Letters to the Editor
Reference 1 Gardner K, Henry A, Thou S et al. Improving VBAC rates: the combined impact of two management strategies. Aust NZ J Obstet Gynaecol 2014; 54: 327–332.
Re: Improving VBAC rates: The combined impact of two management strategies Dear Editor, We thank Professor Dietz for his interest in our paper, Improving VBAC rates: the combined impact of two management strategies.1 We would first like to respond to the criticism regarding the high number of emergency Caesarean sections (35.6%) and instrumental deliveries (17.5%) amongst our cohort of VBAC candidates who elected to have a trial of labour. Our figures are well aligned with the VBAC success rates described in the literature with most series reporting a likelihood of vaginal birth in the range of 60– 80% giving an emergency Caesarean section rate from 20 to 40%.2 It is also comparable to more recent Australian statistics, which report a 30% rate of emergency Caesarean section in this group.3 There is a paucity of published data on instrumental rates for VBACs, but perhaps the most comparable group is primiparous women in labour. The most recent NSW Mothers and Babies Report4 states that the instrumental rate in primiparous women is approximately 23%, well above our rate of 17.5%. With respect to the two perinatal deaths in our cohort, we made no attempt to hide these results even though they did not feature in our abstract. We also had no intention of implying that NSW Health policies be blindly followed, which is why our concluding paragraph criticises the proposed 2015 target for VBAC rates as being unrealistic and potentially dangerous, reiterating that attempting to increase VBAC rates might have ‘significant costs such as increased rates of uterine rupture’. Of course, the VBAC vs elective repeat caesarean (ERCS) debate will always be a matter of perspective. One cannot simply use infrequent adverse outcomes in VBACs to justify a universal recommendation for ERCS, particularly without acknowledging the similarly grave potential consequences of multiple ERCS. By the time of 4th Caesarean section, risk of placenta accreta is 2.1% and rate of peripartum hysterectomy 2.4%.5 Like adverse outcomes from attempted VBAC, such complications threaten both maternal and fetal welfare. Although a 3rd or 4th Caesarean may not be a consideration for many women contemplating VBAC, it cannot be assumed that desire for a large family is the exception to the rule. This is particularly so for socio-demographically diverse communities such as that which is serviced by our hospital.
We acknowledge that in the first instance, efforts must be directed towards lowering the rates of primary Caesarean section. However, once the primary Caesarean has taken place, we stand by our belief that the combination of a well-structured NBAC clinic with the supervision of enthusiastic consultant obstetricians can help to select and support a cohort of women for VBAC to minimise the risks associated with multiple Caesareans. Kate GARDNER1, Amanda HENRY1,2, Steven THOU1, Greg DAVIS1,2 and Trent MILLER1 1 Department of Women and Children’s Health, St George Hospital, Kogarah, 2 School of Women’s and Children’s Health, UNSW Medicine, Randwick, New South Wales, Australia E-mail: [email protected] DOI: 10.1111/ajo.12353
References 1 Gardner K, Henry A, Thou S et al. Improving VBAC rates: the combined impact of two management strategies. Aust N Z J Obstet Gynaecol 2014; 54: 327–332. 2 Turner MJ, Agnew G, Langan H. Uterine rupture and labour after a previous low transverse caesarean section. BJOG 2006; 113: 729–732. 3 Crowther CA, Dodd JM, Hiller JE et al. Planned vaginal birth or elective repeat caesarean: patient preference restricted cohort with nested randomised trial. PLoS Med 2012; 9: e1001192. 4 Centre for Epidemiology and Evidence. New South Wales Mothers and Babies 2010. Sydney: NSW Ministry of Health, 2012. 5 Silver RM, Landon MB, Rouse DJ et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107: 1226–1232.
Re: Paxton JL, Presneill J, Aitken L. Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital. Aust N Z J Obstet Gynaecol 2014; 54: 445–449. Paxton et al.1 make the case that, particularly in the developed world, intensive care unit (ICU) admission per se may not be a clear indicator of severe obstetric morbidity. We agree; in our experience, one reason for this is a lack of obstetric high dependency units (HDUs) to provide close monitoring, for example of women who have had significant haemorrhage (with or without laparotomy) or severe preeclampsia, but who nevertheless do not require intense ICU observation/intervention. However, as the authors note, a substantial number of women with severe morbidity do require significant ICU involvement. We therefore believe that ICU admission
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
195
Letters to the Editor
should not be completely discarded as a marker for severe morbidity, but rather should be examined in the context of the underlying illness and pathology. The World Health Organization (WHO) proposed for identification of maternal near-miss in 2009 uses a combination of criteria to identify these cases: clinical, interventional (including ICU admission), and laboratory based.2 WHO defines a near-miss as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”. We suggest that in the developed world it is more appropriate to consider a combination of criteria as proposed by the WHO and include ICU admission with at least one other indicator of severe morbidity such as the need for peripartum hysterectomy or more than 5U of blood transfusion. We found this system workable in the setting of a large regional hospital in North Queensland in 2009–2010.3 On the other hand, in developing countries ICU admission can be a very useful marker of severe maternal morbidity; in a recent review of maternal morbidity at Port Moresby General Hospital, 70% of maternal near-miss cases should expect to require ICU intervention.4 However, in many under-resourced countries, the lack of ICU beds means that many women for whom intense monitoring and intervention would be indicated are never admitted; here also ICU admission needs to be combined with clinical and laboratory-based criteria to identify nearmisses. The WHO criteria are designed to enable individual units to assess and compare their severe maternal morbidity management and outcomes, and thus differ from the surveillance strategies of bodies such as AMOSS and UKOSS, which deal with national trends and rare events, although the two approaches can be complementary. We are continuing to research the application of the WHO criteria in several other Australasian hospitals and hope that others will do the same. Skandarupan JAYARATNAM1 and Caroline de COSTA2 1 Obstetrics and Gynaecology Clinical Care Unit, King Edward Memorial Hospital, Perth, Western Australia, Australia 2 Obstetrics and Gynaecology, School of Medicine, James Cook University, Cairns, Queensland, Australia E-mail: [email protected] DOI: 10.1111/ajo.12314
196
References 1 Paxton JL, Presneill J, Aitken L. Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital. Aust N Z J Obstet Gynaecol 2014; 54: 445–449. 2 Say L, Souza JP, Pattinson R, for the WHO working group on Maternal Mortality classifications. Maternal near-miss – towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009; 23: 287– 296. 3 Jayaratnam S, de Costa C, Howat P. Developing an assessment tool for maternal morbidity ‘near-miss’ – a prospective study in a large Australian regional hospital. Aust N Z J Obstet Gynaecol 2011; 51: 421–425. 4 World Health Organization (WHO). Evaluating the quality of care for severe pregnancy complications – The WHO near-miss approach for maternal health, 2011. [Accessed 28 November, 2014]. Available from URL: http://www.who.int/reproductivehealth/en
Re: Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital We fully agree with these authors that the fact of an intensive care unit (ICU) admission for an obstetric patient1 is a potentially useful but also confounded marker for severe obstetric morbidity. The receipt of treatment in an ICU by an obstetric patient should be interpreted in the context of the patient’s clinical comorbidities, the modalities of critical care support provided and the characteristics of the health system in the relevant country. We also agree that the absence of a specific obstetric high-dependency unit (HDU) on our campus likely contributed to the relatively high-admission rate of the obstetric cohort to our general adult ICU. There is evidence that specialist obstetric HDUs may be associated with safe care with a lower rate of patient transfer to ICU.2 The absence of an Australian national funding model for HDUs may influence the practices that we reported.3 We strongly support the need for a binational Australian and New Zealand collection of World Health Organization criteria and other relevant data to fully characterise obstetric critical care in our region. The challenge is to reach agreement on the data fields to be collected and the funding mechanism for such an endeavour. Given this area of practice represents the intersection between intensive care and obstetrics, it may be useful to build on the experience of a collaboration between The Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) and the Australasian Maternity Outcomes Surveillance System (AMOSS) which characterised the effects of influenza in the pregnant and post-partum population in 2009.4
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Reference 1 Gardner K, Henry A, Thou S et al. Improving VBAC rates: the combined impact of two management strategies. Aust NZ J Obstet Gynaecol 2014; 54: 327–332.
Re: Improving VBAC rates: The combined impact of two management strategies Dear Editor, We thank Professor Dietz for his interest in our paper, Improving VBAC rates: the combined impact of two management strategies.1 We would first like to respond to the criticism regarding the high number of emergency Caesarean sections (35.6%) and instrumental deliveries (17.5%) amongst our cohort of VBAC candidates who elected to have a trial of labour. Our figures are well aligned with the VBAC success rates described in the literature with most series reporting a likelihood of vaginal birth in the range of 60– 80% giving an emergency Caesarean section rate from 20 to 40%.2 It is also comparable to more recent Australian statistics, which report a 30% rate of emergency Caesarean section in this group.3 There is a paucity of published data on instrumental rates for VBACs, but perhaps the most comparable group is primiparous women in labour. The most recent NSW Mothers and Babies Report4 states that the instrumental rate in primiparous women is approximately 23%, well above our rate of 17.5%. With respect to the two perinatal deaths in our cohort, we made no attempt to hide these results even though they did not feature in our abstract. We also had no intention of implying that NSW Health policies be blindly followed, which is why our concluding paragraph criticises the proposed 2015 target for VBAC rates as being unrealistic and potentially dangerous, reiterating that attempting to increase VBAC rates might have ‘significant costs such as increased rates of uterine rupture’. Of course, the VBAC vs elective repeat caesarean (ERCS) debate will always be a matter of perspective. One cannot simply use infrequent adverse outcomes in VBACs to justify a universal recommendation for ERCS, particularly without acknowledging the similarly grave potential consequences of multiple ERCS. By the time of 4th Caesarean section, risk of placenta accreta is 2.1% and rate of peripartum hysterectomy 2.4%.5 Like adverse outcomes from attempted VBAC, such complications threaten both maternal and fetal welfare. Although a 3rd or 4th Caesarean may not be a consideration for many women contemplating VBAC, it cannot be assumed that desire for a large family is the exception to the rule. This is particularly so for socio-demographically diverse communities such as that which is serviced by our hospital.
We acknowledge that in the first instance, efforts must be directed towards lowering the rates of primary Caesarean section. However, once the primary Caesarean has taken place, we stand by our belief that the combination of a well-structured NBAC clinic with the supervision of enthusiastic consultant obstetricians can help to select and support a cohort of women for VBAC to minimise the risks associated with multiple Caesareans. Kate GARDNER1, Amanda HENRY1,2, Steven THOU1, Greg DAVIS1,2 and Trent MILLER1 1 Department of Women and Children’s Health, St George Hospital, Kogarah, 2 School of Women’s and Children’s Health, UNSW Medicine, Randwick, New South Wales, Australia E-mail: [email protected] DOI: 10.1111/ajo.12353
References 1 Gardner K, Henry A, Thou S et al. Improving VBAC rates: the combined impact of two management strategies. Aust N Z J Obstet Gynaecol 2014; 54: 327–332. 2 Turner MJ, Agnew G, Langan H. Uterine rupture and labour after a previous low transverse caesarean section. BJOG 2006; 113: 729–732. 3 Crowther CA, Dodd JM, Hiller JE et al. Planned vaginal birth or elective repeat caesarean: patient preference restricted cohort with nested randomised trial. PLoS Med 2012; 9: e1001192. 4 Centre for Epidemiology and Evidence. New South Wales Mothers and Babies 2010. Sydney: NSW Ministry of Health, 2012. 5 Silver RM, Landon MB, Rouse DJ et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107: 1226–1232.
Re: Paxton JL, Presneill J, Aitken L. Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital. Aust N Z J Obstet Gynaecol 2014; 54: 445–449. Paxton et al.1 make the case that, particularly in the developed world, intensive care unit (ICU) admission per se may not be a clear indicator of severe obstetric morbidity. We agree; in our experience, one reason for this is a lack of obstetric high dependency units (HDUs) to provide close monitoring, for example of women who have had significant haemorrhage (with or without laparotomy) or severe preeclampsia, but who nevertheless do not require intense ICU observation/intervention. However, as the authors note, a substantial number of women with severe morbidity do require significant ICU involvement. We therefore believe that ICU admission
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
195
Letters to the Editor
should not be completely discarded as a marker for severe morbidity, but rather should be examined in the context of the underlying illness and pathology. The World Health Organization (WHO) proposed for identification of maternal near-miss in 2009 uses a combination of criteria to identify these cases: clinical, interventional (including ICU admission), and laboratory based.2 WHO defines a near-miss as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”. We suggest that in the developed world it is more appropriate to consider a combination of criteria as proposed by the WHO and include ICU admission with at least one other indicator of severe morbidity such as the need for peripartum hysterectomy or more than 5U of blood transfusion. We found this system workable in the setting of a large regional hospital in North Queensland in 2009–2010.3 On the other hand, in developing countries ICU admission can be a very useful marker of severe maternal morbidity; in a recent review of maternal morbidity at Port Moresby General Hospital, 70% of maternal near-miss cases should expect to require ICU intervention.4 However, in many under-resourced countries, the lack of ICU beds means that many women for whom intense monitoring and intervention would be indicated are never admitted; here also ICU admission needs to be combined with clinical and laboratory-based criteria to identify nearmisses. The WHO criteria are designed to enable individual units to assess and compare their severe maternal morbidity management and outcomes, and thus differ from the surveillance strategies of bodies such as AMOSS and UKOSS, which deal with national trends and rare events, although the two approaches can be complementary. We are continuing to research the application of the WHO criteria in several other Australasian hospitals and hope that others will do the same. Skandarupan JAYARATNAM1 and Caroline de COSTA2 1 Obstetrics and Gynaecology Clinical Care Unit, King Edward Memorial Hospital, Perth, Western Australia, Australia 2 Obstetrics and Gynaecology, School of Medicine, James Cook University, Cairns, Queensland, Australia E-mail: [email protected] DOI: 10.1111/ajo.12314
196
References 1 Paxton JL, Presneill J, Aitken L. Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital. Aust N Z J Obstet Gynaecol 2014; 54: 445–449. 2 Say L, Souza JP, Pattinson R, for the WHO working group on Maternal Mortality classifications. Maternal near-miss – towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009; 23: 287– 296. 3 Jayaratnam S, de Costa C, Howat P. Developing an assessment tool for maternal morbidity ‘near-miss’ – a prospective study in a large Australian regional hospital. Aust N Z J Obstet Gynaecol 2011; 51: 421–425. 4 World Health Organization (WHO). Evaluating the quality of care for severe pregnancy complications – The WHO near-miss approach for maternal health, 2011. [Accessed 28 November, 2014]. Available from URL: http://www.who.int/reproductivehealth/en
Re: Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital We fully agree with these authors that the fact of an intensive care unit (ICU) admission for an obstetric patient1 is a potentially useful but also confounded marker for severe obstetric morbidity. The receipt of treatment in an ICU by an obstetric patient should be interpreted in the context of the patient’s clinical comorbidities, the modalities of critical care support provided and the characteristics of the health system in the relevant country. We also agree that the absence of a specific obstetric high-dependency unit (HDU) on our campus likely contributed to the relatively high-admission rate of the obstetric cohort to our general adult ICU. There is evidence that specialist obstetric HDUs may be associated with safe care with a lower rate of patient transfer to ICU.2 The absence of an Australian national funding model for HDUs may influence the practices that we reported.3 We strongly support the need for a binational Australian and New Zealand collection of World Health Organization criteria and other relevant data to fully characterise obstetric critical care in our region. The challenge is to reach agreement on the data fields to be collected and the funding mechanism for such an endeavour. Given this area of practice represents the intersection between intensive care and obstetrics, it may be useful to build on the experience of a collaboration between The Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) and the Australasian Maternity Outcomes Surveillance System (AMOSS) which characterised the effects of influenza in the pregnant and post-partum population in 2009.4
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
