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Re: VBAC and how to fight with anaesthesiaFrom: Braun, R. Daniel (rbraun@iupui.edu)Tue Apr 24 06:47:46 2001
Hear! Hear! Well said Steve. Dan -----Original Message----- From: Steve & Eryl Raymond [mailto:eryl@intekom.co.za] Sent: Monday, April 23, 2001 9:54 PM To: Multiple recipients of list OB-GYN-L Subject: VBAC and how to fight with anaesthesia Paul Prior wrote: "I know we have all discussed VBAC ad nauseum here, but clearly there are several of us currently engaged in dialog with our institutions about how we are going to address this. My hospital is seriously considering doing away with them altogether." If it weren't that you are serious about this and the ACOG also concerned this whole subject would be amusing to those of us who were trained in the British way. When I started in the 70's we would joke about the Americans who held that "once a caesar, always a caesar" as we knew there were cases which could be delivered vaginally with a scarred uterus. We defined these as those without a repeatable reason for their first caesar. Then the Americans cottoned on to the fact that in the UK and Europe there were Obstetricians who were prepared to carry out a trial of scar in some cases and the next thing we knew they had espoused this "strange doctrine" to the absolute limit. So much so that midwives began doing "VBACs" on domiciliary patients. Of course, we knew that in the final analysis it was always a "trial" of scar, and that the middle ground was fundamental to deciding who would and who would not get a repeat C/S, and furthermore, it was for an expert (i.e. a specialist obstetrician) to decide what mode of delivery to advise. To my amusement, and I'm sure to many others' in our discipline we now find that, despite extensive literature (including a VBAC bibliography) the ACOG has now had to step in and swing the pendulum right back to where it started in the 70's with the result that, if Paul's prediction comes true, instead of everyone getting the opportunity to rupture her uterus, no-one will. It may sound arrogant but it is telling the truth when I say that in 13 years of private practice and covering a small public hospital obstetric unit I never saw a ruptured uterus. On moving to South Africa and starting to deal with black patients I started to see such cases, so I have become even more careful about choosing cases for trial of scar, but I am convinced that the good obstetrician sits somewhere in the middle of the road, dealing with each individual patient on her merits and taking into account the reasons for the first C/S, the quality of the healing of that C/S, the race of the patient and other factors, such as need for induction, size of baby, descent of head and progress of labour. If this attitude had prevailed in the first place this whole controversy would never have arisen. Now I await the flames. Steve --
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