Re: Uterine Removal after rupture?

[Guest guest]

This is a hard case. There is definitely a valid health concern and significant chance of repeat uterine rupture, which can cause death of the mother or baby.

Even though this is the case, it does not mean they would have removed the uterus at the time of cesarean section. In an emergency surgery, usually you do the mimimum to sove the problem (deliver the baby and sew up the uterus) and do not perform further surgery (prophhylactic hysterectomy) unless there is no other way to stop bleeding.

D

Subject: Uterine Removal after rupture?To: nfpprofessionals Date: Wednesday, December 30, 2009, 8:37 AM

I have a client who has 5 children.baby #1 was C Sec. due to breech#2 and #3 were V Bac to term#4 was Uterine Rupture, emergency Section at term#5 was planned Section, but emergency section at 30 weeks due to rupture.This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.any thoughts/observatio ns?thank you!lisa roderCCLI Instructor

[Guest guest]

My first thought would be that if she does not have a current clinical indication to do a hysterectomy then it is not justified; trying to justify it on the basis of past complicated ob experience would be faulty. The hysterectomy would then just become an extreme form of sterilization. Without bleeding, pain or pathology, she must have faith and commitment and learn and use NFP.

Les ruppersberger, D.O. FACOOG Uterine Removal after rupture?

I have a client who has 5 children.baby #1 was C Sec. due to breech#2 and #3 were V Bac to term#4 was Uterine Rupture, emergency Section at term#5 was planned Section, but emergency section at 30 weeks due to rupture.This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.any thoughts/observations?thank you!lisa roderCCLI Instructor

[Guest guest]

The question is, can a hysterectomy be done to prevent a putative potential pregnancy complication?

This is tantamount to, can a hysterectomy be done for contraception?

At every Cesarean Section, the uterus is closed with suture.

In a rare instance, it may subsequently rupture.

When ruptures are sewed closed, they are closed in a manner quite similar to any ordinary C/S.

When a previous C/S is examined intraoperatively, it usually looks perfect as if no one had ever been there.

Sometimes, there is a dehiscence with potential to rupture, or even a rupture less commonly.

When a previous rupture is examined intraoperatively, at the next C/S, it usually looks perfect as if no one had ever been there.

Sometimes, there is a dehiscence with potential to rupture, or even a rupture less commonly.

Once the rupture has been closed, it is no different then any other C/S.

When one is closing the uterus, blood is frequently flowing briskly, sometimes anatomy is confusing, and it is sometimes not a trivial operation.

If one were to close the endometrium, but not the myometrium, then the uterus could heal without structural integrity.

This is thought to be a significant cause of uterine rupture.

This mechanism will be the same, whether the uterus was previously ruptured, or it was a C/S without rupture.

Thus, it is not about how the uterus came apart, but about how it came back together, or did not come back together.

It might seem like, how could anyone make such a foolish mistake ?

If one has limited experience doing these operations, one might think, what could go wrong?

But if surgery were in fact so simple, no one would ever have complications.

Complications do occur, and such surgery is not trivial, and even those who are conscientious may still make errors.

One can do everything right and still have complications.

I believe this lady's rupture risk on future pregnancies is low and similar to anyone else.

I believe the ruptures are likely due to closure, not a fundamental problem with her uterus.

Perhaps she had the same surgeon for both C/Ss.

Perhaps this surgeon does one layer closures, and was unlucky.

(I am not saying one should not do one layer closures-I sometimes do them myself. I am only saying that technical factors are much more likely than a fundamental inability of the uterus to heal.)

Thus she would have no more reason to have a TL than anyone who had a C/S.

Obedience is the beginning of wisdom.

This is a surprisingly helpful maxim.

In high risk pregnancies, start from the principle that abortion is never an option.

You may begin with faith, but once your brain needs to find another solution, it will.

When a tubal ligation is advocated to prevent maternal complication, the argument is that the patient could not safely endure pregnancy.

If that is true, then if she were to be pregnant, she would need an abortion to save the life of the mother.

I was told by Byron Calhoun that no one needs an abortion to save her life.

I have never seen an exception, and I do not believe there are any.

If no one needs an abortion to save her life, then no one needs a tubal ligation to save her life either.

And then by corollary, no one needs a hysterectomy to prevent complications of pregnancy.

In fact, if she does have a defective uterus, then what she needs is a uterine repair, rather than a hysterectomy.

This too is a general principle.

If a structural problem of the heart is thought to mandate abortion, abortion will not heal the heart in any way.

It would not only be ethical to repair the heart, it would be much better for the patient.

Whatever the problem, correct the problem, not the fertility.

May God bless you all.

Paddy Jim Baggot MD

To: nfpprofessionals From: laroder@...Date: Fri, 1 Jan 2010 00:54:20 +0000Subject: Re: Uterine Removal after rupture?

>> This is a hard case. There is definitely a valid health concern this is my question- what is the valid health concern atm?and significant chance of repeat uterine rupture, which can cause death of the mother or baby.yes.>Even though this is the case, it does not mean they would have removed the uterus at the time of cesarean section. In an emergency surgery, usually you do the mimimum to sove the problem (deliver the baby and sew up the uterus) this makes sense, thank youand do not perform further surgery (prophhylactic hysterectomy) unless there is no other way to stop bleeding.> D> > > > > > Subject: Uterine Removal after rupture?> To: nfpprofessionals > Date: Wednesday, December 30, 2009, 8:37 AM> > >  > > > > I have a client who has 5 children.> baby #1 was C Sec. due to breech> #2 and #3 were V Bac to term> #4 was Uterine Rupture, emergency Section at term> #5 was planned Section, but emergency section at 30 weeks due to rupture.> > This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.> > I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.> > She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.> > any thoughts/observatio ns?> > thank you!> lisa roder> CCLI Instructor>

Hotmail: Free, trusted and rich email service. Get it now.

[Guest guest]

I agree that performing a hysterectomy on this woman at this point in time is tantamount to sterilization. She needs to be encouraged in NFP with extra precautions, possibly just using the post peak period for intercourse and seeking the counsel of NFP experts in difficult cases.The general medical community is much too aggressive about recommending sterilizations for women with cesarean sections and stirring up fear of rupture. Rupture is a relatively rare event, and in any individual case you do not know whether it is due to poor surgical technique or inadequate healing due to poor nutrition or genetics. But this patient is NOT a typical woman who has merely had c/section(s). She has already had not one but TWO ruptures. She is at high risk for a third rupture if she gets pregnant. We have had women die in our hospital from uterine rupture, usually

occurring at home before labor. It does happen to people. More common is loss of the baby.Has she had a a consultation from a maternal fetal medicine specialist about her risk of rupture? A good one to ask for advice would be T Goodwin, who is head of maternal fetal medicine at USC. He can be reached at . He is a faithful Catholic and would good counsel.Once your client gets accurate appraisal of the risks of her situation - and it should optimally involve review of her medical records - she can decide whether or not to achieve or avoid pregnancy. If she were to get pregnant again, in my opinion she should be followed by a maternal fetal medicine specialist with frequent imaging (ultrasound or MRI) of the uterine scar and consideration to early delivery.Consideration should be given to hospitalization after 24 or 26 weeks in a high risk center if she gets pregnant again. D-

[Guest guest]

thank you all for your responses. I especially appreciate the further education

on rupture and repair. It does seem from what little I know that the desire for

a partial hysterectomy NOW is to prevent a possible future health threat (she

has mentioned cancer, adhesions to bladder from scar tissue, etc.)

She has spoken with a few Drs, including one NFP only. there seems to be some

support if she chooses to go this route, however it is elective.

lisa

>

> I agree that performing a hysterectomy on this woman at this point in time is

tantamount to sterilization. She needs to be encouraged in NFP with extra

precautions, possibly just using the post peak period for  intercourse and

seeking the counsel of NFP experts in difficult cases.

> The general medical community is much too aggressive about recommending

sterilizations for women with cesarean sections and stirring up fear of rupture.

Rupture is a relatively rare event, and in any individual case you do not know

whether it is due to poor surgical technique or inadequate healing due to poor

nutrition or genetics. But this patient is NOT a typical woman who has merely

had c/section(s). She has already had not one but TWO ruptures. She is at high

risk for a third rupture if she gets pregnant. We have had women die in our

hospital from uterine rupture, usually occurring at home before labor. It does

happen to people. More common is loss of the baby.

> Has she had a a consultation from a maternal fetal medicine specialist about

her risk of rupture? A good one to ask for advice would be T Goodwin, who

is head of maternal fetal medicine at USC. He can be reached at .

He is a faithful Catholic and would good counsel.

> Once your client gets accurate appraisal of the risks of her situation - and

it should optimally involve review of her medical records - she can decide

whether or not to achieve or avoid pregnancy. If she were to get pregnant again,

in my opinion she should be followed by a maternal fetal medicine specialist

with frequent imaging (ultrasound or MRI) of the uterine scar and consideration

to early delivery.Consideration should be given to hospitalization  after 24 or

26 weeks in a high risk center if she gets pregnant again.

> D

>

>

> -

>

[Guest guest]

My experience is very different from Paddy Jim's. The uterine ruptures I have seen were due to obstructed labors, looked as if a bomb had gone off, and were so edematous that I was able to literally peel the uterus off the cardinals... No question about Rx- hysterectomy right then. That's different from a scar deshiscence, where you can revise the thin part when closing.

Hanna Klaus

Uterine Removal after rupture?> To: nfpprofessionals > Date: Wednesday, December 30, 2009, 8:37 AM> > > Â > > > > I have a client who has 5 children.> baby #1 was C Sec. due to breech> #2 and #3 were V Bac to term> #4 was Uterine Rupture, emergency Section at term> #5 was planned Section, but emergency section at 30 weeks due to rupture.> > This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.> > I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.> > She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.> > any thoughts/observatio ns?> > thank you!> lisa roder> CCLI Instructor>

Hotmail: Free, trusted and rich email service. Get it now.

Hanna Klaus, M.D.

Natural Family Planning Center of Washington, D.C. and Teen STAR Program

8514 Bradmoor Drive

Bethesda, MD 20817-3810

Tel. , Fax

http://www.teenstarprogram.org

[Guest guest]

As far as the future threat for cancer, one could argue to a total hysterectomy on all women after childbearing to prevent all cervical, uterine and ovarian cancer! Not a practical nor ethical solutionSent from my iPhone

thank you all for your responses. I especially appreciate the further education on rupture and repair. It does seem from what little I know that the desire for a partial hysterectomy NOW is to prevent a possible future health threat (she has mentioned cancer, adhesions to bladder from scar tissue, etc.)

She has spoken with a few Drs, including one NFP only. there seems to be some support if she chooses to go this route, however it is elective.

lisa

>

> I agree that performing a hysterectomy on this woman at this point in time is tantamount to sterilization. She needs to be encouraged in NFP with extra precautions, possibly just using the post peak period for intercourse and seeking the counsel of NFP experts in difficult cases.

> The general medical community is much too aggressive about recommending sterilizations for women with cesarean sections and stirring up fear of rupture. Rupture is a relatively rare event, and in any individual case you do not know whether it is due to poor surgical technique or inadequate healing due to poor nutrition or genetics. But this patient is NOT a typical woman who has merely had c/section(s). She has already had not one but TWO ruptures. She is at high risk for a third rupture if she gets pregnant. We have had women die in our hospital from uterine rupture, usually occurring at home before labor. It does happen to people. More common is loss of the baby.

> Has she had a a consultation from a maternal fetal medicine specialist about her risk of rupture? A good one to ask for advice would be T Goodwin, who is head of maternal fetal medicine at USC. He can be reached at . He is a faithful Catholic and would good counsel.

> Once your client gets accurate appraisal of the risks of her situation - and it should optimally involve review of her medical records - she can decide whether or not to achieve or avoid pregnancy. If she were to get pregnant again, in my opinion she should be followed by a maternal fetal medicine specialist with frequent imaging (ultrasound or MRI) of the uterine scar and consideration to early delivery.Consideration should be given to hospitalization after 24 or 26 weeks in a high risk center if she gets pregnant again.

> D

>

>

> -

>

[Guest guest]

I strongly agree with Hanna. Having had 2 recent experiences, I can say that sewing up a ruptured uterus does no favors for the patient, her future children, or the doctor who has to deal with the recurrent rupture. One of my patients spontaneously ruptured during her third, routine labor. The risk in a woman with no previous scar is one in 15,000. Nonetheless, after delivering her baby vaginally by forceps, I found a lower uterine segment rupture and nearly lost the patient to a consumptive coagulopathy while doing an emergency hysterectomy.

Six weeks later, a patient with a previous classical c/s whose uterus had ruptured last year at 28 weeks, killing her baby and leaving her in the ICU for a week, presented with lower uterine pain and a fetal heart rate in the 60's at 26 weeks. I was the unfortunate attending on call. I found her baby outside the uterus after cutting her under local anesthesia. Both the patient and her baby survived, but leaving her uterus to rupture again would have been irresponsible.

We are trained in emergent caesarean hysterectomy. A ruptured uterus is damaged beyond repair and threatens the life of the patient. While I believe that NFP is superior to contemporary contraception in avoiding pregnancy, leaving a diseased uterus is not good medicine. And removing a diseased uterus is not an ethical dilemma. If we are rusty, or have never performed an emergency caesarean hysterectomy, by all means, call in help. I called in a cardio-thoracic surgeon to ligate the hypogastric artery on the first patient mentioned because I don't have a gyn-oncologist or perinatologist at my hospital and the uterine rupture was in the broad ligament.

So I guess I will respectfully disagree with those who think doing a hysterectomy now on the patient with a damaged uterus constitutes sterilization. If she had a precancerous lesion, adenomyosis, pain, or symptomatic fibroids, none of us would think twice about hysterectomy with a clear conscience. I take issue with simply sewing a ruptured uterus back together again, and wish the doctor who failed to remove the uterus after the second pre-term rupture had done the hysterectomy then. But the fact still remains that a future pregnancy, planned or not, significantly threatens the life of this woman and her child, and her uterus is damaged beyond repair.

Would any of the priests care to set me straight if I am in error, please?

Uterine Removal after rupture?

> To: nfpprofessionals

> Date: Wednesday, December 30, 2009, 8:37 AM

>

>

> Â

>

>

>

> I have a client who has 5 children.

> baby #1 was C Sec. due to breech

> #2 and #3 were V Bac to term

> #4 was Uterine Rupture, emergency Section at term

> #5 was planned Section, but emergency section at 30 weeks due to rupture.

>

> This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.

>

> I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.

>

> She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.

>

> any thoughts/observatio ns?

>

> thank you!

> lisa roder

> CCLI Instructor

>

Hotmail: Free, trusted and rich email service. Get it now.

Hanna Klaus, M.D.

Natural Family Planning Center of Washington, D.C. and Teen STAR Program

8514 Bradmoor Drive

Bethesda, MD 20817-3810

Tel. , Fax

http://www.teenstarprogram.org

[Guest guest]

Thank you, and Hanna for relieving my extreme concerns over this discussion. As now the mother of childbearing daughters, who faithfully practice NFP, I would be grateful for your presence and grasp of the issues if any of them were in trouble. I respectfully stand behind in disagreeing. Most priests that I know are looking to our good judgment in these sticky medical dilemmas. They understand the underlying morals and guideposts, but not always the medical implications of unusual, complex cases.

Let's continue to pray for each other!God bless, Rosko

To: nfpprofessionals From: obdoc2000@...Date: Sat, 2 Jan 2010 09:31:32 -0500Subject: Re: Re: Uterine Removal after rupture?

I strongly agree with Hanna. Having had 2 recent experiences, I can say that sewing up a ruptured uterus does no favors for the patient, her future children, or the doctor who has to deal with the recurrent rupture. One of my patients spontaneously ruptured during her third, routine labor. The risk in a woman with no previous scar is one in 15,000. Nonetheless, after delivering her baby vaginally by forceps, I found a lower uterine segment rupture and nearly lost the patient to a consumptive coagulopathy while doing an emergency hysterectomy.

Six weeks later, a patient with a previous classical c/s whose uterus had ruptured last year at 28 weeks, killing her baby and leaving her in the ICU for a week, presented with lower uterine pain and a fetal heart rate in the 60's at 26 weeks. I was the unfortunate attending on call. I found her baby outside the uterus after cutting her under local anesthesia. Both the patient and her baby survived, but leaving her uterus to rupture again would have been irresponsible.

We are trained in emergent caesarean hysterectomy. A ruptured uterus is damaged beyond repair and threatens the life of the patient. While I believe that NFP is superior to contemporary contraception in avoiding pregnancy, leaving a diseased uterus is not good medicine. And removing a diseased uterus is not an ethical dilemma. If we are rusty, or have never performed an emergency caesarean hysterectomy, by all means, call in help. I called in a cardio-thoracic surgeon to ligate the hypogastric artery on the first patient mentioned because I don't have a gyn-oncologist or perinatologist at my hospital and the uterine rupture was in the broad ligament.

So I guess I will respectfully disagree with those who think doing a hysterectomy now on the patient with a damaged uterus constitutes sterilization. If she had a precancerous lesion, adenomyosis, pain, or symptomatic fibroids, none of us would think twice about hysterectomy with a clear conscience. I take issue with simply sewing a ruptured uterus back together again, and wish the doctor who failed to remove the uterus after the second pre-term rupture had done the hysterectomy then. But the fact still remains that a future pregnancy, planned or not, significantly threatens the life of this woman and her child, and her uterus is damaged beyond repair.

Would any of the priests care to set me straight if I am in error, please?

Uterine Removal after rupture?> To: nfpprofessionals > Date: Wednesday, December 30, 2009, 8:37 AM> > > Â > > > > I have a client who has 5 children.> baby #1 was C Sec. due to breech> #2 and #3 were V Bac to term> #4 was Uterine Rupture, emergency Section at term> #5 was planned Section, but emergency section at 30 weeks due to rupture.> > This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.> > I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.> > She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.> > any thoughts/observatio ns?> > thank you!> lisa roder> CCLI Instructor>

Hotmail: Free, trusted and rich email service. Get it now.

Hanna Klaus, M.D.

Natural Family Planning Center of Washington, D.C. and Teen STAR Program

8514 Bradmoor Drive

Bethesda, MD 20817-3810

Tel. , Fax

http://www.teenstarprogram.org

Hotmail: Powerful Free email with security by Microsoft. Get it now.

[Guest guest]

it does appear that it could be argued to preform the hysterectomy while it was

directly

" sick " makes the most sense ethically and medically.

but, if it has been patched up and restored to the woman, then ethically, is it

acceptable to remove it NOW to prevent a future medical complication?

this seems to be the crux of the question.

thank you for the discussion.

lisa

> >

> >

> > From: lisatrinityacademy <laroder@>

> > Subject: Uterine Removal after rupture?

> > To: nfpprofessionals

> > Date: Wednesday, December 30, 2009, 8:37 AM

> >

> >

> > Â

> >

> >

> >

> > I have a client who has 5 children.

> > baby #1 was C Sec. due to breech

> > #2 and #3 were V Bac to term

> > #4 was Uterine Rupture, emergency Section at term

> > #5 was planned Section, but emergency section at 30 weeks due to rupture.

> >

> > This client is now seeking a Uterine removal, in part because she is fearful

of using NFP " strictly' and fears another, risky, pregnancy.

> >

> > I'm thinking that if there really was a valid concern (health wise) for

uterine removal, this would have occured during one of her last two sections,

and that the " emergency/urgency " has passed.

> >

> > She is not having bleeding issues, there is scar tissue due to all of the

repairs though, but these do not cause pain to her.

> >

> > any thoughts/observatio ns?

> >

> > thank you!

> > lisa roder

> > CCLI Instructor

> >

>

>

>

>

>

> Hotmail: Free, trusted and rich email service. Get it now.

>

>

>

>

>

>

> anna Klaus, M.D.

> atural Family Planning Center of Washington, D.C. and Teen STAR Program

> 514 Bradmoor Drive

> ethesda, MD 20817-3810

> el. , Fax

> ttp://www.teenstarprogram.org

>

[Guest guest]

From the Catholic moral perspective such an operation would not be permissible to prevent a pregnancy (however risky one might be) but would be per missible only and strictly to treat an illness. I haven't fully followed this thread of emails, so I'm sure someone else has pointed this out, and if so I apologize for repeating the -- at least for Catholics -- obvious.Peace and Happy New Year to all!Sent from my Verizon Wireless BlackBerryDate: Sat, 02 Jan 2010 03:33:23 -0000To: <nfpprofessionals >Subject: Re: Uterine Removal after rupture? thank you all for your responses. I especially appreciate the further education on rupture and repair. It does seem from what little I know that the desire for a partial hysterectomy NOW is to prevent a possible future health threat (she has mentioned cancer, adhesions to bladder from scar tissue, etc.)She has spoken with a few Drs, including one NFP only. there seems to be some support if she chooses to go this route, however it is elective.lisa>> I agree that performing a hysterectomy on this woman at this point in time is tantamount to sterilization. She needs to be encouraged in NFP with extra precautions, possibly just using the post peak period for  intercourse and seeking the counsel of NFP experts in difficult cases.> The general medical community is much too aggressive about recommending sterilizations for women with cesarean sections and stirring up fear of rupture. Rupture is a relatively rare event, and in any individual case you do not know whether it is due to poor surgical technique or inadequate healing due to poor nutrition or genetics. But this patient is NOT a typical woman who has merely had c/section(s). She has already had not one but TWO ruptures. She is at high risk for a third rupture if she gets pregnant. We have had women die in our hospital from uterine rupture, usually occurring at home before labor. It does happen to people. More common is loss of the baby.> Has she had a a consultation from a maternal fetal medicine specialist about her risk of rupture? A good one to ask for advice would be T Goodwin, who is head of maternal fetal medicine at USC. He can be reached at . He is a faithful Catholic and would good counsel.> Once your client gets accurate appraisal of the risks of her situation - and it should optimally involve review of her medical records - she can decide whether or not to achieve or avoid pregnancy. If she were to get pregnant again, in my opinion she should be followed by a maternal fetal medicine specialist with frequent imaging (ultrasound or MRI) of the uterine scar and consideration to early delivery.Consideration should be given to hospitalization  after 24 or 26 weeks in a high risk center if she gets pregnant again.> D> > > ->

[Guest guest]

I agree with Dr. -- I think a hysterectomy *now* is probably OK.

The patient has had recurrent uterine rupture, including what sounds

like a (spontaneous?) uterine rupture at 30 weeks. I think the uterus

is structurally abnormal -- whether due to less-than-ideal surgical

technique or to other factors (genetics?) -- regardless, the uterus now

has a pathological lower segment that has been proven twice to be abnormal.

I think it satisfies the principle of double-effect:

Primary intention: removal of a " diseased " structurally abnormal uterus

that has serious, potentially life-threatening, implications for the

woman (e.g. like removing a fibroid uterus for major bleeding)

Secondary (unintended) effect: loss of fertility

Procedure: hysterectomy, which is morally neutral

I would almost argue that the woman -- by not asking for a tubal

ligation or other form of contraception, which would be less morbid for

her than major surgery -- is being almost heroic for choosing a major

surgery to remove the actual diseased organ (uterus), which puts her

health at comparatively increased risk (with previous laparotomies and

two ruptures, the risks of surgery would be higher).

Of course, keeping the uterus and using NFP would be heroic as well.

I'm just not sure it is morally required.

Please correct me if my reasoning is off base.

Sincerely,

lisatrinityacademy wrote:

> it does appear that it could be argued to preform the hysterectomy while it

was directly

> " sick " makes the most sense ethically and medically.

> but, if it has been patched up and restored to the woman, then ethically, is

it acceptable to remove it NOW to prevent a future medical complication?

> this seems to be the crux of the question.

>

> thank you for the discussion.

> lisa

>

>

>>>

>>>

>>> From: lisatrinityacademy <laroder@>

>>> Subject: Uterine Removal after rupture?

>>> To: nfpprofessionals

>>> Date: Wednesday, December 30, 2009, 8:37 AM

>>>

>>>

>>> Â

>>>

>>>

>>>

>>> I have a client who has 5 children.

>>> baby #1 was C Sec. due to breech

>>> #2 and #3 were V Bac to term

>>> #4 was Uterine Rupture, emergency Section at term

>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.

>>>

>>> This client is now seeking a Uterine removal, in part because she is fearful

of using NFP " strictly' and fears another, risky, pregnancy.

>>>

>>> I'm thinking that if there really was a valid concern (health wise) for

uterine removal, this would have occured during one of her last two sections,

and that the " emergency/urgency " has passed.

>>>

>>> She is not having bleeding issues, there is scar tissue due to all of the

repairs though, but these do not cause pain to her.

>>>

>>> any thoughts/observatio ns?

>>>

>>> thank you!

>>> lisa roder

>>> CCLI Instructor

[Guest guest]

For what indication?

Sent from my Verizon Wireless BlackBerry

Uterine Removal after rupture?

>>> To: nfpprofessionals

>>> Date: Wednesday, December 30, 2009, 8:37 AM

>>>

>>>

>>> A

>>>

>>>

>>>

>>> I have a client who has 5 children.

>>> baby #1 was C Sec. due to breech

>>> #2 and #3 were V Bac to term

>>> #4 was Uterine Rupture, emergency Section at term

>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.

>>>

>>> This client is now seeking a Uterine removal, in part because she is fearful

of using NFP " strictly' and fears another, risky, pregnancy.

>>>

>>> I'm thinking that if there really was a valid concern (health wise) for

uterine removal, this would have occured during one of her last two sections,

and that the " emergency/urgency " has passed.

>>>

>>> She is not having bleeding issues, there is scar tissue due to all of the

repairs though, but these do not cause pain to her.

>>>

>>> any thoughts/observatio ns?

>>>

>>> thank you!

>>> lisa roder

>>> CCLI Instructor

------------------------------------

[Guest guest]

For those seeking the definitive teaching on this, check out the vatican's 1994

ruling by googling " Vatican denies bishops' request: ruling limits hysterectomy

option for women... " .

Sent from my Verizon Wireless BlackBerry

Uterine Removal after rupture?

>>> To: nfpprofessionals

>>> Date: Wednesday, December 30, 2009, 8:37 AM

>>>

>>>

>>> A

>>>

>>>

>>>

>>> I have a client who has 5 children.

>>> baby #1 was C Sec. due to breech

>>> #2 and #3 were V Bac to term

>>> #4 was Uterine Rupture, emergency Section at term

>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.

>>>

>>> This client is now seeking a Uterine removal, in part because she is fearful

of using NFP " strictly' and fears another, risky, pregnancy.

>>>

>>> I'm thinking that if there really was a valid concern (health wise) for

uterine removal, this would have occured during one of her last two sections,

and that the " emergency/urgency " has passed.

>>>

>>> She is not having bleeding issues, there is scar tissue due to all of the

repairs though, but these do not cause pain to her.

>>>

>>> any thoughts/observatio ns?

>>>

>>> thank you!

>>> lisa roder

>>> CCLI Instructor

------------------------------------

[Guest guest]

I stand corrected; Dr. Pedullad is correct, there is a definitive

teaching on the matter by the CDF that I was not aware of --

http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_d\

oc_31071994_uterine-isolation_en.html

-- which states that hysterectomy to remove a damaged uterus, if the

danger is not current but only due to a potential *future pregnancy*, is

not permissible.

Germain Grisez (Catholic philosopher) has an interesting reflection on

this teaching in the context of a complex case, in his great work " The

Way of the Lord Jesus " : http://www.twotlj.org/G-3-53.html.

Sincerely,

pedullad@... wrote:

> For those seeking the definitive teaching on this, check out the vatican's

1994 ruling by googling " Vatican denies bishops' request: ruling limits

hysterectomy option for women... " .

> Sent from my Verizon Wireless BlackBerry

>

> Uterine Removal after rupture?

>>>> To: nfpprofessionals

>>>> Date: Wednesday, December 30, 2009, 8:37 AM

>>>>

>>>>

>>>> A

>>>>

>>>>

>>>>

>>>> I have a client who has 5 children.

>>>> baby #1 was C Sec. due to breech

>>>> #2 and #3 were V Bac to term

>>>> #4 was Uterine Rupture, emergency Section at term

>>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.

>>>>

>>>> This client is now seeking a Uterine removal, in part because she is

fearful of using NFP " strictly' and fears another, risky, pregnancy.

>>>>

>>>> I'm thinking that if there really was a valid concern (health wise) for

uterine removal, this would have occured during one of her last two sections,

and that the " emergency/urgency " has passed.

>>>>

>>>> She is not having bleeding issues, there is scar tissue due to all of the

repairs though, but these do not cause pain to her.

>>>>

>>>> any thoughts/observatio ns?

>>>>

>>>> thank you!

>>>> lisa roder

>>>> CCLI Instructor

>

>

> ------------------------------------

>

>

[Guest guest]

Thanks, Dom. That clears everything up for me.

Uterine Removal after rupture?

>>>> To: nfpprofessionals

>>>> Date: Wednesday, December 30, 2009, 8:37 AM

>>>>

>>>>

>>>> A

>>>>

>>>>

>>>>

>>>> I have a client who has 5 children.

>>>> baby #1 was C Sec. due to breech

>>>> #2 and #3 were V Bac to term

>>>> #4 was Uterine Rupture, emergency Section at term

>>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.

>>>>

>>>> This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.

>>>>

>>>> I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.

>>>>

>>>> She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.

>>>>

>>>> any thoughts/observatio ns?

>>>>

>>>> thank you!

>>>> lisa roder

>>>> CCLI Instructor

>

>

> ------------------------------------

>

>

[Guest guest]

Truly amazing that oru Church has an answer for everything.

Les Ruppersberger Uterine Removal after rupture?>>>> To: nfpprofessionals >>>> Date: Wednesday, December 30, 2009, 8:37 AM>>>>>>>>>>>> A >>>>>>>>>>>>>>>> I have a client who has 5 children.>>>> baby #1 was C Sec. due to breech>>>> #2 and #3 were V Bac to term>>>> #4 was Uterine Rupture, emergency Section at term>>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.>>>>>>>> This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.>>>>>>>> I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.>>>>>>>> She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.>>>>>>>> any thoughts/observatio ns?>>>>>>>> thank you!>>>> lisa roder>>>> CCLI Instructor> > > ------------------------------------> >

[Guest guest]

I'd just like to suggest caution regarding the use of the word "definitive" to describe this and similar teachings (I'm focusing here on Q. 2 in the CDF item - which I think is the one that would be most likely to be potentially controversial among faithful Catholics). This teaching is authoritative (for Catholics) - and reasonable - and, I would say, correct. But by a "definitive" teaching is generally meant one whereby the Magisterium explicitly intends to provide a final (for all time) resolution regarding a matter (of faith and/or morals) - in short, an infallible dogmatic "definition." And not every authoritative teaching is an infallible one - e.g., this one surely isn't. A Catholic would be wrong simply to deny that it is true (let alone to act in a way contrary to it). But one could, in certain kinds of appropriate settings, raise certain kinds of respectful questions concerning it that would be out of bounds were it "definitive." And it is possible that the Magisterium could come to alter the conclusion (though since I think this teaching is correct, I don't think that will happen) - unlike in the case of a "definitive" teaching.

Dept. of Theology

Franciscan Univ. of Steubenville

Uterine Removal after rupture?>>>> To: nfpprofessionals >>>> Date: Wednesday, December 30, 2009, 8:37 AM>>>>>>>>>>>> A >>>>>>>>>>>>>>>> I have a client who has 5 children.>>>> baby #1 was C Sec. due to breech>>>> #2 and #3 were V Bac to term>>>> #4 was Uterine Rupture, emergency Section at term>>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.>>>>>>>> This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.>>>>>>>> I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.>>>>>>>> She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.>>>>>>>> any thoughts/observatio ns?>>>>>>>> thank you!>>>> lisa roder>>>> CCLI Instructor> > > ------------------------------------> >

[Guest guest]

Thank you Professor ; the distinction you provide is certainly good and valid as far as scientific theology goes, but I'm guessing wasn't using the word "definitive" in that restricted or specialized, scientific-dogmatic-theological sense which you described below (I mean that sense by which the certainty of doctrinal propositions of the magisterium are judged theologically). What was meant by his use of the term, unless I'm mistaken, was very likely that this help from the CDF was indeed "definitive" for the average doctor concerned about when not -- from the moral perspective -- to do hysterectomies, again in the non-specialized, non-restrictive theological sense of that term "definitive", and he certainly seems right according to that perspective. For the CDF answer to the dubium leaves little doubt and does definitively (precisely, accurately, unambiguously, etc.) address the very issue concerned, it leaves no doubt as to the morality, and it does definitively exclude the contrary opinion. And it does so precisely in the way doctors often need definition, even if as I say peraps not definition in the theological sense. It is a tremendous blessing to have a specific teaching addressing precisely the unique moral dilemma the physician may be faced with. For him this authoritative teaching is indeed "definitive" because of the clarity and authority provided. And clearly the question is definitively settled; i.e., in light of the CDF response no one can any longer say he is on the right track by performing hysterectomy for the forbidden indication, as you point out. I was not at all surprised at 's reaction, for the CDF provided "definitive" (decisive) moorings, something the lack of which is unnecessary for Catholics in this particular case. A CDF response such as this, as can plainly be seen from the thread of discussions on this topic after the CDF 1994 ruling was highlighted, removes any doubt the faithful Catholic physician may previoiusly have entertained, effectively settling the issue definitively, even if theological issues of interest to theologians persist to more completely flesh out any fuller presentation of doctrine or its fundaments/applications.

But by a "definitive" teaching is generally meant one whereby the Magisterium explicitly intends to provide a final (for all time) resolution regarding a matter (of faith and/or morals) - in short, an infallible dogmatic "definition."

Sincerely yours,

Dominic M. Pedulla MD, FACC, CNFPMC, ABVM, ACPh

Interventional Cardiologist, Endovascular Diplomate, Varicose Vein Specialist, Noncontraceptive Family Planning Consultant, Family Planning Researcher

Medical Director, The Oklahoma Vein and Endovascular Center (www.noveinok.com, varicoseveins1@...)

Executive Director, The Edith Stein Foundation (www.theedithsteinfoundation.com)

(office)

(cell)

pedullad@...

"Genuine progress, as the Church’s social teaching insists, must be integral and humane; it cannot prescind from the truth about human beings and must always be directed to their authentic good. In a word, fidelity to man requires fidelity to the truth, which alone is the guarantee of freedom and real development." (Pope Benedict on accepting credentials of U.S. Ambassador to the vatican )

Re: Re: Uterine Removal after rupture?

I'd just like to suggest caution regarding the use of the word "definitive" to describe this and similar teachings (I'm focusing here on Q. 2 in the CDF item - which I think is the one that would be most likely to be potentially controversial among faithful Catholics). This teaching is authoritative (for Catholics) - and reasonable - and, I would say, correct. But by a "definitive" teaching is generally meant one whereby the Magisterium explicitly intends to provide a final (for all time) resolution regarding a matter (of faith and/or morals) - in short, an infallible dogmatic "definition." And not every authoritative teaching is an infallible one - e.g., this one surely isn't. A Catholic would be wrong simply to deny that it is true (let alone to act in a way contrary to it). But one could, in certain kin

ds of appropriate settings, raise certain kinds of respectful questions concerning it that would be out of bounds were it "definitive." And it is possible that the Magisterium could come to alter the conclusion (though since I think this teaching is correct, I don't think that will happen) - unlike in the case of a "definitive" teaching.

Dept. of Theology

Franciscan Univ. of Steubenville

Uterine Removal after rupture?

>>>> To: nfpprofessionals

>>>> Date: Wednesday, December 30, 2009, 8:37 AM

>>>>

>>>>

>>>> A

>>>>

>>>>

>>>>

>>>> I have a client who has 5 children.

>>>> baby #1 was C Sec. due to breech

>>>> #2 and #3 were V Bac to term

>>>> #4 was Uteri

ne Rupture, emergency Section at term

>>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.

>>>>

>>>> This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.

>>>>

>>>> I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.

>>>>

>>>> She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.

>>>>

>>>> any thoughts/observatio ns?

>>>>

>>>> thank you!

>>>> lisa roder

>>>> CCLI Instructor

>

>

> ------------------------------------

>

& g

t;

[Guest guest]

Dominic,

Maybe pursuing this any further is beyond the scope of the list - and, indeed, as I said, I think that the only right thing for a Catholic physician to do is to act (and advise) in accordance with the CDF response.

However, that said, my other point was precisely that it is not quite right to say that the teaching now "leaves no doubt as to the morality, and it does definitively exclude the contrary opinion," etc. The question is not simply whether there can be more complete fleshing out, etc.

That's why I think one ought to be careful about "definitive" - it seems to imply a level of certainty about the truth of the matter at hand - i.e., absolute certainty - that a teaching like this, though authoritative and not to be dissented from, simply doesn't provide.

Uterine Removal after rupture?>>>> To: nfpprofessionals >>>> Date: Wednesday, December 30, 2009, 8:37 AM>>>>>>>>>>>> A >>>>>>>>>>>>>>>> I have a client who has 5 children.>>>> baby #1 was C Sec. due to breech>>>> #2 and #3 were V Bac to term>>>> #4 was Uteri ne Rupture, emergency Section at term>>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.>>>>>>>> This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.>>>>>>>> I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.>>>>>>>> She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.>>>>>>>> any thoughts/observatio ns?>>>>>>>> thank you!>>>> lisa roder>>>> CCLI Instructor> > > ------------------------------------> & g t;

[Guest guest]

Often, our more secular colleagues arrogantly how huff that the Pope has little knowledge or experience at medicine. This they take as their license to disobey.

Yet while the Pope has little experience or training at medicine, they have even less training with theology, philosophy and ethics. Sometimes they don't have experience either. Or, their ethical experience consists of recommending abortion, practicing contraception, etc.

Would that they could wisely and humbly obey teaching, as several colleagues have admirably done below.

Paddy Jim Baggot MD

Hotmail: Trusted email with powerful SPAM protection. Sign up now.

[Guest guest]

thank you all SO much for the wonderful and fruitful discussion.

As an instructor, this was important for me to grasp greater input from the

medical standpoint- my theology degree and first instinct was responding with

teachings mirroring the Vatican Document!

I also took a personal interest in the reponses: I've got two bleeding disorders

(von Willebrand and APS) which cause near emergency bleeds even on medication:

antepartum, postpartum, and cyclically.

lisa roder

>

>

> Often, our more secular colleagues arrogantly how huff that the Pope has

little knowledge or experience at medicine. This they take as their license to

disobey.

>

>

>

> Yet while the Pope has little experience or training at medicine, they have

even less training with theology, philosophy and ethics. Sometimes they don't

have experience either. Or, their ethical experience consists of recommending

abortion, practicing contraception, etc.

>

>

>

> Would that they could wisely and humbly obey teaching, as several colleagues

have admirably done below.

>

>

>

> Paddy Jim Baggot MD

>

>

>

>

>

>

>

>

>

>

> _________________________________________________________________

> Hotmail: Trusted email with powerful SPAM protection.

> http://clk.atdmt.com/GBL/go/177141665/direct/01/

>

[Guest guest]

This has been a very interesting discussion. Has anyone considered writing an

article or doing a case study for the Linacre Quarterly (the journal of the

Catholic Medical Association)?

Huntley CNM MSN

co-moderator

[Guest guest]

OK fair enough, , on the point about absolute certainty. It is certainly true that only the dogmatic definitions provide that level of certainty. However we physicians and artisans of health attained through licit means, men and women of faith, often do not need that level of certainty (absolute certainty). Most times it is not absolute dogmatic certainty we need but rather mere moral certainty, that is to say enough certainty to arrive at a morally secure conscience that is adequately informed to do the right thing and avoid the wrong thing. It may not be 100% correct to say this 1994 CDF ruling therefore removes "absolutely any conceivable doubt" but it certainly is correct to say it removes any reasonable moral doubt (i.e., provides the morally required degree of moral certainty) about how Catholics are to proceed in this circumstance. And the Church thinks, apparently, that this is enough, and that it provides the adequate guidance in the matter, given that even merely authoritative doctrinal pronouncements and clarifications by the magisterium are provided -- according to the CCC and in Ad Tuendam Fidem -- through divine guidance, a process which, even if not always intending to provide the

degree of certainty needed for use of the technical/theological-dogmatic term "definitive", does provide such clarity and safe, secure, trustworthy guidance as to provide moral certainty. And this is certainly "definitive" in another non-technical sense, that most often needed and considered valuable by conscientious physicians and healers. l would say on a practical level of certainty, there is no further reasonable doubt, and the document itself says the contrary opinion is to be excluded, does it not?

Too, wouldn't it be very rare if not completely non-existent for these kinds of responses to dubia ever to be "definitive" in the specialized, technical-theological, stricter sense seeing how invariably they ask very particular questions often related to unique and particular practical applications rather than proposing general doctrinal principles most often? If so then wouldn't this ruling be as highly authoritative an instance as these types of responses ever truly get?

It does bear mentioning that several of you have said you considered this discussion useful, so it wouldn't seem to be out of bounds for this discussion list, at least not so far.

Sincerely yours,

Dominic M. Pedulla MD, FACC, CNFPMC, ABVM, ACPh

Interventional Cardiologist, Endovascular Diplomate, Varicose Vein Specialist, Noncontraceptive Family Planning Consultant, Family Planning Researcher

Medical Director, The Oklahoma Vein and Endovascular Center (www.noveinok.com, varicoseveins1@...)

Executive Director, The Edith Stein Foundation (www.theedithsteinfoundation.com)

(office)

(cell)

pedullad@...

"Genuine progress, as the Church’s social teaching insists, must be integral and humane; it cannot prescind from the truth about human beings and must always be directed to their authentic good. In a word, fidelity to man requires fidelity to the truth, which alone is the guarantee of freedom and real development." (Pope Benedict on accepting credentials of U.S. Ambassador to the vatican )

Re: Re: Uterine Removal after rupture?

Dominic,

Maybe pursuing this any further is beyond the scope of the list - and, indeed, as I said, I think that the only right thing for a Catholic physician to do is to act (and advise) in accordance with the CDF response.

However, that said, my other point was precisely that it is not quite right to say that the teaching now "leaves no doubt as to the morality, and it does definitively exclude the contrary opinion," etc. The question is not simply whether there can be more complete fleshing out, etc.

That's why I think one ought to be careful about "definitive" - it seems to imply a level of certainty about the truth of the matter at hand - i.e., absolute certainty - that a teaching like this, though authoritative and not to be dissented from, simply doesn't provide.

Uterine Removal after rupture?

>>>> To: nfpprofessionals

>>>> Date: Wednesday, December 30, 2009, 8:37 AM

>>>>

>>>>

>>>> A

>>>>

>>>>

>>>>

>>>> I have a client who has 5 children.

>>>> baby #1 was C Sec. due to breech

>>>> #2 and #3 were V Bac to term

>>>> #4 was Uteri ne Rupture, emergency Section at term

>>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.

>>>>

>>>> This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.

>>>>

>>>> I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.

>>>>

>>>> She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.

>>>>

>>>> any thoughts/observatio ns?

>>>>

>>>> thank you!

>>>> lisa roder

>>>> CCLI Instructor

>

>

> ------------------------------------

>

& g t;

[Guest guest]

Dear Group, I think this discussion has been both challenging and necessary. Thank you all for maintaining a charitable spirit as we try and examine this complex situation. Kathy Schmugge, Assistant DirectorFamily Life OfficeDiocese of ton Re: Re: Uterine Removal after rupture?

Dominic,

Maybe pursuing this any further is beyond the scope of the list - and, indeed, as I said, I think that the only right thing for a Catholic physician to do is to act (and advise) in accordance with the CDF response.

However, that said, my other point was precisely that it is not quite right to say that the teaching now "leaves no doubt as to the morality, and it does definitively exclude the contrary opinion," etc. The question is not simply whether there can be more complete fleshing out, etc.

That's why I think one ought to be careful about "definitive" - it seems to imply a level of certainty about the truth of the matter at hand - i.e., absolute certainty - that a teaching like this, though authoritative and not to be dissented from, simply doesn't provide.

Uterine Removal after rupture?

>>>> To: nfpprofessionals

>>>> Date: Wednesday, December 30, 2009, 8:37 AM

>>>>

>>>>

>>>> A

>>>>

>>>>

>>>>

>>>> I have a client who has 5 children.

>>>> baby #1 was C Sec. due to breech

>>>> #2 and #3 were V Bac to term

>>>> #4 was Uteri ne Rupture, emergency Section at term

>>>> #5 was planned Section, but emergency section at 30 weeks due to rupture.

>>>>

>>>> This client is now seeking a Uterine removal, in part because she is fearful of using NFP "strictly' and fears another, risky, pregnancy.

>>>>

>>>> I'm thinking that if there really was a valid concern (health wise) for uterine removal, this would have occured during one of her last two sections, and that the "emergency/urgency" has passed.

>>>>

>>>> She is not having bleeding issues, there is scar tissue due to all of the repairs though, but these do not cause pain to her.

>>>>

>>>> any thoughts/observatio ns?

>>>>

>>>> thank you!

>>>> lisa roder

>>>> CCLI Instructor

>

>

> ------------------------------------

>

& g t;