renew the plasticine lining and repeat the procedure until one is confident in the mechanics of the resectoscope. We have used this model regularly at our gynaecological endoscopy workshops and the response of trainees has been universally positive. With minor modifications, urologists in training and others who use a resectoscope within a cavity may also find it a useful aid for endoscopic procedures.
Doppler studies of the umbilical artery can usually be done quickly, and the results are objective and reproducible. Many district general hospitals now have Doppler equipment attached to their ultrasound scanners, or a separate stand alone machine can be purchased with a spectral analyser. Was one of the reasons why intervention rates were high in those fetuses with a normal umbilical artery waveform because the scoring produced by a biophysical profile was low?
ADAM L MAGOS Minimally Invasive Therapy Unit, Academic Department of Obstetrics and Gynaecology, Royal Free Hospital, London NW3 2QF
Department of Radiology, Singleton Hospital, Swansea SA2 8QA
1 MacIntyre IMC, Munro A. Simulation in surgical training. BrMedJ7 1990;300:1088-9. (28 April.) 2 Semm K. Operative manual for endoscopic abdominal surgery. Chicago: Year Book Medical Publishers, 1987:
251-4. 3 Magos AL, Baumann R, Turnbull AC. Transcervical resection of the endometrium in women with menorrhagia. Br Med J 1989;298: 1209-12.
SIR,-Electronic "multimedia" simulation could partially fill the gap in surgical training described by Messrs I M C Maclntyre and A Munro because its use would not encroach on the operating theatre time allocated to fulfil service needs.' Multimedia simulation is a way of presenting information in a non-linear fashion using text, still pictures, video film sequences, and sound. Computerised simulations cannot mimic the feel of surgical instruments or the texture of human tissue but can teach decision making, present surgical anatomy, and display the sequence of work in operations. I recently evaluated a program dealing with the surgery of aortic aneurysm (The Surgeon. Version 1.5. ISM Inc, October 1985). This program allows the trainee to make decisions about a patient who has been admitted to a surgical ward. The trainee must evaluate the case history, decide what tests and procedures to carry out and in what order and priority, and decide when to operate. The operation is simulated by requiring the trainee to select the necessary surgical instruments and use them with the aid of a "mouse." The surgical approach is shown and the layers of tissue are dissected. Simulated monitors show the patient's heart rate and blood pressure. The trainee is expected to draw conclusions from what is displayed on these monitors and choose drugs to correct any problems shown. This simulation, although extremely simple, is an example of the potential which computer systems could offer the surgical trainee in acquiring knowledge about many aspects of surgical practice. This technology, combined with the expert knowledge and skill of the senior surgeons, provides an alternative training approach for the aspiring surgeon. D A S PEARCE
Information Modelling Programme, Department of Anatomy, University of Leeds, Leeds LS2 9JT
LIAM McKNIGHT
I Burke G, Stuart B, Crowley P, Scanail SN, Drummer J. Is intrauterine growth retardation with normal umbilical artery blood flow a benign condition? Br MedJ 1990;300:1044-5. (21 April.)
AUTHORS' REPLY,-Biophysical profile scoring has become widely used in Ireland mainly because of its corrected stillbirth rate within a week of a normal test of less than 1 per 1000.' While it is only marginally better than cardiotocography at predicting low Apgar scores, the method allows the fetus to be measured and its structure assessed,2' with an average time to record the ultrasonic variables of less than 10 minutes.4 Nevertheless, frequent errors in its application and interpretation have been recognised.5 In our study the score was normal at the last test in 157 patients, and seven (4%) of these pregnancies ended in loss. Only two of the latter were normal babies: one had absent end diastolic flow but aborted at 25 weeks, weighing less than 500 g at birth, and the other was an intrauterine death in a mature fetus with type 2 flow. One baby with a normal score, but abnormal flow, had neonatal cerebral irritation. The score was abnormal in 22 patients, and five (23%) of these pregnancies ended in fetal loss. Two of these fetuses had major congenital malformations; the three normal babies weighed 450-580 g, and Doppler scanning showed absent end diastolic flow. Delivery was decided against in two because of the very low estimated weight and undertaken only in the third because of severe proteinuric hypertension complicated by maternal retinal vein thrombosis. One baby with reduced liquor but with an otherwise normal profile and normal blood flow had neonatal cerebral irritation: two intrapartum fetal scalp blood samples and an umbilical vein blood sample at delivery showed normal pH. Half of those with an abnormal score had abnormal flow and 72% of those with normal scores had normal blood flow. Furthermore, all fetuses with a score of 0 had abnormal blood flow. On the other hand, when blood flow was abnormal only 20% of fetuses had abnormal scores, but when it was normal 91% had normal scores (see table). Relation of biophysical profile score to umbilical blood flow pattern Biophysical
1 Maclntyre IMC, Munro A. Simulation in surgical training. BrMedJ7 1990;300:1088-9. (28 April.)
Intrauterine growth retardation and umbilical artery flow SIR,-Dr Gerard Burke and his colleagues indicate that all the women they studied had a biophysical profile of the fetus. i I would be interested to know whether there was any correlation between the biophysical profile and the Doppler measurements. The biophysical profile is more time consuming to perform and also somewhat subjective. Since the results of the biophysical profile are not given I presume that they did not contribute greatly. BMJ
VOLUME 300
9 JUNE 1990
score 8or6 6* 4 2 0
Umbilical blood flow pattern Total Type 3 Type 1 Type 2 (n= 179) (n= 1) (n= 124) (n=44) 113 3 8 0 0
36 0 5 0 3
8 0 2 0 1
157 3 15 0 4
*Refers to reduced liquor as the reason for assigning a score of 6.
The score was abnormal in 11 (27%) of the 41 patients who had elective caesarean sections but in only 6 (7%) of 87 patients having induction of labour. Of 124 patients with normal flow, 19 had elective caesarean section, the indication (in addition to intrauterine growth retardation) being breech presentation (10), an abnormal biophysical profile score (5), and suspicious findings on cardiotocography (4). In 65 labour was induced, the
indications being growth retardation only (44), pregnancy advanced beyond term with growth retardation (12), hypertension (4), abnormal biophysical profile score (3), and antepartum haemorrhage (2). Thus, in only 8 (10%) of the 84 fetuses electively delivered was an abnormal score a major indication for intervention. Thus, while fetal smallness was the main reason for intervention in the group with normal flow, the biophysical profile score was an important influence in the decision to deliver patients from both groups. It correlated reasonably well with the Doppler findings at the final evaluation. Doppler findings proved to be a useful prognostic indicator in this group of growth retarded fetuses, but their contribution to the timing of delivery remains to be clarified. Neither method should be used as the sole basis for management without reference to the clinical situation and the overall risks. GERARD BURKE BERNARD STUART PATRICIA CROWLEY SIOBHAN NI SCANAILL JOHN DRUMM
Coombe Lying-In Hospital, Dublin 8 1 Manning FA, Morrison I, Lange IR, Harman CR, Chamberlain PF. Fetal assessment based on fetal biophysical profile scoring: experience in 12620 referred high-risk pregnancies. AmJ
Obstet Gynecol 1985;151:343-50. 2 Platt LD, Walla CA, Paul RH, et al. A prospective trial of the fetal biophysical profile versus the non-stress test in the management of high-risk pregnancies. Am J Obstet Gynecol 1985;153:62433. 3 Manning FA, Lange IR, Morrison I, Harman CR. Fetal biophysical profile score and the non-stress test: a comparative trial. Obstet Gynecol 1984;64:326-31. 4 Manning FA, Platt LD. Sipos L. Antepartum fetal evaluation: development of a fetal biophysical profile. AmJ Obstet Gynecol 1980;136:787-95. 5 Vintzileos AM, Campbell WA, Nochimson DJ, Weinbaum PJ. The use and misuse of the fetal biophysical profile. AmJ7 Obstet
Gynecol 1987;156:527-33.
Politicians and scientists SIR,-Dr Tony Smith's editorial attacks the government's health reforms on the basis that they are unscientific' and appears to reopen the BMA's confused and misleading campaign of opposition. The reforms will alter the context and structure of the NHS to make its operations far more scientific -explicit and quantifiable information on quality and value for money will provide the basis for deciding where resources can best be applied to benefit patients. It is futile to continue the arguments for experiments, demonstrations, or pilot studies. The basic principle of money following the patient is agreed on by the government, the Labour party, and the BMA and most of the NHS changes make this a reality. Early self governing trusts and general practice fund holders will be examined closely by the public, the media, and pragmatic politicians within the government. To suggest that those in favour of the reforms do not understand the strong vocational element motivating those directly concerned with health is absurd. Local control of hospitals as NHS trusts and of money by fund holding general practitioners will enable people concerned with health to provide treatment that is better and more suited to local circumstances. Many within the service are currently frustrated by the bureaucracy which prevents them from delivering service in the way they know they could. The NHS reforms are not in any way about profits or pecuniary incentives but are about allowing funds to flow to those hospitals with the capacity and public popularity to attract patients. There is a growing number of doctors who understand the reforms and see the potential benefits. The BMA does its members and the country a considerable disservice by continuing to 1525
Doppler studies of the umbilical artery can usually be done quickly, and the results are objective and reproducible. Many district general hospitals now have Doppler equipment attached to their ultrasound scanners, or a separate stand alone machine can be purchased with a spectral analyser. Was one of the reasons why intervention rates were high in those fetuses with a normal umbilical artery waveform because the scoring produced by a biophysical profile was low?
ADAM L MAGOS Minimally Invasive Therapy Unit, Academic Department of Obstetrics and Gynaecology, Royal Free Hospital, London NW3 2QF
Department of Radiology, Singleton Hospital, Swansea SA2 8QA
1 MacIntyre IMC, Munro A. Simulation in surgical training. BrMedJ7 1990;300:1088-9. (28 April.) 2 Semm K. Operative manual for endoscopic abdominal surgery. Chicago: Year Book Medical Publishers, 1987:
251-4. 3 Magos AL, Baumann R, Turnbull AC. Transcervical resection of the endometrium in women with menorrhagia. Br Med J 1989;298: 1209-12.
SIR,-Electronic "multimedia" simulation could partially fill the gap in surgical training described by Messrs I M C Maclntyre and A Munro because its use would not encroach on the operating theatre time allocated to fulfil service needs.' Multimedia simulation is a way of presenting information in a non-linear fashion using text, still pictures, video film sequences, and sound. Computerised simulations cannot mimic the feel of surgical instruments or the texture of human tissue but can teach decision making, present surgical anatomy, and display the sequence of work in operations. I recently evaluated a program dealing with the surgery of aortic aneurysm (The Surgeon. Version 1.5. ISM Inc, October 1985). This program allows the trainee to make decisions about a patient who has been admitted to a surgical ward. The trainee must evaluate the case history, decide what tests and procedures to carry out and in what order and priority, and decide when to operate. The operation is simulated by requiring the trainee to select the necessary surgical instruments and use them with the aid of a "mouse." The surgical approach is shown and the layers of tissue are dissected. Simulated monitors show the patient's heart rate and blood pressure. The trainee is expected to draw conclusions from what is displayed on these monitors and choose drugs to correct any problems shown. This simulation, although extremely simple, is an example of the potential which computer systems could offer the surgical trainee in acquiring knowledge about many aspects of surgical practice. This technology, combined with the expert knowledge and skill of the senior surgeons, provides an alternative training approach for the aspiring surgeon. D A S PEARCE
Information Modelling Programme, Department of Anatomy, University of Leeds, Leeds LS2 9JT
LIAM McKNIGHT
I Burke G, Stuart B, Crowley P, Scanail SN, Drummer J. Is intrauterine growth retardation with normal umbilical artery blood flow a benign condition? Br MedJ 1990;300:1044-5. (21 April.)
AUTHORS' REPLY,-Biophysical profile scoring has become widely used in Ireland mainly because of its corrected stillbirth rate within a week of a normal test of less than 1 per 1000.' While it is only marginally better than cardiotocography at predicting low Apgar scores, the method allows the fetus to be measured and its structure assessed,2' with an average time to record the ultrasonic variables of less than 10 minutes.4 Nevertheless, frequent errors in its application and interpretation have been recognised.5 In our study the score was normal at the last test in 157 patients, and seven (4%) of these pregnancies ended in loss. Only two of the latter were normal babies: one had absent end diastolic flow but aborted at 25 weeks, weighing less than 500 g at birth, and the other was an intrauterine death in a mature fetus with type 2 flow. One baby with a normal score, but abnormal flow, had neonatal cerebral irritation. The score was abnormal in 22 patients, and five (23%) of these pregnancies ended in fetal loss. Two of these fetuses had major congenital malformations; the three normal babies weighed 450-580 g, and Doppler scanning showed absent end diastolic flow. Delivery was decided against in two because of the very low estimated weight and undertaken only in the third because of severe proteinuric hypertension complicated by maternal retinal vein thrombosis. One baby with reduced liquor but with an otherwise normal profile and normal blood flow had neonatal cerebral irritation: two intrapartum fetal scalp blood samples and an umbilical vein blood sample at delivery showed normal pH. Half of those with an abnormal score had abnormal flow and 72% of those with normal scores had normal blood flow. Furthermore, all fetuses with a score of 0 had abnormal blood flow. On the other hand, when blood flow was abnormal only 20% of fetuses had abnormal scores, but when it was normal 91% had normal scores (see table). Relation of biophysical profile score to umbilical blood flow pattern Biophysical
1 Maclntyre IMC, Munro A. Simulation in surgical training. BrMedJ7 1990;300:1088-9. (28 April.)
Intrauterine growth retardation and umbilical artery flow SIR,-Dr Gerard Burke and his colleagues indicate that all the women they studied had a biophysical profile of the fetus. i I would be interested to know whether there was any correlation between the biophysical profile and the Doppler measurements. The biophysical profile is more time consuming to perform and also somewhat subjective. Since the results of the biophysical profile are not given I presume that they did not contribute greatly. BMJ
VOLUME 300
9 JUNE 1990
score 8or6 6* 4 2 0
Umbilical blood flow pattern Total Type 3 Type 1 Type 2 (n= 179) (n= 1) (n= 124) (n=44) 113 3 8 0 0
36 0 5 0 3
8 0 2 0 1
157 3 15 0 4
*Refers to reduced liquor as the reason for assigning a score of 6.
The score was abnormal in 11 (27%) of the 41 patients who had elective caesarean sections but in only 6 (7%) of 87 patients having induction of labour. Of 124 patients with normal flow, 19 had elective caesarean section, the indication (in addition to intrauterine growth retardation) being breech presentation (10), an abnormal biophysical profile score (5), and suspicious findings on cardiotocography (4). In 65 labour was induced, the
indications being growth retardation only (44), pregnancy advanced beyond term with growth retardation (12), hypertension (4), abnormal biophysical profile score (3), and antepartum haemorrhage (2). Thus, in only 8 (10%) of the 84 fetuses electively delivered was an abnormal score a major indication for intervention. Thus, while fetal smallness was the main reason for intervention in the group with normal flow, the biophysical profile score was an important influence in the decision to deliver patients from both groups. It correlated reasonably well with the Doppler findings at the final evaluation. Doppler findings proved to be a useful prognostic indicator in this group of growth retarded fetuses, but their contribution to the timing of delivery remains to be clarified. Neither method should be used as the sole basis for management without reference to the clinical situation and the overall risks. GERARD BURKE BERNARD STUART PATRICIA CROWLEY SIOBHAN NI SCANAILL JOHN DRUMM
Coombe Lying-In Hospital, Dublin 8 1 Manning FA, Morrison I, Lange IR, Harman CR, Chamberlain PF. Fetal assessment based on fetal biophysical profile scoring: experience in 12620 referred high-risk pregnancies. AmJ
Obstet Gynecol 1985;151:343-50. 2 Platt LD, Walla CA, Paul RH, et al. A prospective trial of the fetal biophysical profile versus the non-stress test in the management of high-risk pregnancies. Am J Obstet Gynecol 1985;153:62433. 3 Manning FA, Lange IR, Morrison I, Harman CR. Fetal biophysical profile score and the non-stress test: a comparative trial. Obstet Gynecol 1984;64:326-31. 4 Manning FA, Platt LD. Sipos L. Antepartum fetal evaluation: development of a fetal biophysical profile. AmJ Obstet Gynecol 1980;136:787-95. 5 Vintzileos AM, Campbell WA, Nochimson DJ, Weinbaum PJ. The use and misuse of the fetal biophysical profile. AmJ7 Obstet
Gynecol 1987;156:527-33.
Politicians and scientists SIR,-Dr Tony Smith's editorial attacks the government's health reforms on the basis that they are unscientific' and appears to reopen the BMA's confused and misleading campaign of opposition. The reforms will alter the context and structure of the NHS to make its operations far more scientific -explicit and quantifiable information on quality and value for money will provide the basis for deciding where resources can best be applied to benefit patients. It is futile to continue the arguments for experiments, demonstrations, or pilot studies. The basic principle of money following the patient is agreed on by the government, the Labour party, and the BMA and most of the NHS changes make this a reality. Early self governing trusts and general practice fund holders will be examined closely by the public, the media, and pragmatic politicians within the government. To suggest that those in favour of the reforms do not understand the strong vocational element motivating those directly concerned with health is absurd. Local control of hospitals as NHS trusts and of money by fund holding general practitioners will enable people concerned with health to provide treatment that is better and more suited to local circumstances. Many within the service are currently frustrated by the bureaucracy which prevents them from delivering service in the way they know they could. The NHS reforms are not in any way about profits or pecuniary incentives but are about allowing funds to flow to those hospitals with the capacity and public popularity to attract patients. There is a growing number of doctors who understand the reforms and see the potential benefits. The BMA does its members and the country a considerable disservice by continuing to 1525
