Re: VBAC and how to fight with anaesthesia
From: art fougner, md (evsono@pipeline.com)
Tue Apr 24 07:52:25 2001
OMG!!! clinical acumen????
perish the thought in these days of metanalyses and EBM.
art
At Tue, 24 Apr 2001, Steve & Eryl Raymond wrote:
>
>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
>
>--
>
>Dr. S.H. Raymond
>Head of Department of O & G
>Empangeni Hospital
>South Africa 3880
>Phone: (+27) 35-7721111
>Fax: (+27) 35-7922596
>
--
art fougner, md
A series of 1000 cases begins with but a single anecdote.
