Re: breech
From: David Priver, MD (dpriver@aol.com)
Thu Dec 23 15:19:11 2004
Art,
I agree with you that arguments about whether vaginal breech delivery is
safe or not are essentially moot. No one gets trained anymore, so the
procedure, in the hands of anyone completing residency since, say, 1980
or so, would most likely not be safe. The more important point is what
this sort of "dumbing down" of our specialty says about where the field
of OB/GYN is headed. The same arguments could be carried on about
forceps deliveries or almost any procedure in which dexterity and
judgment are required. (Note how episiotomy has been determined to be
always bad; no longer can one exercise thoughtful judgment. I suspect
that VBAC will soon be in this same category). What is hard to ignore
is the sense that there are powers afoot who would prefer to see OB/GYN
just disappear, to be replaced by far less expensive (and less
well-trained) alternative practitioners who can catch a baby or, failing
that, can summon a perinatologist. Perhaps that direction is for the
best. Maybe it will produce just as good results less expensively. My
point, however, is that if this is the direction we're going, let's just
be honest about it and state that it's an economic issue and be done
with it. That, I think, is preferable to producing junk science like
the Hannah study.
DP
At Wed, 22 Dec 2004, art fougner, md wrote:
>
>much ado about nothing ... natural selection has been weeding out those
>practitioners skilled at breech deliveries, midforceps, etc for years.
>when extinction occurs, all the cajoling and legislating won't be able
>to resuscitate the moribund. requiescat in pace.
>
>art
>
>At Tue, 21 Dec 2004, Terrence.Jones@kp.org wrote:
>>
>>This is a multipart message in MIME format.
>>--=_alternative 0013526388256F72 Content-Type: text/plain; charset="us-ascii"
>>
>>El,
>>
>> I think the beef is with the "emperors tailors". Kotaska pointed
>>out some deficiencies in the "new clothes" production process. The
>>outcomes were influenced. Not everything evidentiary is what it 'seams' to
>>be. David has itemized this in His 12/19 letter. And Gordon's note from
>>12/20 searches for vested interests. In the not too distant past, Patients
>>were given a choice. They knew the conditions that needed to be present,
>>the dependence of the availability of experienced personnel, and the
>>unpredictability of rare event(s). Now the choice has been eliminated. The
>>fact that this policy change does not have any major impact on Your's and
>>my practice is not the beef, it's that the evidence backing the policy
>>change is in question. And that the magnitude of subjects required to
>>attain a degree of statistical reliability, requires an arbitrary
>>reduction of flexibility, to incorporate multiple centers. And that this
>>loss of flexibility applies pressure to certain centers beyond their
>>capacity. And that certain centers, with internal audits demonstrating
>>safety (Nuernberg), refused to participate. The epidemiologists can make
>>conclusions based only on the numbers they're given. The clinician can
>>assess these numbers WRT validity. If we stop listening to the Kotaskas;
>>'cause it's less stressful to do c/s than, after 10 hours of labor, to
>>watch deep variables in the late second stage; then we (and our Patients)
>>become vulnerable. There's no issue for You to agree with Dr. Kotaska (or
>>Dr. Krause), nor that You should feel compelled in any way to offer
>>vaginal breech delivery to Your Patients. You do what You know is best for
>>Your Patients based on the clinical circumstances and experience brought
>>to bear. The issue is the scientific process of establishing or negating
>>validity; and the crtitique of study design in complex management
>>scenarios. Check the bathwater before Ya' toss it. Oh, and "centers of
>>excellence" is a relative term, utilized here for federal funding
>>designation. The clinical pathways and layers of redundancy are an effort
>>towards optimization. Our local variety is not likely, for example, to be
>>the best resource for a managing the Patient at 20 weeks, with
>>Plamodium...
>>
>>tj
>>
>>Dr Eberhard W Lisse <el@lisse.NA>
>>Sent by: ob-gyn-l@obgyn.net
>>12/16/2004 09:57 PM
>>Please respond to ob-gyn-l
>>
>> To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>> cc:
>> Subject: Re: breech
>>
>>Since it appears from the article in Comemporary OB/Gyn to be true that
>>C/S is as safe or safer than vaginal delivery I really wonder where the
>>beef is?
>>
>>greetings, el
>>
>>--=_alternative 0013526388256F72 Content-Type: text/html; charset="us-ascii"
>>
>><br><font size=2 face="sans-serif">El, </font>
>><br>
>><br><font size=2 face="sans-serif"> I think the beef is with the "emperors tailors". Kotaska pointed out some deficiencies in the "new clothes" production process. The outcomes were influenced. Not everything evidentiary is what it 'seams' to be. David has itemized this in His 12/19 letter. And Gordon's note from 12/20 searches for vested interests. In the not too distant past, Patients were given a choice. They knew the conditions that needed to be present, the dependence of the availability of experienced personnel, and the unpredictability of rare event(s). Now the choice has been eliminated. The fact that this policy change does not have any major impact on Your's and my practice is not the beef, it's that the evidence backing the policy change is in question. And that the magnitude of subjects required to attain a degree of statistical reliability, requires an arbitrary reduction of flexibility, to incorporate multipl!
>> e centers. And that this loss of flexibility applies pressure to certain centers beyond their capacity. And that certain centers, with internal audits demonstrating safety (Nuernberg), refused to participate. The epidemiologists can make conclusions based only on the numbers they're given. The clinician can assess these numbers WRT validity. If we stop listening to the Kotaskas; 'cause it's less stressful to do c/s than, after 10 hours of labor, to watch deep variables in the late second stage; then we (and our Patients) become vulnerable. There's no issue for You to agree with Dr. Kotaska (or Dr. Krause), nor that You should feel compelled in any way to offer vaginal breech delivery to Your Patients. You do what You know is best for Your Patients based on the clinical circumstances and experience brought to bear. The issue is the scientific process of establishing or negating validity; and the crtitique of study design in complex management scenarios. Check the bathwater b!
>> efore Ya' toss it. Oh, and "centers of excellence" is a rela
>>tive term, utilized here for federal funding designation. The clinical pathways and layers of redundancy are an effort towards optimization. Our local variety is not likely, for example, to be the best resource for a managing the Patient at 20 weeks, with Plamodium...</font>
>><br>
>><br><font size=2 face="sans-serif">tj </font>
>><br>
>><table width0%>
>><tr valign=top>
>><td>
>><td><font size=1 face="sans-serif"><b>Dr Eberhard W Lisse <el@lisse.NA></b></font>
>><br><font size=1 face="sans-serif">Sent by: ob-gyn-l@obgyn.net</font>
>><p><font size=1 face="sans-serif">12/16/2004 09:57 PM</font>
>><br><font size=1 face="sans-serif">Please respond to ob-gyn-l</font>
>><br>
>><td><font size=1 face="Arial"> </font>
>><br><font size=1 face="sans-serif"> To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net></font>
>><br><font size=1 face="sans-serif"> cc: </font>
>><br><font size=1 face="sans-serif"> Subject: Re: breech</font></table>
>><br>
>><br><font size=2 face="Courier New"><br>
>><br>
>>Since it appears from the article in Comemporary OB/Gyn to be true that<br>
>>C/S is as safe or safer than vaginal delivery I really wonder where the<br>
>>beef is?<br>
>><br>
>>greetings, el<br>
>></font>
>><br>
>
>--
>art fougner, md
>May the Joy of this Holiday Season Be
>with You and Yours throughout the Coming
>New Year!
>
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