- Email: [email protected]
Reply to Fougner and Wilson
CORRESPONDENCE
Routine cesarean section in twin gestation To the Editors: The article by Chervenak, Johnson, Berkowitz, Grannum, and Hobbins, entitled "Is routine cesarean section necessary for vertex-breech and vertex-transverse twin gestation?" (AM. j. 0BSTET. GYNECOL. 148: 1, 1984), raises several important issues. The first concerns the protocol the authors seem to be promulgating. There is no doubt that the use of high-resolution real-time ultrasound in the labor/ delivery room facilitates the intrapartum management of the twin gestation. Fetal weight may be estimated within an acceptable margin of error. 1 The exact lie of the second twin can be quickly determined, thus simplifying version procedures, whether external or internal. 2 Unfortunately, most labor suites still do not have ultrasound equipment available on site. 1t is unclear from the tone of the article whether the authors' conclusions would be the same concerning version procedures without such assistance. The second problem is more serious than the lack of equipment. We have witnessed a systematic abandonment of the more difficult methods of effecting vaginal delivery in favor of cesarean section. This has resulted in a group of obstetricians who have never witnessed a properly performed internal version and extraction, let alone performed one. The more experienced obstetricians, having been intimidated by the literature and their own past "horrendos," have similarly abandoned these procedures, thus allowing their skills to atrophy from disuse. In proposing a new swing of the pendulum of obstetric practice, the authors must face this dilemma. Finally, we must remind the authors that obstetricians practice in an extremely litigious society. A fractured clavicle and humerus may represent minor morbidity to them but would no doubt be construed differently by their parents as well as their friendly neighborhood lawyers. One case of birth trauma in 76 breech extractions could be interpreted as either evidence of obstetric skill or divine Providence. In either case, should the patient and the practicing obstetrician be willing to take the risk? Is what is good for the goose truly good for the gander? Arthur D. Fougner, M.D. Stephen]. Wilson, M.D. Department of Obstetrics and Gynecology Queens Hospital Center Affiliation of Long Island Jewish -Hillside Medical Center 82-68 164th Street Jamaica, New York 11432
REFERENCES
l. Shepard MJ, Richard VA, Berkowitz RL, et a!. An evaluation of two equations for predicting fetal weight by ultrasound. AM j 0BSTET GYNECOL 1982; 142:47. 2. Chervenak FA, Johnson RE, Berkowitz RL, et a!. Intrapartum external version of the second twin. Obstet Gynecoll983;62:168. Reply to Fougner and Wilson To the Editors: We would like to thank Drs. Fougner and Wilson for their thoughtful comments. We have found sonographic visualization to be of enormous value in the intrapartum management of the mal positioned second twin. Indeed, this is one of the reasons that we advocate that real-time ultrasound equipment be available for all labor and delivery suites. Songraphic visualization is valuable not only for the facilitation of the procedures of breech extraction 1 and external version 2 but also for fetal heart rate monitoring of the second twin following delivery of the first. While ultrasound as an aid to delivery is not essential, we feel that the latter function is an indispensable component of the modern management of twins in the delivery room. If sonographic visualization is not available for intrapartum fetal heart monitoring, then Doppler ultrasound should be used for this purpose. It is true that we are proposing "a new swing of the pendulum" for intrapartum management. In the recent past, there has been strict adherence to such obstetric dogmas as "Once a section, always a section" or "The sun should never set on an undelivered mother with premature rupture of membranes." We believe that the pendulum will swing for "All nonvertex second twins should be delivered by cesarean section," as it has for the two previously mentioned dicta. The mention of "horrendos" in association with vaginal delivery of the second twin in malpresentation has hindered the swing of the pendulum. In how many cases with poor outcome was the second twin not diagnosed before delivery? If there was no antepartum diagnosis of twins, then intrapartum fetal heart monitoring and recognition of fetal distress not due to vaginal delivery was not possible. In addition, in how many cases with poor outcomes were there violations of recognized prerequisites for vaginal delivery, for instance, adequate maternal pelvis, flexed fetal head, and estimated fetal weight >2000 gm but <3500 gm? The failure of both published studies and anecdotal reports to address these issues raises the question of their relevance to situations in which vaginal delivery of the
329
330 Correspondence
malpositioned second twin is practiced in a controlled setting. 1- 3 It is hoped that with increasing acceptance of vaginal delivery of the second twin, the growing clinical experience will allow us to teach resident physicians these important skills. Last, we respect the expressed concerns about litigation resulting from vaginal breech deliveries with bad outcomes. However, one should be cautioned that if a maternal complication were to result after cesarean section for a second twin in malpresentation, then there might be an attack by members of the legal profession for performing an unnecessary surgical intervention.1-8 It is clear that performance of an abdominal delivery does not confer immunity from prosecution. Rather, conscientious efforts to develop a meaningful physician-patient relationship and the execution of a management plan that best serves the interests of both mother and fetus are advocated as more appropriate prophylactic measures against legal assault. Frank A. Chervenak, M.D. Richard L. Berkowitz, M.D. Department of Obstetrics, Gynecology and Reproductive Science The Mount Sinai Medical Center One Gustave L. Levy Place New York, New York 10029 Robert E. Johnson, M.D. Peter Grannum, M.D. John C. Hobbins, M.D. Department of Obstetrics and Gynecology Yale-New Haven Medical Center 333 Cedar Street New Haven, Connecticut 06510 REFERENCES I. Chervenak FA, Johnson RE, Berkowitz RL, eta!. Is routine cesarean section necessary for vertex-breech and vertextransverse twin gestations? AM J OBSTET GYNECOL 1984; 148:1. 2. Chervenak FA, Johnson RE, Berkowitz RL, eta!. Intrapartum external version of the second twin, Obstet Gynecol 1983;62:160.
October I, 1984 Am J Obstet Gynecol
3. Acker D, Lieberman M, Holbrook M, eta!. Delivery of the second twin. Obstet Gynecol 1982;59:710.
Prehysterectomy curettage To the Editors: Lerner (AM. J. 0BSTET. GYNECOL. 148:1055, 1984) reports on the inadequacy of prehysterectomy curetrages for diagnostic purposes. I disagree with him, as I have been doing endometrial biopsies or diagnostic curettages on every nonemergency hysterectomy for years, approximately 2 to 8 weeks preceding the hysterectomy. My findings, with one exception, have always agreed with the final findings on the hysterectomy. This one miss was in a reported uterus didelphys in which I missed one side at curettage. Therefore I would have to infer that either Lerner's technique or the pathologic interpretation was faulty. King eta!. (AM. J. 0BSTET. GYNECOL. 149:10, 1984) apparently agree with me. Eduard Eichner, M.D. Severance Medical Arts Building 5 Severance Circle Cleveland Heights, Ohio 44118
Reply to Eichner To the Editors: Although I am happy that your endometrial biopsies and diagnostic curettages performed 2 to 8 weeks preceding your hysterectomies have yielded accurate diagnostic results, your letter missed the point of my report. I discussed curettages performed in the operating room immediately preceding a hysterectomy when judgments are made on gross observation of curetted tissue. The experience you described has nothing to do with this. In fact, in the last paragraph of the paper, my recommendation is to do precisely what you do: preoperative curettage or biopsies allowing time for microscopic pathology results to be returned. Henry M. Lerner, M.D. 2000 Washington Street Newton, Massachusetts 02162
Routine cesarean section in twin gestation To the Editors: The article by Chervenak, Johnson, Berkowitz, Grannum, and Hobbins, entitled "Is routine cesarean section necessary for vertex-breech and vertex-transverse twin gestation?" (AM. j. 0BSTET. GYNECOL. 148: 1, 1984), raises several important issues. The first concerns the protocol the authors seem to be promulgating. There is no doubt that the use of high-resolution real-time ultrasound in the labor/ delivery room facilitates the intrapartum management of the twin gestation. Fetal weight may be estimated within an acceptable margin of error. 1 The exact lie of the second twin can be quickly determined, thus simplifying version procedures, whether external or internal. 2 Unfortunately, most labor suites still do not have ultrasound equipment available on site. 1t is unclear from the tone of the article whether the authors' conclusions would be the same concerning version procedures without such assistance. The second problem is more serious than the lack of equipment. We have witnessed a systematic abandonment of the more difficult methods of effecting vaginal delivery in favor of cesarean section. This has resulted in a group of obstetricians who have never witnessed a properly performed internal version and extraction, let alone performed one. The more experienced obstetricians, having been intimidated by the literature and their own past "horrendos," have similarly abandoned these procedures, thus allowing their skills to atrophy from disuse. In proposing a new swing of the pendulum of obstetric practice, the authors must face this dilemma. Finally, we must remind the authors that obstetricians practice in an extremely litigious society. A fractured clavicle and humerus may represent minor morbidity to them but would no doubt be construed differently by their parents as well as their friendly neighborhood lawyers. One case of birth trauma in 76 breech extractions could be interpreted as either evidence of obstetric skill or divine Providence. In either case, should the patient and the practicing obstetrician be willing to take the risk? Is what is good for the goose truly good for the gander? Arthur D. Fougner, M.D. Stephen]. Wilson, M.D. Department of Obstetrics and Gynecology Queens Hospital Center Affiliation of Long Island Jewish -Hillside Medical Center 82-68 164th Street Jamaica, New York 11432
REFERENCES
l. Shepard MJ, Richard VA, Berkowitz RL, et a!. An evaluation of two equations for predicting fetal weight by ultrasound. AM j 0BSTET GYNECOL 1982; 142:47. 2. Chervenak FA, Johnson RE, Berkowitz RL, et a!. Intrapartum external version of the second twin. Obstet Gynecoll983;62:168. Reply to Fougner and Wilson To the Editors: We would like to thank Drs. Fougner and Wilson for their thoughtful comments. We have found sonographic visualization to be of enormous value in the intrapartum management of the mal positioned second twin. Indeed, this is one of the reasons that we advocate that real-time ultrasound equipment be available for all labor and delivery suites. Songraphic visualization is valuable not only for the facilitation of the procedures of breech extraction 1 and external version 2 but also for fetal heart rate monitoring of the second twin following delivery of the first. While ultrasound as an aid to delivery is not essential, we feel that the latter function is an indispensable component of the modern management of twins in the delivery room. If sonographic visualization is not available for intrapartum fetal heart monitoring, then Doppler ultrasound should be used for this purpose. It is true that we are proposing "a new swing of the pendulum" for intrapartum management. In the recent past, there has been strict adherence to such obstetric dogmas as "Once a section, always a section" or "The sun should never set on an undelivered mother with premature rupture of membranes." We believe that the pendulum will swing for "All nonvertex second twins should be delivered by cesarean section," as it has for the two previously mentioned dicta. The mention of "horrendos" in association with vaginal delivery of the second twin in malpresentation has hindered the swing of the pendulum. In how many cases with poor outcome was the second twin not diagnosed before delivery? If there was no antepartum diagnosis of twins, then intrapartum fetal heart monitoring and recognition of fetal distress not due to vaginal delivery was not possible. In addition, in how many cases with poor outcomes were there violations of recognized prerequisites for vaginal delivery, for instance, adequate maternal pelvis, flexed fetal head, and estimated fetal weight >2000 gm but <3500 gm? The failure of both published studies and anecdotal reports to address these issues raises the question of their relevance to situations in which vaginal delivery of the
329
330 Correspondence
malpositioned second twin is practiced in a controlled setting. 1- 3 It is hoped that with increasing acceptance of vaginal delivery of the second twin, the growing clinical experience will allow us to teach resident physicians these important skills. Last, we respect the expressed concerns about litigation resulting from vaginal breech deliveries with bad outcomes. However, one should be cautioned that if a maternal complication were to result after cesarean section for a second twin in malpresentation, then there might be an attack by members of the legal profession for performing an unnecessary surgical intervention.1-8 It is clear that performance of an abdominal delivery does not confer immunity from prosecution. Rather, conscientious efforts to develop a meaningful physician-patient relationship and the execution of a management plan that best serves the interests of both mother and fetus are advocated as more appropriate prophylactic measures against legal assault. Frank A. Chervenak, M.D. Richard L. Berkowitz, M.D. Department of Obstetrics, Gynecology and Reproductive Science The Mount Sinai Medical Center One Gustave L. Levy Place New York, New York 10029 Robert E. Johnson, M.D. Peter Grannum, M.D. John C. Hobbins, M.D. Department of Obstetrics and Gynecology Yale-New Haven Medical Center 333 Cedar Street New Haven, Connecticut 06510 REFERENCES I. Chervenak FA, Johnson RE, Berkowitz RL, eta!. Is routine cesarean section necessary for vertex-breech and vertextransverse twin gestations? AM J OBSTET GYNECOL 1984; 148:1. 2. Chervenak FA, Johnson RE, Berkowitz RL, eta!. Intrapartum external version of the second twin, Obstet Gynecol 1983;62:160.
October I, 1984 Am J Obstet Gynecol
3. Acker D, Lieberman M, Holbrook M, eta!. Delivery of the second twin. Obstet Gynecol 1982;59:710.
Prehysterectomy curettage To the Editors: Lerner (AM. J. 0BSTET. GYNECOL. 148:1055, 1984) reports on the inadequacy of prehysterectomy curetrages for diagnostic purposes. I disagree with him, as I have been doing endometrial biopsies or diagnostic curettages on every nonemergency hysterectomy for years, approximately 2 to 8 weeks preceding the hysterectomy. My findings, with one exception, have always agreed with the final findings on the hysterectomy. This one miss was in a reported uterus didelphys in which I missed one side at curettage. Therefore I would have to infer that either Lerner's technique or the pathologic interpretation was faulty. King eta!. (AM. J. 0BSTET. GYNECOL. 149:10, 1984) apparently agree with me. Eduard Eichner, M.D. Severance Medical Arts Building 5 Severance Circle Cleveland Heights, Ohio 44118
Reply to Eichner To the Editors: Although I am happy that your endometrial biopsies and diagnostic curettages performed 2 to 8 weeks preceding your hysterectomies have yielded accurate diagnostic results, your letter missed the point of my report. I discussed curettages performed in the operating room immediately preceding a hysterectomy when judgments are made on gross observation of curetted tissue. The experience you described has nothing to do with this. In fact, in the last paragraph of the paper, my recommendation is to do precisely what you do: preoperative curettage or biopsies allowing time for microscopic pathology results to be returned. Henry M. Lerner, M.D. 2000 Washington Street Newton, Massachusetts 02162