Treating prolonged or repeated seizures and reating prolonged or ...
Induction of labour confers benefit in prolonged pregnancy
1
1102 CORRESPONDENCE Ann Harper & Harith La& The Royal Maternity Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BB Author’s reply Sir, I thank Drs Harper and Lamki for their up-to-date information about part-time training posts in Northern Ireland. It is heartening to see the numbers of part-time trainees increasing in this part of the country, and this is in no small measure due to the efforts of the Northern Ireland Regional Adviser of the Royal College of Obstetrics and Gynaecology, Dr Harith Lamki. To date there is no formal system of applying for part-time training in Northern Ireland. There is no doubt that such a formal system of application has led to a dramatic increase in the number of trainees working part-time throughout the United Kingdom. Currently, 33 % of senior registrars training in England and Wales are female and of these, 31 % are training part-time. Although the Scots were committed to having 3 % of trainees at senior registrar level training part-time, it was only when a formal system of application for posts with guaranteed funding was introduced in 1993 that four separate part-time senior registrar posts in obstetrics and gynaecology were filled. Aspiring part-time trainees in Northern Ireland should currently contact the Royal College of Obstetricians Regional Adviser or the Northern Ireland Council for Postgraduate Medical Education to register an interest in part-time training. The Management Executive in England and Wales in 1993 made available funding for 20 part-time consultant posts. With the general acceptance of part-time trainees, it is to be hoped that there will be more part-time consultant posts. Laura J. Cassidy Department of Obstetrics and Gynaecology, Inverclyde Royal Hospital, Lurkfield Road, Greenock PA16 OXN Induction of labour confers benefit in prolonged pregnancy Sir, Thank you for the excellent review by John Grant (February 101, 1994) on induction of labour in prolonged pregnancy (Grant 1994). One comment, however, must not go unchallenged; “...there is little eviden ce... to support the practice of fetal surveillance after 41 weeks gestation.. .”. Clearly, from available evidence, induction at this gestation will prevent up to three perinatal deaths per thousand births, and perhaps a slightly larger number of hypoxic seizures (Grant 1994). This is a total benefit of perhaps 1 YO. Given that there are other causes of death (0.3 per 1000) and seizure, it would take a truly gargantuan trial to prove any benefit of fetal surveillance. Meanwhile, for those women who prefer to take the risk of prolonged pregnancy, common sense dictates heavy emphasis on observation of fetal movement, backed up by at least cardiotocographic monitoring perhaps every couple of days. Such monitoring would also provide an antenatal tracing with which to compare an intrapartum monitoring. Laurence Wood Walsgrave Hospital NHS Trust, Clrfford Bridge Road, Walsgrave. Coventry CV2 2DX Reference Grant J. M. (1994) Induction of labour confers benefit in prolonged pregnancy. Br J Ohstet Gynaecol 101, 99- 102. Author’s reply Sir, Laurence Wood is right when he implies that the effectiveness of fetal surveillance in the prevention of perinatal mortality “in prolonged pregnancy” has been little researched. In the 11 randomised trials induction of labour was the experimental treatment with fetal surveillance the control. In each trial this method of induction of labour was clearly defined, while the method of fetal surveillance was not, being fetal movement counts, nonstressed cardiotocography, ultrasonic estimation of amniotic fluid volume, fetal biophysical profile, or a mixture of these. In my review I stated that obstetricians should recommend induction of labour in prolonged pregnancy as opposed to the present haphazard methods of fetal surveillance, and this statement is justified in the light of current evidence. The focus of future research should be the effectiveness of specific forms of fetal surveillance compared with induction of labour. The emphasis of the comparison has shifted, for now the method of fetal surveillance, clearly defined, is the experimental group with induction of labour the control. Laurence Wood is also right when he says that such a trial will be large. If a particular method of fetal surveillance is to be successful one would expect it to prevent just as many perinatal deaths as induction of labour. The 11 randomised trials of induction of labour resulted in a perinatal mortality rate of 0.3 per 1000; a doubling of this perinatal mortality rate with a specific method of fetal surveillance may be considered un- acceptable. Such a trial would require at least 150000 women with prolonged pregnancy to be randomised-clearly an im- possible task. Other indicators of perinatal fetal hypoxia should be chosen as outcome measures, such as fetal heart rate abnormalities, caesarean section for fetal distress, time to establish first respiration, and hypoxic ischaemic encephalopathy. John M. Grant Bellshill Hospital, North Road, Bellshill, Lanarkshire ML4 3JN Labour following caesarean section Sir, In the short communication by Roberts (February 101, 1994) on labour following caesarean section, I find it unfortunate that the phrase trial of scar appears on a recurrent basis. I feel very strongly that the correct phrase should be trial of labour after a previous caesarean section, as stated by the Canadian panel in 1986. The term trial of scar would indicate that there was doubt about the mechanical soundness of the scar and, of course, if there was any doubt about this, then labour should not be allowed. D. H. Gudgeon Torbay Hospital, Lawes Bridge, Torquay TQ2 7AA Author’s reply Sir, There are a variety of descriptive terms for the labour of a woman previously delivered abdominally. When compiling our ques- tionnaire we selected the term which, in our experience, is used most frequently (or recognised most easily) by consultants in obstetrics. Having phrased our questions in this manner, we felt it only correct to report the replies using the same term. Personally, I prefer the term vaginal birth after caesarean (VBAC), particularly when discussing the issue with patients, who may find the prospect of a trial of scar a daunting one. Whichever expression is used, I would say that the mechanical soundness of a scarred uterus is always in doubt. This doubt is not so great as to justify routine repeat caesarean section, but it should remain in the minds of all those supervising VBACs so that they are alert to the warning signs of dehiscence. Lawrence J. Roberts University College Hospital, Huntley Street, London
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Transcript of Induction of labour confers benefit in prolonged pregnancy
1102 CORRESPONDENCE
Ann Harper & Harith La& The Royal Maternity Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BB
Author’s reply
Sir, I thank Drs Harper and Lamki for their up-to-date information about part-time training posts in Northern Ireland. It is heartening to see the numbers of part-time trainees increasing in this part of the country, and this is in no small measure due to the efforts of the Northern Ireland Regional Adviser of the Royal College of Obstetrics and Gynaecology, Dr Harith Lamki.
To date there is no formal system of applying for part-time training in Northern Ireland. There is no doubt that such a formal system of application has led to a dramatic increase in the number of trainees working part-time throughout the United Kingdom. Currently, 33 % of senior registrars training in England and Wales are female and of these, 31 % are training part-time. Although the Scots were committed to having 3 % of trainees at senior registrar level training part-time, it was only when a formal system of application for posts with guaranteed funding was introduced in 1993 that four separate part-time senior registrar posts in obstetrics and gynaecology were filled.
Aspiring part-time trainees in Northern Ireland should currently contact the Royal College of Obstetricians Regional Adviser or the Northern Ireland Council for Postgraduate Medical Education to register an interest in part-time training. The Management Executive in England and Wales in 1993 made available funding for 20 part-time consultant posts. With the general acceptance of part-time trainees, it is to be hoped that there will be more part-time consultant posts.
Laura J. Cassidy Department of Obstetrics and Gynaecology, Inverclyde Royal Hospital, Lurkfield Road, Greenock PA16 OXN
Induction of labour confers benefit in prolonged pregnancy
Sir, Thank you for the excellent review by John Grant (February 101, 1994) on induction of labour in prolonged pregnancy (Grant 1994). One comment, however, must not go unchallenged; “...there is little eviden ce... to support the practice of fetal surveillance after 41 weeks gestation.. . ”. Clearly, from available evidence, induction at this gestation will prevent up to three perinatal deaths per thousand births, and perhaps a slightly larger number of hypoxic seizures (Grant 1994). This is a total benefit of perhaps 1 YO. Given that there are other causes of death (0.3 per 1000) and seizure, it would take a truly gargantuan trial to prove any benefit of fetal surveillance. Meanwhile, for those women who prefer to take the risk of prolonged pregnancy, common sense dictates heavy emphasis on observation of fetal movement, backed up by at least cardiotocographic monitoring perhaps every couple of days. Such monitoring would also provide an antenatal tracing with which to compare an intrapartum monitoring.
Laurence Wood Walsgrave Hospital NHS Trust, Clrfford Bridge Road, Walsgrave. Coventry CV2 2DX
Reference Grant J . M. (1994) Induction of labour confers benefit in prolonged
pregnancy. Br J Ohstet Gynaecol 101, 99- 102.
Author’s reply
Sir, Laurence Wood is right when he implies that the effectiveness of fetal surveillance in the prevention of perinatal mortality “in
prolonged pregnancy” has been little researched. In the 11 randomised trials induction of labour was the experimental treatment with fetal surveillance the control. In each trial this method of induction of labour was clearly defined, while the method of fetal surveillance was not, being fetal movement counts, nonstressed cardiotocography, ultrasonic estimation of amniotic fluid volume, fetal biophysical profile, or a mixture of these. In my review I stated that obstetricians should recommend induction of labour in prolonged pregnancy as opposed to the present haphazard methods of fetal surveillance, and this statement is justified in the light of current evidence. The focus of future research should be the effectiveness of specific forms of fetal surveillance compared with induction of labour. The emphasis of the comparison has shifted, for now the method of fetal surveillance, clearly defined, is the experimental group with induction of labour the control.
Laurence Wood is also right when he says that such a trial will be large. If a particular method of fetal surveillance is to be successful one would expect it to prevent just as many perinatal deaths as induction of labour. The 1 1 randomised trials of induction of labour resulted in a perinatal mortality rate of 0.3 per 1000; a doubling of this perinatal mortality rate with a specific method of fetal surveillance may be considered un- acceptable. Such a trial would require at least 150000 women with prolonged pregnancy to be randomised-clearly an im- possible task. Other indicators of perinatal fetal hypoxia should be chosen as outcome measures, such as fetal heart rate abnormalities, caesarean section for fetal distress, time to establish first respiration, and hypoxic ischaemic encephalopathy.
John M. Grant Bellshill Hospital, North Road, Bellshill, Lanarkshire ML4 3JN
Labour following caesarean section Sir, In the short communication by Roberts (February 101, 1994) on labour following caesarean section, I find it unfortunate that the phrase trial of scar appears on a recurrent basis. I feel very strongly that the correct phrase should be trial of labour after a previous caesarean section, as stated by the Canadian panel in 1986. The term trial of scar would indicate that there was doubt about the mechanical soundness of the scar and, of course, if there was any doubt about this, then labour should not be allowed.
D. H. Gudgeon Torbay Hospital, Lawes Bridge, Torquay TQ2 7AA
Author’s reply
Sir, There are a variety of descriptive terms for the labour of a woman previously delivered abdominally. When compiling our ques- tionnaire we selected the term which, in our experience, is used most frequently (or recognised most easily) by consultants in obstetrics. Having phrased our questions in this manner, we felt it only correct to report the replies using the same term. Personally, I prefer the term vaginal birth after caesarean (VBAC), particularly when discussing the issue with patients, who may find the prospect of a trial of scar a daunting one. Whichever expression is used, I would say that the mechanical soundness of a scarred uterus is always in doubt. This doubt is not so great as to justify routine repeat caesarean section, but it should remain in the minds of all those supervising VBACs so that they are alert to the warning signs of dehiscence.
Lawrence J. Roberts University College Hospital, Huntley Street, London
