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Obstetrician vs CNM care
Observers J Obstet 83-6.
Ralph W. Hale, MD,
FACOG
Editor
Infant Mortality Rates Joseph KS, Kramer MS. Recent trends in Canadian infant mortality rates: Effect of changes in registration of live newborns weighing less than 500 g. Can Med Assoc J 1996;155:1047-52.
Synopsis: In 1993 the infant mortality rate in Canada increased. To determine the reason, the authors reviewed all live births between 1987 and 1993 with special consideration of infants <500 g at birth. Over the study period, the proportion of these infants registered as live births increased significantly. Their conclusion was that the increased rate for 1993 was due to increased registration of live born infants weighing <500 g. When these births were eliminated, the 1993 rate was lower than that of 1992.
. . . Commentary: Infant mortality rate often is used as an instrument to evaluate a country’s health care delivery system. We in the United States constantly are reminded of that fact because our rate is 8.4/1000 live births overall and 16.5/1000 for blacks. The Canadian rate of 6.1/1000 in 1992 was the lowest in the world. However, in 1993 it increased to 6.3. After careful review by the authors, this increase was determined to result from live born infants weighing ~500 g. Many countries exclude infants weighing 1500 g from their statistics. The World Health Organization recommends that international comparisons eliminate these births. In fact, countries with the lowest infant mortalities restrict live birth registration to infants weighing > 500 g.
Assessing Fetal Heart Rate Tracings Todros T, Preve CU, Plazzotta C, Biolcati M, Lombard0 I’. Fetal heart rate tracings:
versus computer
Gynecol Reprod
assessment. Eur Biol 1996;68:
Synopsis: This study assessed the reproducibility of fetal heart rate readings among observers and between observers and the computer. The observers consisted of two experienced and two inexperienced clinicians. Fetal heart rate tracings from 63 patients were used. The variables included baseline rate, long-term variability, accelerations, and decelerations. The agreement between observers was rated as fair to good but not excellent. The agreement between observer and computer was similarly fair to good. The authors concluded that there is an advantage to computer assessment, but how it will improve monitoring is unproven.
. . . Commentary: Interpretation of fetal heart rate tracings has long been subject to readers’ bias. Any physician who has suffered through a malpractice claim based on a tracing has seen two “experts” disagree as to what the tracing means. Unfortunately, this article adds little to this debate. It only confirms that observations by two or more observers can result in different conclusions. The computer’s assessment was in contradiction to those of the observers. This would be significant if the computer diagnosis consistently was deemed to be correct. However, this is yet to be proven. Unlike the electrocardiographic computer interpretation, the fetal heart tracing changes rapidly and is not a consistent finding. Thus, interpretation takes on a larger role.
VBAC in Twins Miller DA, Mullin I’, Hou D, Paul RH. Vaginal birth after cesarean section in twin gestation. Am J Obstet Gynecol 1996;175: 194-8.
Synopsis: This report is based on 10 years’ experience at Los Angeles County/University of Southern California Women’s Hospital. There were 210 women with a previous cesarean
birth who delivered twins during that time. Of these, 118 had a repeat procedure without a labor trial, and 92 had a trial of labor. This resulted in vaginal delivery of both twins in 64 (70%) women. After review of maternal and neonatal outcome, the authors concluded that a trial of labor after a previous cesarean section is a safe alternative to repeat cesarean delivery in a woman with twins.
. . . Commentary: The safety of a vaginal delivery following a cesarean delivery has been shown in numerous studies. Although this is a retrospective study and, thus, suffers from the inherent problems of such a review, its design should not detract from the authors’ conclusion. However, a prospective randomized trial in twins will be necessary to confirm or refute the conclusion. Until that time, the clinician should feel confident that without evidence of contraindications, a trial of labor in a patient with twins who has had a prior cesarean delivery is appropriate.
Obstetrician vs CNM Care Oakley D, Murray ME, Murtland T, Hayashi R, Andersen HF, Mayes F, et al. Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives. Obstet Gymcol 1996;88:823-9. Synopsis: This study conducted at the University of Michigan was undertaken to determine pregnancy outcomes by provider groups. The study group consisted of 710 women cared for by obstetricians and 471 women cared for by certified nurse-midwives. Perinatal mortality, satisfaction, cost, and 30 clinical factors were reviewed. Although consumer choice prevented randomized assignment, multivariate analysis was used to minimize confounding factors. No significant differences were reported for the important outcomes between the provider groups. In the physician group, 19% had a cesarean section delivery, whereas 13% in the
certified nurse-midwife group had a cesarean section. Vacuum or forceps delivery occurred in 16% of the physician group as compared with 7% in the midwife group. The authors recognized that selfselection may have contributed to these results.
Commentary: The findings in this study show some limited differences between the care of midwives and obstetricians. Unfortunately, the process of self-selection contributes to differences in cases and a randomized blinded study must be performed before the important question can be answered. Multivariate analysis of confounding factors is not a substitute. Women who are pregnant deserve the best care available. Who delivers that care depends on numerous factors, not the least of which is the knowledge and skill of the provider. In most instances, that is and should be the trained obstetrician. In situations in which less skill and knowledge are needed, a certified nurse-midwife with obstetrician backup and availability can be an alternative.
Tocolysis & Cephalic Version Chung T, Neale E, Lau TK, Rogers M. A randomized, double blind, controlled trial of tocolysis to assistexternal cephalic version in late pregnancy. Acta Obstet Gynecol Stand 1996;75:720-4. Synopsis: In this study, 51 patients with a singleton breech presenting fetus were identified between 36 and 38 weeks’ gestation and confirmed by ultrasound. Patients were then divided into two groups: parous and nulliparous. Each group was then divided randomly by computer into treatment with Ritodrine or treatment with placebo. External cephalic version was then attempted by two physicians in accordance with double-blind study requirements. Following the procedure, ultrasound was used to confirm presentation, and if all was well after 20 minutes of observation, the patient
was managed according to the physicians’ regular practice. Version was successful in 17 of the 25 patients who received the Ritodrine therapy and in eight of the 25 who received the placebo. Although the nulliparas demonstrated a statistically significant benefit from tocolysis, there were too few patients in the multiparous group to achieve statistical significance. In those who successfully converted, only one reverted to the breech presentation at delivery. . . .
Commentary: These authors have shown the value of external cephalic version in late pregnancy when a breech presentation is identified. The use of tocolytic therapy as an adjunct is also shown in this study. This is a small study with a limited number of patients and, thus, can be criticized as inadequate. However, the study confirms the work of others and adds to the ever-growing list of studies supporting this procedure. It is becoming evident that the diagnosis of breech presentation in late pregnancy may be an indication for an attempt at external cephalic version. It would appear from this study that this procedure should be performed in a controlled setting with the use of tocolysis. The ability to monitor the fetus and assess the successful conversion is required. Trauma to the mother, as well as injury to the fetus or placenta, is a possibility. However, the increased incidence of cesarean section in persistent breech presentation and the increasing lack of physicians experienced in breech delivery encourages us to explore and use external cephalic version.
Ma nesium Sulpi ate & Eclampsia Chien PFW, Khan KS, Amott N. Magnesium sulfate in the treatment of eclampsia and pre-eclampsia: An overview of the evidence from randomised trials. Br J Obstet Gynaecol 1996;103:1085-91. Synopsis: The authors reviewed MEDLINE and bibliographies of primary studies and review articles for research on the use of magnesium sul-
phate in eclampsia and preeclampsia. From the 395 citations found, they selected nine randomized trials enrolling a combined total of 1743 women with eclampsia and 2390 with preeclampsia for their study. The authors reviewed the study design, outcome measures as based on seizure activity, and therapeutic intervention along with methodologic quality in selecting the nine trials for review. The results of their careful review concluded that recurrence of seizures was less common with magnesium sulphate therapy when compared with phenytoin and diazepam. The authors also noted a trend toward reduction in maternal mortality. The effect of cesarean section as a secondary outcome measure was not statistically significant. In the treatment of preeclampsia, magnesium sulphate was found to be more effective than phenytoin in preventing seizure activity.
. . .
Commentary: Until the etiology of this condition is identified, there will continue to be confusion as to the appropriate therapeutic regimen. This article is an attempt to evaluate the existing literature and ascertain an appropriate intervention for the most apparent event, seizure activity. There is no question that a seizure in a woman with preeclampsia is an undesired complication. Fetal and maternal morbidity and mortality rates greatly increase when a seizure occurs. To prevent seizures many therapeutic interventions have been recommended. One of the oldest and, based on this review, best is the use of magnesium sulphate. Unfortunately, this treatment does not address the cause, only the major effect of the disease by blocking the myoneural junction.
Early Amniocentesis Wilson RD. An evaluation of early amniocentesis.J Sot Obstet Gyoaecol Cao 1996; 18:773-85. Synopsis: Early amniocentesis has become common in obstetric practice
Ralph W. Hale, MD,
FACOG
Editor
Infant Mortality Rates Joseph KS, Kramer MS. Recent trends in Canadian infant mortality rates: Effect of changes in registration of live newborns weighing less than 500 g. Can Med Assoc J 1996;155:1047-52.
Synopsis: In 1993 the infant mortality rate in Canada increased. To determine the reason, the authors reviewed all live births between 1987 and 1993 with special consideration of infants <500 g at birth. Over the study period, the proportion of these infants registered as live births increased significantly. Their conclusion was that the increased rate for 1993 was due to increased registration of live born infants weighing <500 g. When these births were eliminated, the 1993 rate was lower than that of 1992.
. . . Commentary: Infant mortality rate often is used as an instrument to evaluate a country’s health care delivery system. We in the United States constantly are reminded of that fact because our rate is 8.4/1000 live births overall and 16.5/1000 for blacks. The Canadian rate of 6.1/1000 in 1992 was the lowest in the world. However, in 1993 it increased to 6.3. After careful review by the authors, this increase was determined to result from live born infants weighing ~500 g. Many countries exclude infants weighing 1500 g from their statistics. The World Health Organization recommends that international comparisons eliminate these births. In fact, countries with the lowest infant mortalities restrict live birth registration to infants weighing > 500 g.
Assessing Fetal Heart Rate Tracings Todros T, Preve CU, Plazzotta C, Biolcati M, Lombard0 I’. Fetal heart rate tracings:
versus computer
Gynecol Reprod
assessment. Eur Biol 1996;68:
Synopsis: This study assessed the reproducibility of fetal heart rate readings among observers and between observers and the computer. The observers consisted of two experienced and two inexperienced clinicians. Fetal heart rate tracings from 63 patients were used. The variables included baseline rate, long-term variability, accelerations, and decelerations. The agreement between observers was rated as fair to good but not excellent. The agreement between observer and computer was similarly fair to good. The authors concluded that there is an advantage to computer assessment, but how it will improve monitoring is unproven.
. . . Commentary: Interpretation of fetal heart rate tracings has long been subject to readers’ bias. Any physician who has suffered through a malpractice claim based on a tracing has seen two “experts” disagree as to what the tracing means. Unfortunately, this article adds little to this debate. It only confirms that observations by two or more observers can result in different conclusions. The computer’s assessment was in contradiction to those of the observers. This would be significant if the computer diagnosis consistently was deemed to be correct. However, this is yet to be proven. Unlike the electrocardiographic computer interpretation, the fetal heart tracing changes rapidly and is not a consistent finding. Thus, interpretation takes on a larger role.
VBAC in Twins Miller DA, Mullin I’, Hou D, Paul RH. Vaginal birth after cesarean section in twin gestation. Am J Obstet Gynecol 1996;175: 194-8.
Synopsis: This report is based on 10 years’ experience at Los Angeles County/University of Southern California Women’s Hospital. There were 210 women with a previous cesarean
birth who delivered twins during that time. Of these, 118 had a repeat procedure without a labor trial, and 92 had a trial of labor. This resulted in vaginal delivery of both twins in 64 (70%) women. After review of maternal and neonatal outcome, the authors concluded that a trial of labor after a previous cesarean section is a safe alternative to repeat cesarean delivery in a woman with twins.
. . . Commentary: The safety of a vaginal delivery following a cesarean delivery has been shown in numerous studies. Although this is a retrospective study and, thus, suffers from the inherent problems of such a review, its design should not detract from the authors’ conclusion. However, a prospective randomized trial in twins will be necessary to confirm or refute the conclusion. Until that time, the clinician should feel confident that without evidence of contraindications, a trial of labor in a patient with twins who has had a prior cesarean delivery is appropriate.
Obstetrician vs CNM Care Oakley D, Murray ME, Murtland T, Hayashi R, Andersen HF, Mayes F, et al. Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives. Obstet Gymcol 1996;88:823-9. Synopsis: This study conducted at the University of Michigan was undertaken to determine pregnancy outcomes by provider groups. The study group consisted of 710 women cared for by obstetricians and 471 women cared for by certified nurse-midwives. Perinatal mortality, satisfaction, cost, and 30 clinical factors were reviewed. Although consumer choice prevented randomized assignment, multivariate analysis was used to minimize confounding factors. No significant differences were reported for the important outcomes between the provider groups. In the physician group, 19% had a cesarean section delivery, whereas 13% in the
certified nurse-midwife group had a cesarean section. Vacuum or forceps delivery occurred in 16% of the physician group as compared with 7% in the midwife group. The authors recognized that selfselection may have contributed to these results.
Commentary: The findings in this study show some limited differences between the care of midwives and obstetricians. Unfortunately, the process of self-selection contributes to differences in cases and a randomized blinded study must be performed before the important question can be answered. Multivariate analysis of confounding factors is not a substitute. Women who are pregnant deserve the best care available. Who delivers that care depends on numerous factors, not the least of which is the knowledge and skill of the provider. In most instances, that is and should be the trained obstetrician. In situations in which less skill and knowledge are needed, a certified nurse-midwife with obstetrician backup and availability can be an alternative.
Tocolysis & Cephalic Version Chung T, Neale E, Lau TK, Rogers M. A randomized, double blind, controlled trial of tocolysis to assistexternal cephalic version in late pregnancy. Acta Obstet Gynecol Stand 1996;75:720-4. Synopsis: In this study, 51 patients with a singleton breech presenting fetus were identified between 36 and 38 weeks’ gestation and confirmed by ultrasound. Patients were then divided into two groups: parous and nulliparous. Each group was then divided randomly by computer into treatment with Ritodrine or treatment with placebo. External cephalic version was then attempted by two physicians in accordance with double-blind study requirements. Following the procedure, ultrasound was used to confirm presentation, and if all was well after 20 minutes of observation, the patient
was managed according to the physicians’ regular practice. Version was successful in 17 of the 25 patients who received the Ritodrine therapy and in eight of the 25 who received the placebo. Although the nulliparas demonstrated a statistically significant benefit from tocolysis, there were too few patients in the multiparous group to achieve statistical significance. In those who successfully converted, only one reverted to the breech presentation at delivery. . . .
Commentary: These authors have shown the value of external cephalic version in late pregnancy when a breech presentation is identified. The use of tocolytic therapy as an adjunct is also shown in this study. This is a small study with a limited number of patients and, thus, can be criticized as inadequate. However, the study confirms the work of others and adds to the ever-growing list of studies supporting this procedure. It is becoming evident that the diagnosis of breech presentation in late pregnancy may be an indication for an attempt at external cephalic version. It would appear from this study that this procedure should be performed in a controlled setting with the use of tocolysis. The ability to monitor the fetus and assess the successful conversion is required. Trauma to the mother, as well as injury to the fetus or placenta, is a possibility. However, the increased incidence of cesarean section in persistent breech presentation and the increasing lack of physicians experienced in breech delivery encourages us to explore and use external cephalic version.
Ma nesium Sulpi ate & Eclampsia Chien PFW, Khan KS, Amott N. Magnesium sulfate in the treatment of eclampsia and pre-eclampsia: An overview of the evidence from randomised trials. Br J Obstet Gynaecol 1996;103:1085-91. Synopsis: The authors reviewed MEDLINE and bibliographies of primary studies and review articles for research on the use of magnesium sul-
phate in eclampsia and preeclampsia. From the 395 citations found, they selected nine randomized trials enrolling a combined total of 1743 women with eclampsia and 2390 with preeclampsia for their study. The authors reviewed the study design, outcome measures as based on seizure activity, and therapeutic intervention along with methodologic quality in selecting the nine trials for review. The results of their careful review concluded that recurrence of seizures was less common with magnesium sulphate therapy when compared with phenytoin and diazepam. The authors also noted a trend toward reduction in maternal mortality. The effect of cesarean section as a secondary outcome measure was not statistically significant. In the treatment of preeclampsia, magnesium sulphate was found to be more effective than phenytoin in preventing seizure activity.
. . .
Commentary: Until the etiology of this condition is identified, there will continue to be confusion as to the appropriate therapeutic regimen. This article is an attempt to evaluate the existing literature and ascertain an appropriate intervention for the most apparent event, seizure activity. There is no question that a seizure in a woman with preeclampsia is an undesired complication. Fetal and maternal morbidity and mortality rates greatly increase when a seizure occurs. To prevent seizures many therapeutic interventions have been recommended. One of the oldest and, based on this review, best is the use of magnesium sulphate. Unfortunately, this treatment does not address the cause, only the major effect of the disease by blocking the myoneural junction.
Early Amniocentesis Wilson RD. An evaluation of early amniocentesis.J Sot Obstet Gyoaecol Cao 1996; 18:773-85. Synopsis: Early amniocentesis has become common in obstetric practice