Right of confidentiality

One of my Patient visited me recently for a follow up visit.I think she sounded quite satisfied with the overall experience she had under my care but at the end of consultation gave me two feedbacks

• I should not have discussed her condition in front of her mother in Law
• I should not have gone to Germany for an official commitment just before her due date.

In Indian setting family members are usually a part of the final decision taken regarding medical condition of a person.5years back when I returned from UK I was much more sensitive of these issues as confidentiality,patient should be told the condition first even if it is cancer,to keep a chaperon while examining a patient to avoid any complaint of sexual assault etc.In last 5 years I do realize that these issues got a little diluted.I did loose the focus.I apologised her for her first complaint as she was perfectly alright in complaining about telling her medical condition in presence of people she would not have liked to know about it.This particular incident has made me once again sensitive to these issues as I was 5 years back.Thanks for the feedback!!

second feedback......I was not impressed.I am a human being first and doctor later.I have my personal as well as non clinical official responsibilities including conferences,courses etc which I need to attend to keep myself updated with the latest in my field of work.Now what I agree is that if some one is my Patient, should not be left high and dry if I am out of town.It is more correct for pregnant Ladies.That is why as a responsible person, I have a team where consultant level Gynaecologists
help me out in taking care of my patients in my absence.I have my team member Dr Deepa Maheshwari and the blog regular are already familiar with the name of Dr veenu.They are consultant level gynaecologist delegated by me ( not my hospital) to take care of any Lady who goes in labour in my absence.Even in western countries no doctor is working 24 x 7/365 days a week.Doctors are much more frequently on vacation than India.So in future if I am away rest assured that there are competent doctors to take care of you and advice you but I can't be expected not to move out of Gurgaon at all.These doctors have been trained by me and thus the unit protocol still remains the same even in my absence.

BTW from 3rd jan to 6th jan and then 29th jan to 3rd feb I am out of India.

Fundal pressure for second stage of labour

As luck would have been just yeaterday in Gurgaon Live,the supplement of Hindustan Times,I came across an article by a very learned doctor of Gurgaon on epidural analgesia.A very well written article but again 'the uterine pressure' for delivery was considered an option.I think we need to review our practice and follow the world wide accepted practice........where instrumental delivery is found to be a safer often than brute force of fundal pressure.
Few scientific evidences are as follows :

[Interventions during labor for reducing instrumental deliveries].

[Article in French]

Schmitz T, Meunier E.

Source

Maternité Port-Royal, hôpital Cochin, AP-HP, 123, boulevard de Port-Royal, 75014 Paris, France. thomas.schmitz@cch.aphp.fr

Abstract

Several interventions have been demonstrated, with high evidence levels (EL), to be associated with reduced instrumental deliveries and should therefore be undertaken during labor for increasing spontaneous vaginal deliveries. Using a partogram (EL1) and continuous support during labor and childbirth (EL1) lead to fewer operative vaginal deliveries. Systematic early amniotomy increases the frequency of fetal heart rate abnormalities (EL2) without decreasing the incidence of instrumental deliveries (EL1) and should thus be avoided. Early oxytocin in dysfunctional labor (EL2) and manual rotation of posterior and transverse presentations (EL3) may reduce operative vaginal deliveries. Even without epidural analgesia, any upright or lateral positions compared to supine or lithotomy positions do not reduce instrumental deliveries (EL2). Epidural analgesia alters significantly instrumental delivery rates and therefore patient management in the labor ward. Indeed, when used with high concentration of local anesthetic, epidural analgesia is associated with increased operative vaginal deliveries (EL1), at least in part because of increased posterior presentations (EL2). However, the effect of epidural analgesia on instrumental delivery rates closely depends from the type of anesthetic and concentrations used. This effect is reduced when low concentrations of local anesthetic are used in combination with fat-soluble morphinated agent (EL1). Finally, for nulliparous women with continuous epidural analgesia, unless irresistible urge to push or medical indication to shorten second stage of labor, delayed pushing is associated with reduced difficult instrumental deliveries (EL1). Fundal pressure maneuvers should be prohibited because of their inefficiency (EL2) and dangerousness (EL4).

Delayed diagnosis of an atypical rupture of an unscarred uterus due to assisted fundal pressure: a case report.

Kurdoglu M, Kolusari A, Yildizhan R, Adali E, Sahin HG.

Source

Department of Obstetrics and Gynecology, Yuzuncu Yil University School of Medicine Van Turkey. mkurdoglu@doctor.com

Abstract

INTRODUCTION:

Although rare, rupture of an unscarred uterus is one of the most dangerous obstetric complications, resulting in maternal and fetal jeopardy.

CASE PRESENTATION:

A 30-year-old grand multiparous Turkish woman without any history of uterine surgery gave birth vaginally at 37 weeks of gestation with fundal pressure applied in the second stage of labor. Transabdominal sonography performed 32 hours after delivery due to postural hypotension and a drop in hemoglobin values in the postpartum period revealed massive intra-abdominal free fluid. On emergency laparotomy, serosal rupture of the uterus on the left posterior side was observed. She underwent a subtotal hysterectomy and did well postoperatively.

CONCLUSION:

Postural hypotension in postpartum patients without any evident vaginal bleeding may be an early sign of possible uterine rupture, even if the vital signs are stable. Early diagnosis is important if maternal morbidity and mortality are to be decreased.

Uterine rupture: preventable obstetric tragedies?

Mishra SK, Morris N, Uprety DK.

Source

Department of Obstetrics and Gynaecology, BP Koirala Institute of Health Sciences, Dharan, Nepal. sangeetamishra2002@yahoo.co.in

Abstract

BACKGROUND:

Although ruptured uterus is nowadays a rare obstetric emergency in Western countries, it is still alarmingly common in developing countries, where it remains a major cause of maternal mortality and morbidity.

AIMS:

To review the recent experience of uterine rupture at a tertiary obstetric unit in eastern Nepal and to recommend improvements in the current management of labour, especially obstructed labour, in a poorly resourced country.

METHODS:

All cases of uterine rupture managed from March 2002 to March 2006 were identified retrospectively, and details were retrieved from medical records.

RESULTS:

Fifty-two women suffered from uterine rupture during the four-year period, approximately one woman per month. Most were unbooked multigravidae, with no antenatal care. They nearly all began labour at home in the absence of a skilled birth attendant. After prolonged labour, usually prolonged second stage, various interventions had often been attempted at home or in other health facilities before admission. Most were shocked and required urgent laparotomy and blood transfusion. Many required intensive care and ventilatory support. Forty-six per cent required hysterectomy and 5.8% subsequently suffered from a urogenital fistula. The maternal mortality rate in this series was 13.5%, and the stillbirth rate was 94.2%.

CONCLUSIONS:

Unsafe obstetric practices were identified, especially the injudicious use of oxytocic drugs and fundal pressure in prolonged second stage. Several achievable improvements in obstetric care are recommended, particularly aimed at reducing the delay in women reaching emergency obstetric care when labour is prolonged.

Fundal pressure during the second stage of labor.

Simpson KR, Knox GE.

Source

St. John's Mercy Medical Center, Women and Children's Care Center, St. Louis, Missouri, USA. KRSimpson@prodigy.net

Abstract

The role of fundal pressure during the second stage of labor is controversial and can result in clinical disagreements between nurses and physicians. Clearly the time for resolution of this issue is not when there is a physician request at the bedside in front of the patient. A prospectively agreed upon plan specifying how this request will be addressed is ideal. In order to develop this plan, risks, benefits, and alternative approaches to the use of fundal pressure should be reviewed by an interdisciplinary perinatal team. Much of the data about maternal-fetal injuries related to fundal pressure are not published for medical-legal reasons; however, anecdotal reports suggest that these risks exist. Unfortunately, it is therefore difficult to quantify with any degree of accuracy the exact number of maternal-fetal injuries that are directly related to use of fundal pressure to shorten an otherwise normal second stage of labor. However, there is enough evidence to suggest that if injury does occur when fundal pressure is used, there are significant medical-legal implications for the health care providers involved. This article will review what is currently known about fundal pressure including risks, benefits, and alternative approaches. In that context, suggestions will be offered for a safe approach to managing the second stage of labor.

Comment in

• Fundal pressure. [MCN Am J Matern Child Nurs. 2001]