of for behavioural problems with an odd ratio of 1.4. They suggested that 37 weeks’ gestation may not be the optimal cutoff for defining perinatal risk as it applies to behavioural development.  http://onlinelibrary.wiley.com/doi/10.1111/ajo.12012/abstract

RANZCOG, BCOG and ACOG all recommend that unless there is a compelling medical indication, that a caesarean section be deferred until 39 weeks.  To me it seems sensible to apply the same rules to an induction of labour given that the end are the same.

In the US, the March of Dimes organisation is leading a campaign to reduce early term deliveries. “We know the best incubator is the uterus, and if there is no reason for a baby to be delivered early then it should never occur before 39 weeks.”

So, 39 weeks it will be from now on…patience may be indeed a virtue.

And then to throw a spanner into my logic, I find a paper that found that at least in one US hospital a policy limiting elective delivery before 39 weeks was associated with a small reduction in NICU admissions; however, macrosomia (>4000 grams) and stillbirth (2.5 to 9.1 per 10,000 term pregnancies) increased. Actual numbers of still births were 7 versus 15, and all were in the under 37 to 38 week group. Damned statistics. http://journals.lww.com/greenjournal/Abstract/2011/11000/Neonatal_Outcomes_After_Implementation_of.12.aspx

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Some things in General Practice can be really challenging

Without a tertiary Emergency Department at the end of quick ambulance ride Rural Procedural General Practice holds lots challenges, some more satisfying than others.

And that is not saying that rural practice is better than urban practice; we both serve our communities well.

Recollections from this week with details muffled to protect the innocent.

A young guy from Canada comes in worried he has caught a STD, as he called it. Should be about time to change STI to something else? Seems whilst backpacking on his way through Asia he had unprotected sex with a fellow  backpackers and ever since then he had been worried about the possibility that a little penile irritation was a sinister disease. I know that  PCR techniques on urine are considered as good as culture these days, but when I was a lad being threatened with a swab down the urethra was a good incentive to wear a condom.

I’m not sure if country folk are more resilient or its a generational thing? A 70-year old farmer turns up saying he wanted to find out if he had a heart attack….a week ago! Was too busy with the sheep at the time but it did slow him down, his wife’s GTN spray he borrowed without telling her had helped.  His ECG showed his diagnosis was probably right  and the 15 minute consult blew out as I organised transfer to a friendly cardiologist. He had a CABG later that week – now that will slow him down. The cracked chest will probably hurt more than his heart attack.

Not to be outdone a few patients latter another bloke comes suggesting he had a stroke this morning. Fell over all weak and confused for a while and still a bit unsteady on the legs. He had driven in from his farm. Similar thing  happened a few weeks ago but the wife thought is was low sugar. She had given him a jam sandwich which maybe helped a bit. Today he had breakfast, so his sugar couldn’t be too low this time.  True enough, Rhomberg was positive, he had left sided weakness. More phone calls, and thankfully for the rest of the afternoon patients, a colleague doing on-call at the local hospital offered to organise the transfer. My patient was a bit cross he couldn’t drive home to drop his dogs off first.

I few year ago I began wondering  what people do with sheep that makes them neglect their own health. Since then I have delivered a still born sheep, helped shear (very badly, but did a great job of fixing the cuts, IMO), and discovered that a granny knot in an excised rectum was important in not letting fresh sheep poo mess up a hanging carcass. So that where lamb chops really come from. If I had to look after 1000 of the buggers I’d probably be busy too.

A fellow with a lump in his nose tells me he saw an ENT specialist three years ago and was patiently, very patiently waiting for a city tertiary hospital to tell him when his operation would happen. A quick call discovered that he had been dropped off the list for no good reason and would need a new referral to get back on it. A careful look at he lump revealed it pretty much unchanged from previous descriptions (thankfully not some nasty malignancy) but still in the way and needing removal.

Obstetrics care can be unpredictable. One evening, a young lass presents to the midwife in early labour thinking her waters have broken. The midwife agrees with her and tells me that there may be possibly meconium stained. Up until now everything all had been normal, normal, normal. A CTG showed variable dips, examination showed she was indeed in early labour. Within the next hours or so she fully and pushing, fetal heart beat 60 for far too long, instrumental delivery, neonatal resuscitation, cord pH 6.9, blood glucose 1.5, so IV in, glucose drip and transfer to tertiary hospital in case of seizures. Bed in the wee hours of next morning.

“About this sore on my leg doc it isn’t healing”. Hmm. Pathologist suggested I had biopsied a morphoeic BCC. My reading and chat to a friendly dermatologist suggested Moh’s surgery which meant a trip to town. Second best was a wide 15 mm excision. Patient had to stay to look after sheep (again) so I did the 15 mm excision around a 20 mm lesion and closed the hole some artful cutting and suturing. Fingers crossed and antibiotics to keep poo and sheep bugs at bay. The pathologist suggested I had cut a clear margin which was good. We’ll wait to see how well he heals. Now how about sunscreen and a hat and a closer look at his nose!

And talking about skin cancers. The tragedy of  putting a bandaid over a SCC for six months thinking it is a spider bite is all so real as I help a man and his family through the final phases of his palliative journey.

Each week is an interesting week.

Some things in General Practice really make me feel used and abused!

I recently had a short break for study in beautiful New Zealand. It was nice to tack three days of walking and climbing onto the end of it without small children.

I got back to work to a waiting ream of letters. One set of correspondence really got me a bit cranky, a simply titled request for medical history report from an insurance company. In the first letter, in bold,

Please be aware that the finalisation of your patient’s insurance application is dependent upon your timely completion of this report

That was fine, expect I hadn’t seen the said patient since 2010 so I don’t know if the patient is really mine anymore despite their election that I am their GP.

I noted that the recommended fee was $70.

There was five pages of questions to answer. That would probably take 30 to 40 minutes of looking at their notes to complete. And to be fair to the patient may require a consultation.

I was instructed to print clearly and legibly (in bold) and do not leave questions unanswered (in bold and underlined) That was getting a little bit patronising.

An accompanying authorisation to release someone’s private medical information has been signed by presumably the patient in question. I wonder how many would actually check with the patient to ensure that this is genuine.

A week latter (whilst I was still away) the insurance company sent me a reminder.

As doctor’s, we understand the time pressures and competing demands being confronted in modern medical practice and that these may lead to a delay for a valid and acceptable reasons. However, the finalisation of your patient’s insurance application is dependent upon your timely completion of this report” (the last sentence in bold)

So what happened to acceptable reasons. Now the hackles a little get raised.

Firstly, the letter has not signed by a doctor so “as doctors” seems quite ingenuous.

And secondly, I think whole statement is patronising.

The final letter arrives a week later and I am back to work. I am now told my report is overdue! Am I back at school?

But what really gets me annoyed is the request to have the report finished in 2 days or “arrange time this weekend to compete your patients report

Well, I am sorry “this weekend” I am not on call, I am spending quality time with my children and wife, sanding back a deck chair and possibly chopping the head off a goose and plucking it for roast dinner. What I am specifically not doing, is writing a medical report. And I told Mr case manager thus. I am yet to hear back from them.

Am I bad?