Re: Flamm/Phalen Debate: risk mitigation of VBAC
From: art fougner, md (evsono@pipeline.com)
Wed Feb 10 09:22:36 1999
let's put this in perspective. the risks of uterine rupture associated
with a trial of labor after lower segment transverse cesarean are quite
low. however, they are NOT zero and, to date, there is no reliable
method of prevention short of elective repeat cesarean. when
catastrophic rupture occurs, it can produce significant maternal and
neonatal morbidity or worse. therefore, each patient deserves the right
to choose for herself what degree of risk is acceptable.
as an aside, when a catastrophe occurs, prompt response is crucial. to
that end, attempted vbac in a center which must summon nurses and
anesthetists from home seems foolhardy.
to quote dennis miller, "of course that's just my opinion. i could be
wrong."
Art
At Wed, 10 Feb 1999, Ken Turkowski wrote:
>
>>>In a message dated 2/2/99 08:29:09 AM, DoctorJoe@aol.com:
>>In a message dated 2/2/99 4:29:43 AM, turk@apple.com writes:
>>
>><<I agree with Dr. Phalen that the patient needs to be better informed, but
>>I can't follow his analogy with GBS cultures. I disagree with Dr. Flamm
>>that "brain damage and death" are too strong to be used in the
>>disclosure. "Injury to the fetus" conjures up images of a scalpal
>>puncture instead. The possibilities of brain damage and death are easier
>>to deal with when the probabilities are remote.>>
>>
>>Just to add a couple of pennies here:
>>
>>I was turned off by one of Flamm's early papers, comparing VBAC to elective
>>C/S at term, when they DISAVOWED neonatal death due to meconium aspiration in
>>a couple of the VBAC babies as being unrelated to the VBAC, hence not a
>>"significant" complication. The point was, IF the baby had been delivered by
>>elective C/S at 39 weeks, it would NOT have had meconium aspiration in labor
>>at 41 weeks... Therefore the death WAS attributable to the VBAC (preventable
>>by the C/S before labor). I considered this to be publicatory sleight of hand
>>(how's that for a phrase?) and now take EVERYTHING Flamm publishes or opines
>>with a HUGE grain of NaCl.
>
>Flamm is, however, one of the most vocal proponents of VBAC. He's not the
>only one who has interpreted the statistics in a way to better prove his
>point. Others have chosen the samples in a way that skews the results as
>well. The point is that both Flamm and Phelan agree that VBACs need to be
>made safer. So does ACOG. I'd venture to say that there are thousands of
>other medical professionals that agree. There's also the opinions of the
>popular press and the pregnant C-scarred mothers. You shouldn't disregard
>Flamm's opinion *as well* as that of those that share it.
>
>Your position seems to be that the risks associated with VBAC are higher
>than those published in Flamm's papers. Especially in that light, it
>seems prudent to attempt to reduce the risks associated with VBAC.
>McMahon's paper, "Comparison of TOL with an elective second cesarean
>section" (NEJM), indicates that MAJOR COMPLICATIONS were nearly TWICE AS
>LIKELY among women undergoing a trial of labor, compared with an elective
>cesarean. I don't know of any other studies that corroborate this claim,
>but if it is indeed true, then aren't we doing the client a disservice by
>offering VBAC and cesarean as equivalent options?
>
>Given the disparity in cost between VBAC and cesarean, how about using
>some of that cost difference to decrease the risks of VBAC? Improved
>monitoring equipment can detect bradycardia, tachycardia, variable
>decelerations, late decelerations, and even loss of beat-to-beat
>variability. An increase in staffing, and pre-packaged stat-C kits can
>reduce response time for stat C's.
>
>Think of this incremental cost to be a kind of insurance. By reducing the
>risks of VBAC, we are also reducing the quantity (N) of huge postnatal
>bills ($20K-$20M) resulting from catastrophic VBACs. For the insurance
>bean-counters out there, this will result in lower TOTAL costs.
>
>______________________________________________
>Ken Turkowski, research scientist
>______________________________________________
>
>--
>______________________________________________
>annotated VBAC bibliography maintenance, updated quarterly:
>______________________________________________
>http://www.worldserver.com/turk/rrvbac.html
>
--
art fougner, md
SonoScan/Genetic Sciences
forest hills, ny
evsono@pipeline.com
