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Re: tire forceps and vacuums?From: Efrain Ramirez (eramirezt@coqui.net)Sun Oct 15 18:03:53 2006
I avoid pushing efforts unless the head is almost visible ... AND Sign Out: Are you ready for the fallout from the NIH consensus on patient choice C/S? Oct 1, 2006 By: Arnold W. Cohen, MD Contemporary OB/GYN "Is this really fetal distress?" "Is the presenting part really engaged?" "Am I risking a shoulder dystocia if I allow this woman to deliver vaginally?" Arnold W. Cohen, MD Those are the questions you and I spent years in residency learning how to answer so the mother and fetus were treated appropriately. That was our "training." One of the key assumptions was that vaginal delivery had less morbidity for the mother, and possibly, the baby. Why do major surgery-cesarean delivery (C/S)-on a mother who doesn't need it, or a fetus who will not benefit? C/S, we believed, would increase the risk of bleeding, injury to other organs, infection, and possibly maternal death. We also recognized that performing a C/S today not only meant major surgery for the woman now, but a repeat C/S in future. Sure, repeat C/S can be scheduled for the "convenience" of patient and obstetrician, but that doesn't mean it will be easy. We have all had difficult repeats. How risky is C/S? And now we have a report from the National Institutes of Health's (NIH) "Consensus Hearing" on short- and long-term morbidity and mortality associated with vaginal delivery and C/S. After reviewing all of the known data, the participants concluded that there is no good evidence that vaginal delivery is safer than an elective, nonmedically or obstetrically indicated C/S-at least for women who absolutely know that they will have a "small family." The implication seems to be that we've become so good at doing C/S that the risks are really not that high. (That's good news, isn't it?) The panel also said the data are not convincing that C/S decreases the risk of urinary and/or fecal incontinence. The implication of this conference was that performing an elective C/S might be less dangerous, more efficient, and less expensive in some patients than allowing patients to labor. The report also suggests that we should be able to forecast the number of children a woman will have before we do her first C/S. We would then avoid the real risks of placenta accreta. But can we really be sure that we'll only perform elective C/S on women who know that they want "small" families? Let's not forget that 50% of pregnancies are unplanned and 50% of marriages end in divorce. Will we then be held liable if a woman changes her mind and has subsequent complications? It seems to me that the NIH report has put obstetricians in a difficult position. We need to use all of our knowledge and skills to help patients who don't want elective C/S make the right choices based on evidence, but we are also being asked to give up all of our decision-making responsibility when a woman says that she wants an unindicated C/S. One decision-making process is evidence-based, and the other is based purely on patient autonomy. "Do I section a woman now or watch the questionable fetal heart rate tracing?" "Should I do the C/S now or turn up the oxytocin?" "Should I let the patient push and see if the head comes down, or do a C/S now?" We used to answer those questions based on what we thought was in the best interest of the mother and baby. We knew that if we were wrong, even once, we could possibly be sued, but it was the right thing to do. The NIH report now says there really is no significant difference between a vaginal delivery and C/S for women who will limit their family size, so why spend the time creating anxiety for us, and our patients? Wouldn't it just be simpler to do a C/S for any hint of a maternal or fetal problem? Maybe it will even help us avoid lawsuits.The "consensus" could change our entire decision-making process. It could increase the C/S rate from 29%, to 40%, 50%, or even 80%. I predict that the NIH report will make it difficult to defend, in our own minds-and in the courtroom-decisions to allow a patient to deliver vaginally when there is any abnormality in labor (or before). That, I think, will be the unintended consequence of the well-thought-out NIH consensus opinion
At Sun, 15 Oct 2006, David Priver wrote:
>
-- “ The greatest obstacle to knowledge is not ignorance, it is the illusion of knowledge.” Daniel J. Boorstin - Historian
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