- Email: [email protected]
Dr Gluck and Bell Reply
, , , caused to anyone or anything, if the driver is caught. In the law under which our work is scrutinized, damage must be demonstrated in the first place and "safe driving" (the standard of care) must clearly emerge from the documentation so as to satisfy reviewers that all due care and precaution were taken. In that circumstance, damage - no matter what its ex te nt - can be successfully defended. At the risk of overemphasis, we affirm that good clinical judgement should always prevail over any medicolegal considerations and, when an obstetrician can confidently predict good outcome for the baby with the interference contemplated, there is no need, nor should there be any need, to involve oneself in the logistical difficulties mentioned by Doctor Carson. Yours sincerely, Manuel Gluck, MD, FRCSC, E. Douglas Bell, MD, FRCSC
force ps delivery, bearing in mind the numbers that are performed. Are we talking about major suits and babies with central nervous system damage or minor, superficial trauma? Yours sincerely, J.J. Boyd, MB, FRCSC, Edmonton, Alberta
RE: FORCEPS: MEDICO-LEGAL ASPECTS.
DR GLUCK AND BELL REPLY.
To THE EDITOR:
To THE EDITOR:
I write in regard to the article in Volume 16, No. 12, Page 2455, of the Journal SOCG, entitled Medical Legal Implications in the Use of Obstetric Forceps, by Gluck and Bell. I promptly turned to this hoping to see the number of lawsuits pertinent to forceps delivery. Were these in large or small hospitals? Were they to do with trauma or asphyxia or both? I also wondered if there had been any successful cases where babies had had minor bruising or faciallacerations. I was disappointed. There only seemed to be reasonable fatherly advice on how to perform and document forceps deliveries properly, which is the same as most of us try and pass on to our residents and medical students; advice stemming back to the 1700s when the first textbooks appeared. T 0 get a perspective, I enquired in Alberta, and you will see the percentage of forceps deliveries (see Table). I have extrapolated this to Canada, which in the same period had 398,64 2 deliveries. Without going into detail, most of us who remember obstetrics in the 1960s, will remember forceps rates varied between 17 and 24 percent with of course, a very very much lower Caesarean section rate. I would very much like to hear the Canadian Medical Protective Association give us some sort of perspective on the legal problems which have arisen with
Doctor Boyd's disappointment with our article is understandable. The overriding consideration for any physician obstetrician or other - is to see to it that, whenever there is interference, the clinical outcome is optimized. This is common sense. The numbers cited for deliveries in Alberta far 1992, extrapolated to the whole of Canada, indicate that roughly 12 percent of vaginal deliveries were performed with forceps or vacuum. The problem is not the numbers of such procedures that are performed but the outcome clinically, in particular with respect to the baby. Looking at Doctor Boyd's numbers for Canada and accepting that the epidemiologic estimate of cerebral palsy in the general population is two per thousand, there would have been some 797 cases of cerebral palsy arising from the numbers ofbirths cited by Doctor Boyd. Assuming there are that many, we see only a small fraction of them. We can confirm that, in our highly-selected cases wh ich are only those with bad outcomes, it matters not whether the delivery was by Caesarean section or by forceps. Ir is not the procedure that is used but how that procedure is used that matters. Delays in diagnosis and delays in treatment vastly outweigh any consideration of mode of delivery.
JOURNAL SOGC
TABLE 1 FORCEPS DELIVERY N . ALBERTA-EXTRAPOLATION TO CANADA-1992 N . Alberta Total Deliveries
17,803
Canada 398,642
Low Forceps
723 (4.1%)
16,344
Mid Forceps
428 (2.4%)
9,567
Rot. M/F*
130 (0.7%)
2,790
Vacuum
933 (5.2%)
20,729
+Mid Forceps Rotation
834
SEPTEMBER 1995
, , , The Association has reviewed its recent experience in defending cases involving long-term neurologically compromised babies. Obstetrical forceps operations were involved in 30 percent of the cases in which we were unable to mount a successful defence. Ten percent of all indefensible cases involved a failed attempt at mid-forceps delivery. We would be less than complete if we were not to address Doctor Boyd's specific quest ions. Forceps cases occurred in both large and small hospitals. These cases had to do with trauma and with asphyxia, and sometimes both. Indeed, the Association has been involved in the unsuccessful defence of legal actions involving forceps and babies whose only discernible injuries were minor bruising or faciallacerations. There is not the expectation legally that outcomes will be uniformly perfect. Rather, there is the expectation that the standard of care will be respected and, when it does happen, we are successful in defence. Yours sincerely, Manuel Gluck, MD, FRCSC, E. Douglas Bell, MD, FRCSC
An uncommon solution (or an all-too-common condition. ~ Menopause. Medication. BreastFeeding. Oral contraceptives. Exercise. Stress. These are just some of the most common causes of vaginal dryness, a medical condition that occurs when a woman~ estrogen le'tls deeline. It affeets some 60 million orth American women at any one time. And most women sometime in their lil .
W4:r·j. Among the many moisturizers on the market, AstroGlide tands alone. It doesn' look, feel or act like any other personallubricant, and for several good reason . Developed by an aerospace chemist - hence the name AstroGlide is a clear, water-soluble, non-staining liquid that mimics a woman~own lubricatingfluids.1t i n't sticky or greasy and, in contact with the air, it doesn't dry out. And on the praetieal ide, AstroG lide is surpri ingly economieal to use: Alittle goes a longway.
that the lubrieant i as efTectil'C and pleasurable to use as it i nonirritating and nontoxic. And since BioFilm, Ine., the company that produces AstroG lide own the world' upply of the polymer, it' safe to say there's no other product quite like it in the "orld. In it's unrivalled ability to reliel'C vaginal dryness and enhance intimate aetivity troG lide truly is .. trolld olll} 10 110111"".
M:[.]:_
(Admtorial)
pfoplr .lw Ilril/~ Ilral colldolllS dOll i Juil/olllral. /I)' addillg a Je.' drops oJ ASlroGlidr il/sidr - ol/d olllside - Ilrf colldolll. 1I "ill Julwolldfrjlll." Which ans\\ers one other oblious qu tion: Whocan useA troGlide? In short, an)one. _~~~
WU I#;1. AstroG lide is available from PharmaSales. For physician sampies. eall: 1-800-668-341J
From a long list of medical profesionals and public health departments to nationally syndicatedsex counsellor, ue Johanson, 10 a number of Canadian hospital (Toronto' Princess Margaret, Bayview- unnybrook, Women' College, Toronto General , t. Michael' , Henderson Cancer Centre and Chedoke-McMaster hospitals among them), AstroGlide has no hortage of profi ional endorsements. In particular, Johanson has gone on record as saying, "111 111)' opilliOll, A IroGlidt is Ilrr ..er)' besl prrsollal IlIbricolII )'011 rall bll)'''. Furthermore, rml'ZII she advises her lisAt the heart of AstroGlide's unique tenm that Astrosolution lies a polymerie material that boasts remarkable lubricating quali- Glide is ideally AST:'DIOGUDf~ ft ~ ties. In addition to various humec- uited to use with a eondom. Says tants, emollients and a compatible pH Johanson, "IJ of 5.0, this special eompound ensures )'011 're Ollt oJ Ilr0st
JOURNAL SOGC
835
SEPTEMBER 1995
force ps delivery, bearing in mind the numbers that are performed. Are we talking about major suits and babies with central nervous system damage or minor, superficial trauma? Yours sincerely, J.J. Boyd, MB, FRCSC, Edmonton, Alberta
RE: FORCEPS: MEDICO-LEGAL ASPECTS.
DR GLUCK AND BELL REPLY.
To THE EDITOR:
To THE EDITOR:
I write in regard to the article in Volume 16, No. 12, Page 2455, of the Journal SOCG, entitled Medical Legal Implications in the Use of Obstetric Forceps, by Gluck and Bell. I promptly turned to this hoping to see the number of lawsuits pertinent to forceps delivery. Were these in large or small hospitals? Were they to do with trauma or asphyxia or both? I also wondered if there had been any successful cases where babies had had minor bruising or faciallacerations. I was disappointed. There only seemed to be reasonable fatherly advice on how to perform and document forceps deliveries properly, which is the same as most of us try and pass on to our residents and medical students; advice stemming back to the 1700s when the first textbooks appeared. T 0 get a perspective, I enquired in Alberta, and you will see the percentage of forceps deliveries (see Table). I have extrapolated this to Canada, which in the same period had 398,64 2 deliveries. Without going into detail, most of us who remember obstetrics in the 1960s, will remember forceps rates varied between 17 and 24 percent with of course, a very very much lower Caesarean section rate. I would very much like to hear the Canadian Medical Protective Association give us some sort of perspective on the legal problems which have arisen with
Doctor Boyd's disappointment with our article is understandable. The overriding consideration for any physician obstetrician or other - is to see to it that, whenever there is interference, the clinical outcome is optimized. This is common sense. The numbers cited for deliveries in Alberta far 1992, extrapolated to the whole of Canada, indicate that roughly 12 percent of vaginal deliveries were performed with forceps or vacuum. The problem is not the numbers of such procedures that are performed but the outcome clinically, in particular with respect to the baby. Looking at Doctor Boyd's numbers for Canada and accepting that the epidemiologic estimate of cerebral palsy in the general population is two per thousand, there would have been some 797 cases of cerebral palsy arising from the numbers ofbirths cited by Doctor Boyd. Assuming there are that many, we see only a small fraction of them. We can confirm that, in our highly-selected cases wh ich are only those with bad outcomes, it matters not whether the delivery was by Caesarean section or by forceps. Ir is not the procedure that is used but how that procedure is used that matters. Delays in diagnosis and delays in treatment vastly outweigh any consideration of mode of delivery.
JOURNAL SOGC
TABLE 1 FORCEPS DELIVERY N . ALBERTA-EXTRAPOLATION TO CANADA-1992 N . Alberta Total Deliveries
17,803
Canada 398,642
Low Forceps
723 (4.1%)
16,344
Mid Forceps
428 (2.4%)
9,567
Rot. M/F*
130 (0.7%)
2,790
Vacuum
933 (5.2%)
20,729
+Mid Forceps Rotation
834
SEPTEMBER 1995
, , , The Association has reviewed its recent experience in defending cases involving long-term neurologically compromised babies. Obstetrical forceps operations were involved in 30 percent of the cases in which we were unable to mount a successful defence. Ten percent of all indefensible cases involved a failed attempt at mid-forceps delivery. We would be less than complete if we were not to address Doctor Boyd's specific quest ions. Forceps cases occurred in both large and small hospitals. These cases had to do with trauma and with asphyxia, and sometimes both. Indeed, the Association has been involved in the unsuccessful defence of legal actions involving forceps and babies whose only discernible injuries were minor bruising or faciallacerations. There is not the expectation legally that outcomes will be uniformly perfect. Rather, there is the expectation that the standard of care will be respected and, when it does happen, we are successful in defence. Yours sincerely, Manuel Gluck, MD, FRCSC, E. Douglas Bell, MD, FRCSC
An uncommon solution (or an all-too-common condition. ~ Menopause. Medication. BreastFeeding. Oral contraceptives. Exercise. Stress. These are just some of the most common causes of vaginal dryness, a medical condition that occurs when a woman~ estrogen le'tls deeline. It affeets some 60 million orth American women at any one time. And most women sometime in their lil .
W4:r·j. Among the many moisturizers on the market, AstroGlide tands alone. It doesn' look, feel or act like any other personallubricant, and for several good reason . Developed by an aerospace chemist - hence the name AstroGlide is a clear, water-soluble, non-staining liquid that mimics a woman~own lubricatingfluids.1t i n't sticky or greasy and, in contact with the air, it doesn't dry out. And on the praetieal ide, AstroG lide is surpri ingly economieal to use: Alittle goes a longway.
that the lubrieant i as efTectil'C and pleasurable to use as it i nonirritating and nontoxic. And since BioFilm, Ine., the company that produces AstroG lide own the world' upply of the polymer, it' safe to say there's no other product quite like it in the "orld. In it's unrivalled ability to reliel'C vaginal dryness and enhance intimate aetivity troG lide truly is .. trolld olll} 10 110111"".
M:[.]:_
(Admtorial)
pfoplr .lw Ilril/~ Ilral colldolllS dOll i Juil/olllral. /I)' addillg a Je.' drops oJ ASlroGlidr il/sidr - ol/d olllside - Ilrf colldolll. 1I "ill Julwolldfrjlll." Which ans\\ers one other oblious qu tion: Whocan useA troGlide? In short, an)one. _~~~
WU I#;1. AstroG lide is available from PharmaSales. For physician sampies. eall: 1-800-668-341J
From a long list of medical profesionals and public health departments to nationally syndicatedsex counsellor, ue Johanson, 10 a number of Canadian hospital (Toronto' Princess Margaret, Bayview- unnybrook, Women' College, Toronto General , t. Michael' , Henderson Cancer Centre and Chedoke-McMaster hospitals among them), AstroGlide has no hortage of profi ional endorsements. In particular, Johanson has gone on record as saying, "111 111)' opilliOll, A IroGlidt is Ilrr ..er)' besl prrsollal IlIbricolII )'011 rall bll)'''. Furthermore, rml'ZII she advises her lisAt the heart of AstroGlide's unique tenm that Astrosolution lies a polymerie material that boasts remarkable lubricating quali- Glide is ideally AST:'DIOGUDf~ ft ~ ties. In addition to various humec- uited to use with a eondom. Says tants, emollients and a compatible pH Johanson, "IJ of 5.0, this special eompound ensures )'011 're Ollt oJ Ilr0st
JOURNAL SOGC
835
SEPTEMBER 1995