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Richard Chudacoff, MD
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net]On Behalf Of Steve &
Eryl Raymond
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
--
Dr. S.H. Raymond
Head of Department of O & G
Empangeni Hospital
South Africa 3880
Phone: (+27) 35-7721111
Fax: (+27) 35-7922596
