Correspondence
Volume 162 Number 6
blood gas and acid-base status in response to anemia and transfusion of adult blood were similar to our findings. I, 2 However, their use of blood obtained from the fetal heart and imperfect statistical analysis may explain the differences from our results. Fetal heart blood is a mixture of blood from the ductus venosus, upper and lower parts of the body in descending order of oxygenation. Streaming of blood within the heart is thought to minimize mixing and so the blood gas results would depend on the exact site of sampling, even within a chamber of the heart. Their statement "the primary target for the puncture was the left ventricle" suggests that sometimes the blood was obtained from other chambers. Therefore, at the very least they need to publish control data for heart blood from fetuses without erythroblastosis. As they state in the article they also need to investigate changes with gestational age because these are important in cord blood' and our data analysis corrected for this factor. Westgren et al. found no fall in pH or rise in base excess in the heart when fetuses had adult blood in their circulation, whereas our study found these changes in umbilical arterial blood. The most likely explanation for this difference is that heart blood is a mixture of umbilical arterial and venous blood so abnormalities we found in the former were not detected. Finally, their data were 70 observations from 26 fetuses, whereas ours were 80 observations from 80 fetuses. This means that they included multiple observations from some pregnancies and the data were not independent as required for multivariate analysis. Peter Soothill, MRCOG Department of Obstetrics and Gynecology Kings College Denmark Hill London SE5, England
REFERENCES 1. Soothill PW, Nicolaides KH, Rodeck CH. The effect of anaemia on fetal acid-base status. Br J Obstet Gynaecol 1987;94:880-3. 2. Soothill PW, Nicolaides KH, Rodeck CH, Bellingham AJ. The effect of replacing fetal with adult hemoglobin on blood gas and acid-base parameters in human fetuses. AM J OBSTET GYNECOL 1988;158:66-9. 3. Soothill PW, Nicolaides KH, Rodeck CH, Campbell S. The effect of gestational age on blood gas and acid-base values in human pregnancy. Fetal Ther 1986;11:168-75.
Reply To the Editors:
We wish to refute the challenge of Dr. Soothill that the difference between our results and theirs is because of "imperfect statistical analysis." Before use of a multivariate analysis, stratification was performed for dependent observations in our study so the statistical analysis does not explain the discrepancy between our two studies. A more likely explanation is that different sites were
1637
used to obtain fetal blood. We studied mixed venous and arterial blood, whereas Soothill et al. studied pure umbilical artery blood. It is not surprising that these two puncture sites differ in respect to studied parameters. Finally, although the study by Sooth ill et al. included 80 observations, they based their analyses in respect to umbilical artery blood on 13 pairs, 26 observations, which is a rather limited number to achieve a high degree of confidence (p < 0.036). Magnus Westgren, MD, PhD Department of Obstetrics and Gynaecology Karolinska Institute Danderyd Hospital S-J82 88 Danderyd, Sweden Active management of labor To the Editors:
I have been studying active management of labor as described by O'Driscoll and Meagher' in connection with the preparation of my master's thesis in nursing at the University of Washington. I have just read the latest response by Leveno et al. 2 to O'Driscoll et al. 3 in the continuing repartee between Dallas and Dublin. A few thoughts and questions have occurred to me concerning the merits of the active management protocol, and the challenge to them put forth by Leveno et aP The effect that active management has on several of the outcome variables of labor has been measured by researchers among different populations. In Canada, Akoury et al. 4 compared a sample of 552 normal nulliparous women delivered of infants in accordance with the system of active management with 553 similar control subjects managed with routine care. Turner et al.' studied a multiracial sample of 1000 nulliparous patients whose labors were actively managed, and Sheehan6 compared the records of 569 low-risk nulliparous patients from the National Maternity Center in Dublin, where active management is practiced, with 471 similar patients who were delivered of infants in a hospital in the United States. The findings of these three groups of investigators included decreased rate of cesarean section, length of labor, and rate of forceps delivery among the actively managed parturients, with no increase noted in perinatal morbidity or mortality. These results would indicate, as Turner et al. 5 stated, " ... active management can be safely applied outside Ireland to reduce the incidence of Caesarean childbirth." From a nursing perspective, other studies also add an interesting dimension to the active management debate. Research conducted by the pediatricians Klaus et aI.' and Kennell et aJ.B has evaluated one component of active management, that of constant supportive companionship for the laboring patient. With no changes in medical care, these researchers have found in controlled, randomized trials that the constant presence of a reassuring female companion for the woman has produced statistically significant reductions in the rate of
1638 Correspondence
cesarean section, duration of labor, and perinatal complications. Their results were comparable to the effects of active management of labor as measured by O'Driscoli and Meagher.' O'Driscoll and Meagher' have written, "Strict limitation of the duration of labor and continuous personal attention throughout are considered to be the basic requirements on which a high standard of care depends ... neither is possible without the other." Could it be that the constant supportive and individualized nursing care practiced in active management is in large part responsible for its beneficial effects on the outcome of labor? I await with interest the reply from Dublin to the report of Leveno et al! If, after the results are in, active management does not fulfill its promises, this debate has at least encouraged a critical appraisal of the high cesarean section rate in the United States. Women in this country are perhaps due a reasoned and well researched justification for the frequent use of this procedure. Ann Lynch, RN 602 Laurel Drive Everett, WA 98201 This letter is a personal communication and is not intended to reflect the views of the University of Washington.
REFERENCES 1. O'Driscoll K, Meagher D. Active management of labour, 2nd ed. London: Bailliere Tindall, 1986. 2. Leveno Kj, Cunningham FG, Prichard jA. Cesarean section: the House of Horne revisited. AM j OBSTET GVNECOL 1989;160:78-9. 3. O'Driscoll K, Foley M, MacDonald D, Stronge J. Cesarean section and perinatal outcome: response from the House of Horne. AM j OBSTET GVNECOL 1988; 158:449-52. 4. Akoury HA, Brodie G, Caddick R, McLaughlin VD, Pugh P. Active management of labor and operative delivery in nulliparous women. AM j OBSTET GVNECOL 1988; 158: 255-8. 5. Turner Mj, Brassil M, Gordon H. Active management of labor associated with a decrease in the cesarean section rate in nulliparas. Obstet Gynecol 1988;71:150-4. 6. Sheehan KH. Cesarean section for dystocia: a comparison of practices in two countries. Lancet 1987;1:548. 7. Klaus MK, Kennell JH, Robertson SS, Sosa R. Effects of social support during parturition on maternal and infant morbidity. Br Med j 1986;293:585-7. 8. Kennellj, Klaus MH, McGrath S, Robertson S, Hinkley C. Medical intervention: the effect of social support during labor [Abstract). Pediatr Res 1988;23(pt 2):21IA.
Reply To the Editors: We are delighted with Nurse Lynch's letter concerning our report on cesarean section. Nurse Lynch correctly emphasizes that "constant supportive and individualized nursing care" is undoubtedly pivotal in good obstetric care. However, we are reluctant to broaden the cesarean rate debate to allegations about superiority (or inferiority) of nursing on two continents. Indeed, we are prepared to rise up for our own nurses!
June 1990 Am J Obstet Gynecol
We too are of the view that "women in this country are ... due a reasoned and well researched justification of the frequent use of this procedure (cesarean)." We believe this sentiment has fueled our participation in the debate. Our purpose has not been to defend abuse of cesarean section but instead to encourage its prudent use. Kenneth]. Leveno, MD F. Gary Cunningham, MD Jack A. Pritchard, MD Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center 5323 Harry Hines Blvd. Dallas, TX 75235-9032 Subspecialty of gynecologic oncology proposed to manage breast disease To the Editors: I read with great interest the article by Dr. Norbert Gleicher (Gleicher N. Breast disease programs in obstetrics and gynecology: a plea for training in mammography. AM J OBSTET GYNECOL 1989; 161 :267 -70). His point that the gynecologist most often faces breast disease and should be familiar with mammography is excellent. I would like to take his suggestion one step further. It is disconcerting to the patient to be seen by different physicians for the detection, diagnosis, and treatment of breast disease. When a malignancy is detected, the patient is often treated not only by a surgeon but also by a medical oncologist and a radiotherapist. Inasmuch as the breast is a reproductive organ, I suggest that the subspecialty of gynecologic oncology have a role in the care of the patient with breast cancer. In this subspecialty the physician is trained in the detection of malignancy and coordinates the surgical, medical, and radiotherapeutic management. I believe this goal could be accomplished by incorporating training in the management of breast cancer into fellowship programs. Although this concept would represent a major change in the present approach to women with breast cancer and will certainly encounter resistance and criticism, I suggest a pilot program be established at several centers to evaluate the role of the gynecologic oncologist in the treatment of this disease. Ultimately I believe the care of women will be improved by such action. Joseph L. Kelley, MD 2001 Holcombe Blvd. Houston, TX 77030
Placental siderosis in maternal IHhalassemia To the Editors: Whereas the article by Birkenfeld and coworkers (Birkenfeld A, Mordel N, Okon E. Direct demonstration of iron in a term placenta in a case of ~-thalassemia major. AM J OBSTET GYNECOL 1989;160:562-3) is of interest, such placental deposits of stainable iron have
Volume 162 Number 6
blood gas and acid-base status in response to anemia and transfusion of adult blood were similar to our findings. I, 2 However, their use of blood obtained from the fetal heart and imperfect statistical analysis may explain the differences from our results. Fetal heart blood is a mixture of blood from the ductus venosus, upper and lower parts of the body in descending order of oxygenation. Streaming of blood within the heart is thought to minimize mixing and so the blood gas results would depend on the exact site of sampling, even within a chamber of the heart. Their statement "the primary target for the puncture was the left ventricle" suggests that sometimes the blood was obtained from other chambers. Therefore, at the very least they need to publish control data for heart blood from fetuses without erythroblastosis. As they state in the article they also need to investigate changes with gestational age because these are important in cord blood' and our data analysis corrected for this factor. Westgren et al. found no fall in pH or rise in base excess in the heart when fetuses had adult blood in their circulation, whereas our study found these changes in umbilical arterial blood. The most likely explanation for this difference is that heart blood is a mixture of umbilical arterial and venous blood so abnormalities we found in the former were not detected. Finally, their data were 70 observations from 26 fetuses, whereas ours were 80 observations from 80 fetuses. This means that they included multiple observations from some pregnancies and the data were not independent as required for multivariate analysis. Peter Soothill, MRCOG Department of Obstetrics and Gynecology Kings College Denmark Hill London SE5, England
REFERENCES 1. Soothill PW, Nicolaides KH, Rodeck CH. The effect of anaemia on fetal acid-base status. Br J Obstet Gynaecol 1987;94:880-3. 2. Soothill PW, Nicolaides KH, Rodeck CH, Bellingham AJ. The effect of replacing fetal with adult hemoglobin on blood gas and acid-base parameters in human fetuses. AM J OBSTET GYNECOL 1988;158:66-9. 3. Soothill PW, Nicolaides KH, Rodeck CH, Campbell S. The effect of gestational age on blood gas and acid-base values in human pregnancy. Fetal Ther 1986;11:168-75.
Reply To the Editors:
We wish to refute the challenge of Dr. Soothill that the difference between our results and theirs is because of "imperfect statistical analysis." Before use of a multivariate analysis, stratification was performed for dependent observations in our study so the statistical analysis does not explain the discrepancy between our two studies. A more likely explanation is that different sites were
1637
used to obtain fetal blood. We studied mixed venous and arterial blood, whereas Soothill et al. studied pure umbilical artery blood. It is not surprising that these two puncture sites differ in respect to studied parameters. Finally, although the study by Sooth ill et al. included 80 observations, they based their analyses in respect to umbilical artery blood on 13 pairs, 26 observations, which is a rather limited number to achieve a high degree of confidence (p < 0.036). Magnus Westgren, MD, PhD Department of Obstetrics and Gynaecology Karolinska Institute Danderyd Hospital S-J82 88 Danderyd, Sweden Active management of labor To the Editors:
I have been studying active management of labor as described by O'Driscoll and Meagher' in connection with the preparation of my master's thesis in nursing at the University of Washington. I have just read the latest response by Leveno et al. 2 to O'Driscoll et al. 3 in the continuing repartee between Dallas and Dublin. A few thoughts and questions have occurred to me concerning the merits of the active management protocol, and the challenge to them put forth by Leveno et aP The effect that active management has on several of the outcome variables of labor has been measured by researchers among different populations. In Canada, Akoury et al. 4 compared a sample of 552 normal nulliparous women delivered of infants in accordance with the system of active management with 553 similar control subjects managed with routine care. Turner et al.' studied a multiracial sample of 1000 nulliparous patients whose labors were actively managed, and Sheehan6 compared the records of 569 low-risk nulliparous patients from the National Maternity Center in Dublin, where active management is practiced, with 471 similar patients who were delivered of infants in a hospital in the United States. The findings of these three groups of investigators included decreased rate of cesarean section, length of labor, and rate of forceps delivery among the actively managed parturients, with no increase noted in perinatal morbidity or mortality. These results would indicate, as Turner et al. 5 stated, " ... active management can be safely applied outside Ireland to reduce the incidence of Caesarean childbirth." From a nursing perspective, other studies also add an interesting dimension to the active management debate. Research conducted by the pediatricians Klaus et aI.' and Kennell et aJ.B has evaluated one component of active management, that of constant supportive companionship for the laboring patient. With no changes in medical care, these researchers have found in controlled, randomized trials that the constant presence of a reassuring female companion for the woman has produced statistically significant reductions in the rate of
1638 Correspondence
cesarean section, duration of labor, and perinatal complications. Their results were comparable to the effects of active management of labor as measured by O'Driscoli and Meagher.' O'Driscoll and Meagher' have written, "Strict limitation of the duration of labor and continuous personal attention throughout are considered to be the basic requirements on which a high standard of care depends ... neither is possible without the other." Could it be that the constant supportive and individualized nursing care practiced in active management is in large part responsible for its beneficial effects on the outcome of labor? I await with interest the reply from Dublin to the report of Leveno et al! If, after the results are in, active management does not fulfill its promises, this debate has at least encouraged a critical appraisal of the high cesarean section rate in the United States. Women in this country are perhaps due a reasoned and well researched justification for the frequent use of this procedure. Ann Lynch, RN 602 Laurel Drive Everett, WA 98201 This letter is a personal communication and is not intended to reflect the views of the University of Washington.
REFERENCES 1. O'Driscoll K, Meagher D. Active management of labour, 2nd ed. London: Bailliere Tindall, 1986. 2. Leveno Kj, Cunningham FG, Prichard jA. Cesarean section: the House of Horne revisited. AM j OBSTET GVNECOL 1989;160:78-9. 3. O'Driscoll K, Foley M, MacDonald D, Stronge J. Cesarean section and perinatal outcome: response from the House of Horne. AM j OBSTET GVNECOL 1988; 158:449-52. 4. Akoury HA, Brodie G, Caddick R, McLaughlin VD, Pugh P. Active management of labor and operative delivery in nulliparous women. AM j OBSTET GVNECOL 1988; 158: 255-8. 5. Turner Mj, Brassil M, Gordon H. Active management of labor associated with a decrease in the cesarean section rate in nulliparas. Obstet Gynecol 1988;71:150-4. 6. Sheehan KH. Cesarean section for dystocia: a comparison of practices in two countries. Lancet 1987;1:548. 7. Klaus MK, Kennell JH, Robertson SS, Sosa R. Effects of social support during parturition on maternal and infant morbidity. Br Med j 1986;293:585-7. 8. Kennellj, Klaus MH, McGrath S, Robertson S, Hinkley C. Medical intervention: the effect of social support during labor [Abstract). Pediatr Res 1988;23(pt 2):21IA.
Reply To the Editors: We are delighted with Nurse Lynch's letter concerning our report on cesarean section. Nurse Lynch correctly emphasizes that "constant supportive and individualized nursing care" is undoubtedly pivotal in good obstetric care. However, we are reluctant to broaden the cesarean rate debate to allegations about superiority (or inferiority) of nursing on two continents. Indeed, we are prepared to rise up for our own nurses!
June 1990 Am J Obstet Gynecol
We too are of the view that "women in this country are ... due a reasoned and well researched justification of the frequent use of this procedure (cesarean)." We believe this sentiment has fueled our participation in the debate. Our purpose has not been to defend abuse of cesarean section but instead to encourage its prudent use. Kenneth]. Leveno, MD F. Gary Cunningham, MD Jack A. Pritchard, MD Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center 5323 Harry Hines Blvd. Dallas, TX 75235-9032 Subspecialty of gynecologic oncology proposed to manage breast disease To the Editors: I read with great interest the article by Dr. Norbert Gleicher (Gleicher N. Breast disease programs in obstetrics and gynecology: a plea for training in mammography. AM J OBSTET GYNECOL 1989; 161 :267 -70). His point that the gynecologist most often faces breast disease and should be familiar with mammography is excellent. I would like to take his suggestion one step further. It is disconcerting to the patient to be seen by different physicians for the detection, diagnosis, and treatment of breast disease. When a malignancy is detected, the patient is often treated not only by a surgeon but also by a medical oncologist and a radiotherapist. Inasmuch as the breast is a reproductive organ, I suggest that the subspecialty of gynecologic oncology have a role in the care of the patient with breast cancer. In this subspecialty the physician is trained in the detection of malignancy and coordinates the surgical, medical, and radiotherapeutic management. I believe this goal could be accomplished by incorporating training in the management of breast cancer into fellowship programs. Although this concept would represent a major change in the present approach to women with breast cancer and will certainly encounter resistance and criticism, I suggest a pilot program be established at several centers to evaluate the role of the gynecologic oncologist in the treatment of this disease. Ultimately I believe the care of women will be improved by such action. Joseph L. Kelley, MD 2001 Holcombe Blvd. Houston, TX 77030
Placental siderosis in maternal IHhalassemia To the Editors: Whereas the article by Birkenfeld and coworkers (Birkenfeld A, Mordel N, Okon E. Direct demonstration of iron in a term placenta in a case of ~-thalassemia major. AM J OBSTET GYNECOL 1989;160:562-3) is of interest, such placental deposits of stainable iron have
