“Where is it safe to practice obstetrics?” is a broader question

“SHOULD THE 30-MINUTE RULE FOR EMERGENT CESAREAN DELIVERY BE APPLIED UNIVERSALLY?”

“Where is it safe to practice obstetrics?” is a broader question Drs. Chauhan and Mendez-Figueroa presented a thoughtful series of case studies. Unfortunately, the cases were intended for the considerate ObGyn—the one who can appreciate that every case has a differing set of variables—and did not account for the context and legal environment in which we practice. In the theater that is our malpractice reality, these cases would carry little weight with a jury that is empathizing with a child with cerebral palsy, often years after the event.

“Where is it safe to practice obstetrics?” is a broader, and perhaps more interesting, question. And a more relevant case would involve a smaller hospital, perhaps in a rural area, that does not have in-house anesthesia available for 30-minute starts.

Daniel R. Szekely, MD, PhD
Tacoma, Washington

We are hoisted on a petard of our own makingThere is absolutely no justification for ObGyns being held to this so-called “standard of care.” The evidence is scant or lacking that delivery in a 30-minute timeframe has any significant bearing on the neonatal outcome. Despite this, the lay public and medical-legal community see this as an absolute rule to be followed. If there is a less-than-perfect outcome, we are hoisted on this petard of our own making.

We as a group (that is, the American College of Obstetricians and
Gynecologists) need to work to right this unfortunate wrong!

William H. Deschner, MD
Seattle, Washington

Practicing is downright scary
The “30-minute rule” is no help to ObGyns in the field. At a community hospital, where surgical teams are called in from home (we cannot afford to do otherwise), it is often impossible to meet this standard. University-level care even cannot meet the measure at times. We never should have been painted into this corner. Now, any attempts to loosen the rule will be seen as trying to practice defensive medicine.

People who do not do what we do for a living have no concept of the anxiety and sleep loss we incur while seeking the best outcomes for our patients. I long for the soon-to-come day when I retire. Due to the litigious environment, I am saddened that I cannot heartily recommend the field to young doctors.

James Nunn, MD
Chicago, Illinois

“UPDATE ON VAGINAL HYSTERECTOMY”
BARBARA S. LEVY, MD (SEPTEMBER 2015)

Why has TAH remained the dominant hysterectomy route for generations?I read with great interest Dr. Levy’s recent comments on the benefits of new technology to improve the vaginal hysterectomy (VH) rate. Thank you and Dr. Levy for all the work you have done to advance the care of our patients. I have some other fundamental concerns about the future of hysterectomy.

Why has total abdominal hysterectomy (TAH) remained the dominant route of hysterectomy for generations? Why have past efforts to minimize TAH met with limited results?

Dr. Levy maintains in her article that, “the biggest barrier to widespread use [of VH] may simply be the lack of industry support.” What industry has supported TAH in a manner not also applicable to VH?

What do the techniques in Dr. Levy’s article and the efforts by ACOG and other authorities¹ offer that will materially increase the adoption of VH? What evidence is there that the use of such devices as VITOM system will overcome the low rate of VH? How much training is required before a surgeon can realize patient-centered benefit from using the VITOM or other new devices during VH?

The lack of evidence-based training and implementation of robotic surgery has resulted in well-deserved criticism of robotics, centered, in part, around complications. Will the complication rate rise as those who do not perform VH transition to its adoption using VITOM and other devices?

I hope that the generations-long failure of all efforts to raise the VH rate is overcome with evidence-based educational protocols.

Antonio R. Pizarro, MD
Shreveport, Louisiana

Reference
1. Bosworth T. ACOG taking steps to increase vaginal hysterectomy rates. Ob.Gyn. News. http://www.obgynnews.com/?id=11146&tx_ttnews[tt_news]=392609&cHash=d78b8bea4aa3483c10dc5d843207d211. Posted April 6, 2015. Accessed October 2, 2015.

The problem: lack of trainingSadly, lack of training is the problem in this best approach to removing the benign uterus. These tools are helpful and should be in the surgeon’s armamentarium. We need experienced vaginal surgeons to teach this procedure. In some ways, just as much skill and dexterity are needed as with laparoscopic or robotic methods.

William H. Deschner, MD
Seattle, Washington

Dr. Levy respondsI appreciate the insightful comments of Drs. Pizarro and Deschner. Clearly, as the volume of hysterectomies has decreased and the number of techniques we must teach our residents has expanded, we are challenged to provide robust training in all hysterectomy routes. TAH, as the status quo, has not required the development of new equipment and technology, whereas assisting gynecologic surgeons to convert open procedures to minimally invasive approaches has been advanced and driven by our industry partners.