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Brew-ha-ha brewing?From: RModugno@aol.comTue Sep 6 16:14:39 2005
>From 9/1/05 OB/GYN News:: New clinical guidelines issued by the American Academy of Family Physicians have raised concerns at the American College of Obstetricians and Gynecologists. Under those guidelines, a trial of labor after cesarean section should be offered to all appropriate candidates, and not restricted to those in facilities with surgical teams that are immediately available and present throughout labor. The recommendation differs from that of ACOG, which specifies that vaginal birth after cesarean (VBAC) should be attempted only in institutions equipped to respond to emergencies with immediately available physicians. The AAFP based its new guidelines on the 2003 trial of labor report issued by the Agency for Healthcare Research and Quality and on numerous studies published since then. None of these data sources contained clinical evidence supporting a restriction of trial of labor to facilities with immediately available surgical teams, said AAFP President Mary Frank, M.D. “The question is, have there been any studies showing that having the team onsite vs. in close proximity increases the risk of death or other problems or complications,†she said in an interview. “There are just no studies that show an increase in loss of life or bad outcome because the team isn't immediately on site.†The new AAFP guidelines provoked heated comment from Gary Hankins, M.D., chairman of ACOG's Committee on Obstetric Practice. “It's very troubling when people who may not even be qualified to perform a cesarean section start issuing guidelines about the safety of this kind of thing,†Dr. Hankins told this newspaper. “Their argument is that the available data don't prove it's unsafe— they're not arguing that it is safe. To me, the motive should be patient safety. Guidelines should be outcome-driven—and driven by good outcomes.†Although the AAFP guidelines don't restrict a trial of labor to certain facilities, they do specify that an individually constructed emergency management plan should be in place for each woman who attempts a trial of labor after cesarean (TOLAC). Such a plan would include being able to get a surgical team on site quickly. Dr. Frank said, “We're not saying attempt VBAC without surgical support. We understand the necessity for the team to be available close by, but that could be on another floor or across the street. We want our members to have a plan in place about how to access surgical support quickly.†According to the AAFP's guidelines, ACOG's recommendation may unnecessarily restrict access to vaginal delivery for some women, especially those living in rural areas. “One consequence of the … policy appears to be that some hospitals have discontinued VBAC services entirely, forcing women to present late in labor, to travel to another facility … or to submit to a scheduled repeat cesarean delivery that they may not have wanted,†the paper says. But Dr. Hankins said physicians should offer the safest possible delivery strategy, regardless of what the woman might eventually choose to do. “We should be offering this in the safest environment possible, and if people don't come in, that's their own choice,†he said. He also bristled at AAFP's suggestion that ACOG's guidelines are motivated by legal worries. According to the AAFP paper, “… current risk management policies across the United States restricting a trial of labor after previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence.†Dr. Hankins said, “Our main concern is with having the best possible outcome for mother and baby. If women are given the true numbers about the bad outcomes that can be associated with VBAC, no woman is going to take the chance†of laboring without immediately available surgical support. It's misleading for AAFP to say there's no evidence that VBAC can be dangerous, he added; a 4-year, prospective study of more than 32,000 women clearly showed the risks (N. Engl. J. Med. 2004;351:2581–9). “In the trial of labor group, there were 124 uterine ruptures and none in the elective repeat cesarean group. There were 12 babies with hypoxic-ischemic encephalopathy in the TOL group and none in the cesarean group, and 13 infant deaths vs. 7 in the cesarean group. You don't have to be as statistician to see those are highly significant numbers,†Dr. Hankins said. The AAFP panel noted this study appeared after its initial literature search. But the panel said it would not have changed its recommendations, because the comparison groups in the study were not equivalent. The TOL group included more premature deliveries, which may have skewed the encephalopathy numbers. In addition, prostaglandins were still being used to induce some laboring women during this study, which the panel said limited its applicability. Prostaglandins are now contraindicated for TOL after cesarean. Of the 124 women with uterine ruptures, 13 had been exposed to prostaglandins. The AAFP paper should be viewed as a means of opening the lines of communication about trial of labor between doctors and their patients, Dr. Frank said. “ACOG is being more conservative, and we are a little more open to dialogue. We hope this will encourage our members to talk with their patients about the potential risks and the potential benefits. We're not saying do it or don't attempt it. We're saying talk with the patient about the risks and what the plan is should something happen.†****************************************************************************** *************8=20 "The best laid emergency management plans may go awry" Robert Modugno MD MBA FACOG Marietta, GA
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