Re: Brew-ha-ha brewing?
From: art fougner, md (evsono@pipeline.com)
Tue Sep 6 17:25:07 2005
And who will place the bell on this proverbial cat? Sit back as the
bloviating fur flies...
art
At Tue, 6 Sep 2005, RModugno@aol.com wrote:
>
>>From 9/1/05 OB/GYN News::
>New clinical guidelines issued by the American Academy of Family Physician
>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 hroughout
>labor.
>The recommendation differs from that of ACOG, which specifies that vaginal
>birth after cesarean (VBAC) should be attempted only in institutions equip ed
>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 eviden e
>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 he team
>onsite vs. in close proximity increases the risk of death or other problem or
>complications,� she said in an interview. “There are just n 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 tro bling 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. Ha kins told this
>newspaper. “Their argument is that the available data don't prove t'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 out omes.�
>Although the AAFP guidelines don't restrict a trial of labor to certain
>facilities, they do specify that an individually constructed emergency man gement
>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 t am
>on site quickly. Dr. Frank said, “We're not saying attempt VBAC wi hout
>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 quick y.�
>According to the AAFP's guidelines, ACOG's recommendation may unnecessaril
>restrict access to vaginal delivery for some women, especially those livin
>in rural areas. “One consequence of the … policy appears to be that some
>hospitals have discontinued VBAC services entirely, forcing women to prese t late
>in labor, to travel to another facility … or to submit to a schedu ed 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. â €œWe
>should be offering this in the safest environment possible, and if people on'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 isk management
>policies across the United States restricting a trial of labor after previ us
>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 possib e 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 c ance�
>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 one in
>the elective repeat cesarean group. There were 12 babies with hypoxic-isch mic
>encephalopathy in the TOL group and none in the cesarean group, and 13 inf nt
>deaths vs. 7 in the cesarean group. You don't have to be as statistician t
>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, ecause
>the comparison groups in the study were not equivalent. The TOL group incl ded
>more premature deliveries, which may have skewed the encephalopathy number .
>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 omen
>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 on't
>attempt it. We're saying talk with the patient about the risks and what th
>plan is should something happen.�
>*************************************************************************** **
>*************8=20
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>"The best laid emergency management plans may go awry"
>Robert Modugno MD MBA FACOG
>Marietta, GA
--
art fougner, md
"If you don't know where you are going, you will wind up somewhere else."
Lawrence Peter Berra
