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Re: A case From: Robert J. Woolley (wooll005@gold.tc.umn.edu) Sun Dec 8 23:03:53 1996 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Robert J. Woolley: "Re: Ob database project" Previous message: Richard Kaplan: "Re: Re Fwd: First Do No Harm (fwd)" Maybe in reply to: Sing-Hung Chang: "A case" Next in thread: rbraun@indyunix.iupui.edu: "Re: A case" Reply: rbraun@indyunix.iupui.edu: "Re: A case" In message <1.5.4.16.19961208174541.2dd750e4@pop.unixg.ubc.ca> writes: > > Actually you are aguing against yourself, the C/S rate was lower in the > Induction group, I understand that. That's not my point. My point is that you are adding a twist to the Nahhan protocol that must increase your section rate over what it would have been without this twist. if this is a small though statistically sig difference, > then I should induce all patients at 41 weeks (as I do). I see no evidence in the Hannah study that failed inductions were routinely followed by sections. This is your innovation, which will necessarily result in a higher section rate than if you did not always do this. If you can explain > how serial inductions improve your section rate I would certainly like to > see the data, because everything I have read so far does not agree with > that. I do not induce patients that do not need to be delivered, therefore > if an induction fails I deliver abdominally. Yes, you said that. I am trying to determine whether you consider every patient at 41 weeks to "need to be delivered." It appears that you do, even if there is no objective sign of fetal compromise. And, no my C/S rate is not > high, it runs between 15 and 17%. Why did we used to induce at 43 or 42 > weeks? Because of the M&M graphs which show that the nadir of the curve is > at 40 weeks. The Canadian guidlines are based on Hannah's Study and > recommend routine induction at 41 weeks to avoid foetal distress and > decrease your C/S rate. What is going to improve at 42 weeks that you are > more likely to get a vaginal delivery if you failed at 41 weeks? Is the > baby going to get smaller from poorer placental function as the placenta > ages? Is that what you want to happen? Perhaps we are speaking of induction failures in different ways. If we reach reasonable doses of oxytocin and get no consistent contraction pattern or cervical changes, I consider that a failure. If there is no sign of fetal compromise, I would back off, wait a few days, and try again. Many do succeed the second time, presumably because of increased uterine susceptibility to the effects of oxytocin. If you section all of those, then you must section some that would otherwise have been able to deliver vaginally, given a little patience. Naturally, if there were good evidence of increased fetal morbidity or mortality from this strategy, the benefit of a lower section rate would be outweighed. However, as I assume you know, no study has shown any decrease in fetal morbidity or mortality by following your strategy. --------------------------------------------------------------------------- --------------------------------------------------------------------------- Bob Woolley -- --------------------------------------------------------------------------- St. Paul, Minnesota "Two vast things, each wondrous in itself, contribute to make this book a prodigy--the author's industry and her ignorance. Once can only be so intricately wrong by deep study and long effort.... The result has an eerie perfection, as if all the world's greatest builders had agreed to rear, with infinite skill, the world's ugliest building." --Garry Wills, on Fawn Brodie's psychobiography of Thomas Jefferson Next message: Robert J. Woolley: "Re: Ob database project" Previous message: Richard Kaplan: "Re: Re Fwd: First Do No Harm (fwd)" Maybe in reply to: Sing-Hung Chang: "A case" Next in thread: rbraun@indyunix.iupui.edu: "Re: A case" Reply: rbraun@indyunix.iupui.edu: "Re: A case"

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