Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Awaiting the new generation of trained obstetricians
- David JR Hutchon (23 September 2006)
-
Revisit the past
- Dermot Ryan (26 September 2006)
-
Reducing second stage Caesarean Sections - need for a multi-pronged attack
- Parivakkam S Arunakumari (26 September 2006)
-
Is the functionally intact female perineum less valuable than a reduced caesarian section rate?
- Michelle J Thornton (27 September 2006)
-
A device to make labour assessment more objective
- Andrew D Weeks (6 October 2006)
-
Caesarean Delivery in the Second Stage of Labour: An Indian Perspective
- Nirmala Rai, Prathima Reddy, Consultant Obstetrician&Gynaecologist, Mallya Hospital, Bangalore, India (14 October 2006)
-
Better training in instrumental delivery may reduce caesarean section rates
- John Kelly, Heather Winter (17 October 2006)
-
Re: Caesarean delivery in the second stage of labour (Spencer et al BMJ 2006; 333: 613-4)
- Joan Melendez, Valerie Forson, Sanhana Gupta, Nicola Milestone and Wai Yoong (25 October 2006)
|
|
|||
|
David JR Hutchon, Consultant Obstetrician and Gynaecologist Memorial Hospital, Darlington. DL3 8QZ
Send response to journal:
|
As an obstetrician who trained in the nineteen seventies I learnt and became comfortable with vaginal breech deliveries, kiellands rotational forceps as well as ventouse and lift-out forceps. So obstetricians of my generation might welcome the message of this editorial. However over the years we experienced increasing publications claiming evidence of the safety of Caesarean over vaginal delivery in many of these circumstances. Papers such as that on Kiellands forceps that I referred to in my letter in 1979 (1) through to recent the term breech trial.(2) Four years on, the researchers published their follow-up of children at age 2, and found that the between-group differences had disappeared, and that vaginal breech birth was no more risky for offspring in the longer-term. (3) The researchers concluded, in retrospect, that their trial was underpowered, and would have required follow-up of more than 4,000 children. The worldwide response to this update, and its impact on women carrying breech babies, has been negligible.(4) Although I have maintained my skills, my enthusiasm has been sapped by such reports together with fear of litigation or disciplinary action. I am grateful to have had the opportunity now to read this paper by Olah.(5) Readers will be forgiven if they assume from the title of the paper and this editorial that more than one consultant was involved. Although the editorial refers to “consultants” in the plural, the study clearly only involved one. Olah is to be congratulated on his skills but there is no mention of measuring neonatal morbidity or mortality, nor any mention of maternal morbidity in his paper. One has to assume that there was none. The favourable results were down to a single skilled individual and this is the only evidence provided by the authors in the editorial to support their main argument. Statistical analysis is used in one element of the analysis which showed a significant difference between assessment of station between registrars and consultant. Using the published figures, my analysis shows a very significant reduction in Caesarean Sections. OR = 0.0416 (from 0.0068 to 0.2529 ) However this very personal skill level may not be transferable. Further one highly publicised adverse outcome may make recourse to Caesarean Section an easier decision.(6) Also there were only twenty vaginal deliveries over a five year period. In some areas of practice it is argued that carrying out only four cases per annum is insufficient to maintain the skill. Further and unbiased evidence is required. While a worthwhile publication, it cannot be considered “good evidence” and it is questionable that the evidence from this single paper can be used to determine policy throughout the UK. I fully support any efforts to reduce the Caesarean Section rate and I agree that attention should be directed to Caesarean delivery in the first pregnancy which greatly influences the rates in any subsequent pregnancy. I have never considered that vaginal assessment of station is particularly accurate. Olah (5) refers to station of the head but does not give us an explanation of his definition. I also find there are considerable differences in understanding among my consultant colleagues. Some use the leading bony point, some the biparietal diameter (BPD) as the reference point on the head. Very often the relationship of one of these is made to the ischial spines in terms of centimeters above or below. My understanding of the traditional teaching is that station assessed on vaginal examination refers to the BPD relationship and to the midpelvic plane. A minimum of three points are required to define a plane. Indeed referring the BPD to the ischial spines or a line between the ischial spines is meaningless. The BPD may never pass exactly between the ischial spines. The assessment should therefore be to determine the shortest distance from any point on the BPD to any point on the midpelvic plane. To do this to an accuracy of at least one centimetre on vaginal examination is cloud cuckoo land although of course one can never be proved wrong. I have therefore always taught that abdominal assessment is preferable and logically gives what we really want to know – how much more of the head needs to pass through the midpelvis. Very rarely do we need to be concerned about the pelvic outlet. However assessment of the head abdominally can be difficult especially in the obese and without an epidural. I have found that combining an abdominal examination with the vaginal examination results in a much better assessment of station. The presence of caput and moulding adds further difficulty to these assessments. Even with optimal skills, at what station is it unsafe to attempt vaginal delivery? This needs to be rather more clearly defined. Lastly it is my experience that often there are a combination of problems, with malposition of the head leading to a long labour, an exhausted mother and a distressed baby. Maternal effort may be less than ideal to minimise instrumental traction and fetal acidosis may already put the baby at risk. Of course sometimes there may be no good solution, with both vaginal delivery and Caesarean Section presenting considerable risks. In retrospect it is easy in these cases to advocate an earlier Caesarean Section. There cannot be an obstetrician alive who does not wish they could carry around the retrospectocope. 1. Hutchon DJR and McFadyen I. Kielland’s Forceps British Medical Journal (Letter) 1979 1 408 2. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan A. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000;356: 1375-83. 3. Whyte H, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol 2004;191(3):864-71. 4. Buckley SJ Short-term outcomes, long-term questions Rapid response BMJ 9 September 2005 5. Olah KS. Reversal of the decision for caesarean section in the second stage of labour on the basis of consultant vaginal assessment. Journal of Obstetrics and Gynaecology 2005;25(2):115-116 6. Whitehouse v Jordan (1981) 1 AER 267 Competing interests: None declared |
|||
|
|
|||
|
Dermot Ryan, GP Principal Woodbrook Medical Centre, Loughborough, LE11 1NH
Send response to journal:
|
It is perhaps surprising that a GP responds to an editorial such as this, but the effects of poorly managed labour spill over into primary care with GP's having to pick up the pieces of an exhausted woman having endured a 48 hour labour, a failed forceps delivery and finally ended up having a caesarian section. The focus of the management of labour seems to have shifted from ensuring the outcome of a healthy mother and healthy baby to the more nebulous outcome of a positive or meaningful experience in keeping with the philosophy of patient choice. This seems to have been embodied in Changing Childbirth ( DoH: 1993) a report which put the management of labour in the hands of midwives and which has not been successful in reducing the number of caesarian sections performed. It is faulty logic to examine outcomes of the second stage of labour in isolation. Labour is a continuous dynamic process, the successful outcome of which depends on the successful management of each stage of labour. Each stage requires monitoring and its own set of decisions. In the national Maternity Hospital in Dublin active mangement of labour set out out to describe and manage what these should be (1). This led to very low caesarian section rates and low operative delivery. This was recently revisited in a prospective trial of primips resulting in a section rate of 4.2% and the operative vaginal delivery rate of 24% (2). From the outside it appears that sub optimal management of labour is now the norm in UK units, with junior doctors not having sufficient training in order to do the job properly with the process being overseen by midwives who do not adequately monitor or intervene leading to the less than perfect outcomes which we now witness. Perhaps political correctness and the innappropiate exclusion of the medical profession from the management of labour , and indeed the whole of maternity care, has led us to this point. There are lessons to be learnt here. The doctor is not always right. Patient choice does not exist unless the patient fully understands the implications of these choices. Nurse led services lead to a lower level of skills being employed. Dumbing down of medical interventions and the blame culture make specialties unnattractive which in turn means fewer recruits who are not adequately trained or supervised progressing the downward spiral of quality. The lessons to be learnt are not just applicable to obstetrics but apply throughout the whole of the medical profession. Leaders in all specialties please note. (1)O'Driscoll K, Jackson RJ, Gallagher JT. Prevention of prolonged labour. BMJ 1969;2 477-80 (2)Bohra U. Donnelly J. O'Connell MP. Geary MP. MacQuillan K. Keane DP. Active management of labour revisited: the first 1000 primiparous labours in 2000. Journal of Obstetrics & Gynaecology. 23(2):118-20, 2003 Mar. Competing interests: None declared |
|||
|
|
|||
|
Parivakkam S Arunakumari, Specialist Registrar Southmead Hospital, Bristol. BS10 5NB
Send response to journal:
|
Reducing second stage Caesarean Sections – need for a multi-pronged attack The call to reduce the rates of second stage caesarean section is well timed. In the current volatile malpractice environment, clinical behaviour alters because of the threat of liability. Procedures that are perceived to elevate the probability of litigation are avoided. Instrumental vaginal delivery is one such procedure. Caesarean Section(with all its attendant risks) is still perceived to be safer than assisted vaginal delivery by women and their partners. Towards this end, the midwives can play a powerful role by adequately counselling the women during pregnancy and in labour to dispel the myths surrounding the ‘horror of forceps delivery’. Patient safety agencies could form pressure groups to popularise the benefits of vaginal delivery and highlight the risks of caesarean sections. The power of the mass media could also be harnessed to the same effect. The editorial also suggests that input from the consultant obstetrician at delivery enhances the chances of vaginal delivery. Although this is broadly true, this cannot be universally applicable. Deeply held personal beliefs will undoubtedly impact on the intrapartum care of the patients. Where the consultant believes that Caesarean section is either less litigious or more safe than instrumental delivery, the above editorial suggestion is unlikely to hold good. There have been instances were the registrar was not supported by the consultant in the decision to proceed to a safely conducted vaginal delivery, in the absence of a sound medical reason. The obstetrician’s attitudes rather than the level of seniority are of greater relevance. To mitigate against this we need to ensure that a system is in place to harmonize injury compensation, provider accountability and patient safety. The society at large needs to take responsibility for creating environment in which enthusiasm for vaginal delivery will flourish and we as a fraternity should continue advocating for vaginal delivery and against needless Caesarean sections so that instrumental delivery stays in ‘fashion’. Dr P.S.Arunakumari
References “No-Fault Compensation in New Zealand: Harmonizing Injury Compensation, Provider Accountability, and Patient Safety” (Health Affairs, Jan./Feb. 2006), Competing interests: None declared |
|||
|
|
|||
|
Michelle J Thornton, consultant colorectal surgeon Wishaw General Hospital ML2 0DP
Send response to journal:
|
Editor – Spencer et al1 suggest that instrumental delivery may reduce the caesarian section rate in the second stage of labour. While this may be an important agenda for the 2006 NHS budget, saving anaesthetic, theatre and hospital costs in the short-term, the longer-term health outcomes and costs of a high forceps delivery are concerning and go unmentioned. Recognised third and fourth degree perineal tears occur in 0.5-6 percent of vaginal deliveries in the Western World.2,3 A further 30-44 percent are estimated to be unrecognised.1 One of the most significant factors, clinically and statistically, to be associated with perineal injury is an instrumental delivery.2,3 Up to 25 percent of women with a tear will experience faecal incontinence.3 Faecal continence is the result of several complex, inter-related factors. While perineal injury during childbirth may not be the sole factor for faecal incontinence, perineal damage does significantly increase the likelihood of incontinence.3 The economic costs of faecal incontinence are large, lifetime cost estimates range from £7,000 to 43,000, dependent on treatment.4 The social implications are unmeasurable. In a questionnaire of their personal birthing choices even female obstetricians chose caesarian section over an instrumentally assisted delivery.5 In the era of increasing the validity of informed consent, it is concerning that an obstetric management which has been declined by their educated colleagues is suggested as appropriate management for the potentially less informed masses, particularly when the social and economic costs are so great. Thornton MJ, consultant colorectal surgeon
Competing interests: None declared. 1. Spencer C, Murphy D, Bewley S. Caesarian section in the second stage of labour. BMJ 2006; 333:613-4. 2. Sultan A.H, Kamm M.A, Hudson N.H, Thomas J.M, Bartram C.I. Anal- Sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905- 1911. 3. Abramowitz L, Sobhani I, Ganasia R, Vuagnat A, Benifla J.L, Darai E, Madelenat P, Mignon M. Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Dis Colon Rectum 2000;43:590-6. 4. Adang EM, Engel GL, Rutten FF, Geerdes BP, Baeten CG. Cost- effectiveness of dynamic graciloplasty in patients with faecal incontinence. Dis Colon Rectum 1998;41:725-734. 5. Al-Mufti R, McCarthy A, Fisk N.M. Obstetrician's personal choice and mode of delivery. Lancet 1996;347:544. Competing interests: None declared |
|||
|
|
|||
|
Andrew D Weeks, Senior Lecturer in Obstetrics University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool L25 6HE
Send response to journal:
|
In their editorial on caesarean delivery, Spencer et al point out the problems that arise from the inaccuracy of vaginal examination in the second stage of labour(1). This subjectivity is well recognised, especially in the assessment of head descent (2,3). Using a system whereby the head descent is described in terms of ‘fifths of head palpable abdominally’ may improve the reproducibility, but it is difficult to do in those who are overweight or in pain. The University of Liverpool have developed a device called the ‘Station Master’ that is currently undergoing clinical trials. The device is essentially an extendable amniotomy hook with centimetre markings along the side. After initial calibration during an internal examination, the station of the leading part of the head can be read off from the device when the end is touched to the leading part of the head (see www.liv.ac.uk/stationmaster for details). The minimally invasive nature of the test means that accurate measurements can be repeated frequently without fear of infection or injury. If clinical studies confirm that the device is accurate, reproducible and acceptable, then it will provide the first truly objective measurement of labour progress. This will prove invaluable for clinical evaluation prior to operative delivery and for the early identification of failed head descent in the second stage. Given that the use of cervical dilation for assessing labour progress is subjective and is limited to use in the first stage, the ‘Station Master’ could also challenge the use of cervical dilation as primary mode of assessment in labour. 1. Spencer C, Murphy D, and Bewley S. Caesarean delivery in the second stage of labour. BMJ 2006; 333: 613-614 2. Olah KS. Reversal of the decision for Caesarean section in the second stage of labour on the basis of consultant vaginal assessment. J Obstet Gynecol 2005;25: 115-6. 3. Dupuis O, Silveira R, Zentner A, Dittmar A, Gaucherand P, Cucherat M, Redarce T, Rudigoz RC. Birth simulator: reliability of transvaginal assessment of fetal head station as defined by the American College of Obstetricians and Gynecologists classification. Am J Obstet Gynecol. 2005 Mar;192(3):868-74. Competing interests: Andrew Weeks invented the Stationmaster and is a director of the company that owns it. |
|||
|
|
|||
|
Nirmala Rai, Clinical Research Fellow Cardiff and Vale NHS Trust, University Hospital of Wales, Cardiff CF14 4XN, Prathima Reddy, Consultant Obstetrician&Gynaecologist, Mallya Hospital, Bangalore, India
Send response to journal:
|
The Caesarean Section (CS) rate in India varies from 6.4 – 39.6%1. The Public Sector hospitals (where services are provided free by the state) have lower rates, whereas the Private Sector hospitals (where services are provided on payment) have the highest rate2. Public sector hospitals receive fair numbers of women in obstructed labour3, often with dead babies, from the peripheral and rural areas. In such women caesarean section in the second stage would be life saving. A skilled obstetrician’s assessment would be invaluable in the judicious selection of patients for caesarean section as opposed to heroic vaginal procedures. On the other hand, the high rates of CS in the private sector (which accounts for 50% of inpatient care4) may mean that very few women reach the second stage of labour. Because of this, many consultant obstetricians are probably losing their skill to perform assisted vaginal deliveries in the second stage of labour. We agree with Spencer et al that it is imperative for obstetricians to maintain and develop their skills if women are to be offered safe alternatives to CS when complications arise in the second stage of labour5. This impacts not just the rising CS rates, but also the future of obstetric trainees, because in India training is still largely through apprenticeship. 1 US Mishra, Mala Ramanathan. Delivery-related complications and determinants of caesarean section rates in India. Health and Policy Planning; 17(1) 90-98 2 S Sreevidya, B.W.C.Sathiyasekaran. High caesarean rates in Madras (India): a population based cross sectional study. BJOG: an International Journal of Obstetrics and Gyanecology February 2003, Vol. 110, pp.106–111 3 Chhabra S, Gandhi D, Jaiswal M. Obstructed Labour – A Preventable Entity. J Obstet Gynaecol. 2000 Mar; 20(2) 4 Duggal R, Amin S. Cost of Health Care- ‘A Household Survey in an Indian District’. Mumbai: Foundation for Research in Community Health, 1989 5 Spencer C, Murphy D, Bewley S. Caesarean delivery in the second stage of labour. BMJ 2006; 333: 613-4. (23 September) Competing interests: None declared |
|||
|
|
|||
|
John Kelly, Fistula surgeon to many countries in the developing world c/o Department of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT, Heather Winter
Send response to journal:
|
Editor - Spencer et al rightly emphasise 'the need for obstetricians to maintain and develop their skills of vaginal delivery when complications arise in labour’(1). In developing countries the skills of important vaginal procedures (symphysiotomy, internal version breech extraction, even ventouse) are also declining. This is possibly the result of greater emphasis on caesarean section. While appropriate caesarean section will avoid some maternal mortality and morbidity, it may cause some of these if a subsequent delivery does not occur in a centre providing appropriate emergency obstetric care 24 hours per day, 7 days per week. An increase in uretero-vaginal fistula following caesarean section has been noted(2). We should avoid the impression that all current and future obstetric problems will be solved by having someone available, who is capable of doing a caesarean section alone. Full Emergency Obstetric Care (EOC) requires that the obstetrician or someone trained as such, should know how, when and when not to perform all vaginal operative procedures, as well as caesarean and how to deal with ruptured uterus. The correct anaesthesia for each procedure is also important. In most parts of the developing world having a doctor anaesthetist, although desirable, will not be achievable for many years. The input of such a specialist with experience of what anaesthesia and machine is appropriate and safe, in training of non-doctor anaesthetists and devising protocols for practice is essential. 1 Spencer C, Murphy D, Bewley S. Caesarean delivery in the second stage of labour: better training in instrumental delivery may reduce rates. BMJ 2006;333:613-4. 2 Kelly J. Outreach programmes for obstetric fistulae. J Obstet Gynaecol 2004;24:117-8. Competing interests: None declared |
|||
|
|
|||
|
Joan Melendez, Clinical attachment North Middlesex Hospital N18 1QX, Valerie Forson, Sanhana Gupta, Nicola Milestone and Wai Yoong
Send response to journal:
|
The Editor BMJ Dear Sir We read with considerable interest the editorial by Spencer and his colleagues1 expressing concerns about the current rise in caesarean section (CS) delivery in the second stage of labour. They cited that many obstetric trainees are not proficient in instrumental delivery due to the lack of experience and that consultant involvement may enable more instrumental deliveries to be performed, thus avoiding CS at full dilatation2. We would like to share the findings of an anonymous survey that we performed in 2004 which support Spencer’s opinion. Our department conducted a telephone survey of 102 registrar grade doctors (ranging from year 1 to 5) in the North Thames with regards to their views on training in instrumental vaginal deliveries. Of those questioned, 31/102 (30%) were senior trainees of Year 4 and above. 47.5% were UK graduates and 61% were post MRCOG. Most of the trainees (72.8% and 76.3% respectively) had done less than 20 directly supervised ventouse and forceps before being allowed to perform these procedures independently. There were more trainees who felt “not confident” doing forceps compared to ventouse deliveries (11.9% vs 0%). There was more direct supervision and teaching by consultants in forceps compared to ventouse (30% vs 12%) deliveries; in fact, 70% of current registrars had been taught ventouse by their registrars. Thus although the bulk of training in instrumental deliveries was conducted by registrars, there was more consultant input in forceps deliveries. Interestingly, registrars who had been taught by their consultants in either forceps or ventouse deliveries expressed that they feel better “trained”, compared to those who had been taught by their registrars. 89% of trainees thought themselves confident (Visual Analogue Score of more than 7/10) when doing ventouse but only 57.84% expressed confidence when performing forceps deliveries. Uncomplicated instrumental vaginal deliveries comprise up to 24% of all deliveries in the United Kingdom (Middle and McFarlane 1995) and it is worrying that 11% of obstetric registrars in the North Thames region feel that they are inadequately trained in ventouse deliveries and nearly half did not feel confident when doing forceps. Calmanisation of training and the implementation of the European Time Directive has resulted in less opportunities available to acquire skill on labour wards and many trainees express concern about performing uncomplicated instrumental delivery. This lack of confidence may be contributing to the higher rates of caesarean sections under difficult circumstances 2. If this is true then consultant led structured training with particular attention to vaginal assessment should increase confidence and experience in the use of instrumental procedures and thus limit the rise of caesarean sections and associated complications. References 1. Spencer C, Murphy D, Bewley S. Caesarian section in the second stage of labour. BMJ 2006; 333:613-4. 2. Olah KS. Reversal of the decision for caesarean section in the second stage of labour on the basis of consultant vaginal assessment. Journal of Obstetrics and Gynaecology 2005;25(2):115-116 3. Middle C and McFarlane A. Labour and delivery of normal primiparous women: Analysis of routinely collected data. Br J Obstet Gyanecol 1995; 102: 970-977. Authors:
J Melendez, V Forson, Gupta S, Milestone N and Yoong W.
Competing interests: None declared |
|||