Re: Brew-ha-ha brewing?
From: Larry Glazerman (l.glazerman@rcn.com)
Tue Sep 6 19:42:00 2005
Had an interesting discussion this evening with the chair of FP at one of my
hospitals about this issue. We talked about geographical differences, the
"national standard of care", and the fact that, de facto, lots of babies are
delivered by FPs in rural areas. AS much as I'm personally against VBACs in
those situations, there's a part of me that would let the TRULY informed
patient choose a VBAC in a rural area, if she understands the risks (do they
ever), and chooses not to travel hundreds of miles to a facility that is
better equipped. The fact is that most VBACs do well.
Again, I personally agree with ACOG's position (and it makes me REALLY glad
I'm giving up OB after 7 more deliveries :-)), but his point was that
sometimes the enemy of good is perfect.
Food for thought - please hold the flames!
--
Larry R. Glazerman, MD
Ob-Gyn at Trexlertown, PC
610-402-0161
l.glazerman@rcn.com
_____
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Lynn D.
Montgomery, M.D.
Sent: Tuesday, September 06, 2005 6:48 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: Brew-ha-ha brewing?
Now first let me say that I have the ultimate respect for family
practitioners, particularly those who are out in truly rural areas and don't
have the benefit of all the technology of larger centers. That said, since
finishing training, every where I have been, it seems that FP's have tried
their best to be contrary with regard to OB/GYN. First it was doing
c-sections - several programs were "getting" their residents 10 sections
during their last year and sending them out to do sections. When OB
departments question the credentials, their response is that they have their
own department and we don't have any say in credentialing - but who do they
call when it hits the fan. Then there is the tubal issue - one place I
practiced, the two FP's remaining were routinely taking an hour or more to
do a postpartum tubal and often through an incision about the size of a
section incision. Again, when brought to question, the response is that we
don't credential them. Now the VBAC issue - even though I have attended
several ruptures over the years, I don't cherish the ongoing possibility of
ever seeing another and I am in a center with "immediate" coverage. The
prospects of an FP having a rupture in Podunk, Wyoming, based on the AAFP
policy is ridiculous, but again, they seem resistant to listen to reason...
Lynn
Lynn D. Montgomery, M.D.
Maternal-Fetal Medicine, OB/GYN
Rocky Mountain Women's Health
2835 Fort Missoula Rd., Suite 304
Missoula, Montana, 59804
406-549-0978
fax 406-549-0987
e-mail: apgar10@montanadsl.net
_____
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
RModugno@aol.com
Sent: Tuesday, September 06, 2005 3:17 PM
To: Multiple recipients of list OB-GYN-L
Subject: Brew-ha-ha brewing?
>From 9/1/05 OB/GYN News::
New clinical guidelines issued by the American Academy of Family Physicians
have raised concerns at the American College of Obstetricians and
Gynecologists.
Under those guidelines, a trial of labor after cesarean section should be
offered to all appropriate candidates, and not restricted to those in
facilities with surgical teams that are immediately available and present
throughout labor.
The recommendation differs from that of ACOG, which specifies that vaginal
birth after cesarean (VBAC) should be attempted only in institutions
equipped to respond to emergencies with immediately available physicians.
The AAFP based its new guidelines on the 2003 trial of labor report issued
by the Agency for Healthcare Research and Quality and on numerous studies
published since then. None of these data sources contained clinical evidence
supporting a restriction of trial of labor to facilities with immediately
available surgical teams, said AAFP President Mary Frank, M.D.
"The question is, have there been any studies showing that having the team
onsite vs. in close proximity increases the risk of death or other problems
or complications," she said in an interview. "There are just no studies that
show an increase in loss of life or bad outcome because the team isn't
immediately on site."
The new AAFP guidelines provoked heated comment from Gary Hankins, M.D.,
chairman of ACOG's Committee on Obstetric Practice. "It's very troubling
when people who may not even be qualified to perform a cesarean section
start issuing guidelines about the safety of this kind of thing," Dr.
Hankins told this newspaper. "Their argument is that the available data
don't prove it's unsafe-they're not arguing that it is safe. To me, the
motive should be patient safety. Guidelines should be outcome-driven-and
driven by good outcomes."
Although the AAFP guidelines don't restrict a trial of labor to certain
facilities, they do specify that an individually constructed emergency
management plan should be in place for each woman who attempts a trial of
labor after cesarean (TOLAC). Such a plan would include being able to get a
surgical team on site quickly. Dr. Frank said, "We're not saying attempt
VBAC without surgical support. We understand the necessity for the team to
be available close by, but that could be on another floor or across the
street. We want our members to have a plan in place about how to access
surgical support quickly."
According to the AAFP's guidelines, ACOG's recommendation may unnecessarily
restrict access to vaginal delivery for some women, especially those living
in rural areas. "One consequence of the . policy appears to be that some
hospitals have discontinued VBAC services entirely, forcing women to present
late in labor, to travel to another facility . or to submit to a scheduled
repeat cesarean delivery that they may not have wanted," the paper says.
But Dr. Hankins said physicians should offer the safest possible delivery
strategy, regardless of what the woman might eventually choose to do. "We
should be offering this in the safest environment possible, and if people
don't come in, that's their own choice," he said.
He also bristled at AAFP's suggestion that ACOG's guidelines are motivated
by legal worries. According to the AAFP paper, ". current risk management
policies across the United States restricting a trial of labor after
previous cesarean section appear to be based on malpractice concerns rather
than on available statistical and scientific evidence."
Dr. Hankins said, "Our main concern is with having the best possible outcome
for mother and baby. If women are given the true numbers about the bad
outcomes that can be associated with VBAC, no woman is going to take the
chance" of laboring without immediately available surgical support.
It's misleading for AAFP to say there's no evidence that VBAC can be
dangerous, he added; a 4-year, prospective study of more than 32,000 women
clearly showed the risks (N. Engl. J. Med. 2004;351:2581-9).
"In the trial of labor group, there were 124 uterine ruptures and none in
the elective repeat cesarean group. There were 12 babies with
hypoxic-ischemic encephalopathy in the TOL group and none in the cesarean
group, and 13 infant deaths vs. 7 in the cesarean group. You don't have to
be as statistician to see those are highly significant numbers," Dr. Hankins
said.
The AAFP panel noted this study appeared after its initial literature
search. But the panel said it would not have changed its recommendations,
because the comparison groups in the study were not equivalent. The TOL
group included more premature deliveries, which may have skewed the
encephalopathy numbers. In addition, prostaglandins were still being used to
induce some laboring women during this study, which the panel said limited
its applicability. Prostaglandins are now contraindicated for TOL after
cesarean. Of the 124 women with uterine ruptures, 13 had been exposed to
prostaglandins.
The AAFP paper should be viewed as a means of opening the lines of
communication about trial of labor between doctors and their patients, Dr.
Frank said. "ACOG is being more conservative, and we are a little more open
to dialogue. We hope this will encourage our members to talk with their
patients about the potential risks and the potential benefits. We're not
saying do it or don't attempt it. We're saying talk with the patient about
the risks and what the plan is should something happen."
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"The best laid emergency management plans may go awry"
Robert Modugno MD MBA FACOG
Marietta, GA
