violence screening. J Womens Health (Larchmt) 2005;14:713–20. 3. Sprague S, Madden K, Simunovic N, Godin K, Pham NK, Bhandari M, et al. Barriers to screening for intimate partner violence. Women Health 2012;52: 587–605. 4. Intimate partner violence. Committee opinion No. 518. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:412–7.
What is New in Labor Management? Best Articles From the Past Year To the Editor: The age-old method of determining fetal station depends on our ability, through a vaginal examination, to create an imaginary line between both ischial spines and then, with more imagination, to subtract in centimeters the difference between this concocted line and another parallel line traversing through the leading edge of the fetal skull. Throw in 2–3 cm of caput and a head deep in the pelvis, and this becomes a process of, essentially, “winging it.” This is how we diagnose failure to progress, the most common reason that more than 30% of women have cesarean deliveries. In 20091 we introduced a method to accurately determine fetal station with transperineal ultrasound and validated the concept with computed tomography using a geometric model of the pelvis.2 Since then, there have been 12 articles, one editorial, and a book devoted to the use of ultrasonography in labor management—all but one emanating from outside the United States. In the December 2014 issue of the journal3 the “Practice Issues” segment touched on some important facets of labor management, but there was no mention of any of the four articles published last year on ultrasonography in labor. This common oversight is probably why most clinicians in the United States are either uninterested in or even aware of this idea. Vaginal assessment of fetal station (presently the “gold standard”) is subjective, whereas an operatorindependent ultrasound method (should-be gold standard) is objective. Today, when we seem bound by protocols and management algorithms, our present method may seem like our last
1494
Letters
chance, through experience and gestalt, to employ pure clinical acumen. However, this imperfect method can be improved on by an adjunctive boost from ultrasonography. Yes, there is more to clinical management than a drop-down menu, but there also is more to the art of medicine than winging it. Financial Disclosure: The authors did not report any potential conflicts of interest.
John C. Hobbins, MD Department of OB/GYN, University of Colorado, Denver, Colorado Antonino Barbera, MD Department of OB/GYN Banner Fort Collins Medical Center Fort Collins, Colorado
REFERENCES 1. Barbera AF, Pombar X, Perugino G, Lezotte DC, Hobbins JC. A new method to assess fetal head descent in labor with transperineal ultrasound. Ultrasound Obstet Gynecol 2009;33:313–19. 2. Barbera AF, Imani F, Becker T, Lezotte DC, Hobbins JC. Anatomic relationship between the pubic symphysis and ischial spine and its significance in the assessment of the fetal head engagement and station during labor. Ultrasound Obstet Gynecol 2009;33:320–5. 3. Repke JT. What is new in labor management? Best articles from the past year. Obstet Gynecol 2014;124:1207–9. Editor’s Note: Dr. Repke declined to respond.
that a great number of so-called indicated premature deliveries can be avoided by more intensive management of the conditions complicating pregnancy. Secondly, a more intensive and comprehensive approach to prevention is possible. Regarding the administration of multiple dosages and the association with decreased fetal brain growth, I would be interested in knowing what else may have contributed to the apparent lack of growth. Knowing that this may happen with repeat dosing, I would suggest proactively using the agents that may counter such consequences. Low-dose aspirin and eicosapentaenoic acid have been shown to improve fetal growth. I believe that our attitude toward prevention must be changed and that we must overcome the fear of being sued lest we make a misstep. I believe that lack of progress in prevention of premature birth is due to reluctance of getting out of our comfort zone; “lack pizzazz,” as some put it. Premature births are preventable in a majority of cases. Financial Disclosure: The author did not report any potential conflicts of interest.
Stefan Semchyshyn, MD Jonesborough, Tennessee
REFERENCES 1. Liggins GC, Howie RN. A controlled trial of antepartum treatment for prevention of the respiratory distress syndrome. Pediatrics 1972;50:515.
Appropriate Use of Antenatal Corticosteroid Prophylaxis
2. Goldenberg RL, McClure EM. Appropriate use of antenatal corticosteroid prophylaxis. Obstet Gynecol 2015;125: 285–7.
To the Editor:
3. Semchyshyn S. Patients made key to successful prenatal care. Innovations. Philadelphia (PA): The American College of Physicians; 1993:231.
One wonders whether Dr. Goldenberg and Dr. McClure can answer why it took so long1 to recognize the value of antenatal corticosteroid administration.2 Is it so difficult to discern good news from bad information? Just think how many patients were denied beneficial therapy under the pretense of being cautious. I agree that this mode of prophylaxis is one of the most important interventions, and the most important in prevention of premature birth. Prevention of premature birth is possible more often than you think.3 From my own practice of maternal–fetal medicine for nearly 30 years I can conclude
In Reply: In his letter, Dr. Semchyshyn confuses prevention of preterm birth with prevention of the complications of preterm birth. Antenatal corticosteroids reduce complications but not the risk of preterm birth itself. Preventing preterm birth is complex. With the exceptions of progesterone for some indications, perhaps cervical cerclage, and reducing inappropriate inductions and cesarean
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
What is New in Labor Management? Best Articles From the Past Year To the Editor: The age-old method of determining fetal station depends on our ability, through a vaginal examination, to create an imaginary line between both ischial spines and then, with more imagination, to subtract in centimeters the difference between this concocted line and another parallel line traversing through the leading edge of the fetal skull. Throw in 2–3 cm of caput and a head deep in the pelvis, and this becomes a process of, essentially, “winging it.” This is how we diagnose failure to progress, the most common reason that more than 30% of women have cesarean deliveries. In 20091 we introduced a method to accurately determine fetal station with transperineal ultrasound and validated the concept with computed tomography using a geometric model of the pelvis.2 Since then, there have been 12 articles, one editorial, and a book devoted to the use of ultrasonography in labor management—all but one emanating from outside the United States. In the December 2014 issue of the journal3 the “Practice Issues” segment touched on some important facets of labor management, but there was no mention of any of the four articles published last year on ultrasonography in labor. This common oversight is probably why most clinicians in the United States are either uninterested in or even aware of this idea. Vaginal assessment of fetal station (presently the “gold standard”) is subjective, whereas an operatorindependent ultrasound method (should-be gold standard) is objective. Today, when we seem bound by protocols and management algorithms, our present method may seem like our last
1494
Letters
chance, through experience and gestalt, to employ pure clinical acumen. However, this imperfect method can be improved on by an adjunctive boost from ultrasonography. Yes, there is more to clinical management than a drop-down menu, but there also is more to the art of medicine than winging it. Financial Disclosure: The authors did not report any potential conflicts of interest.
John C. Hobbins, MD Department of OB/GYN, University of Colorado, Denver, Colorado Antonino Barbera, MD Department of OB/GYN Banner Fort Collins Medical Center Fort Collins, Colorado
REFERENCES 1. Barbera AF, Pombar X, Perugino G, Lezotte DC, Hobbins JC. A new method to assess fetal head descent in labor with transperineal ultrasound. Ultrasound Obstet Gynecol 2009;33:313–19. 2. Barbera AF, Imani F, Becker T, Lezotte DC, Hobbins JC. Anatomic relationship between the pubic symphysis and ischial spine and its significance in the assessment of the fetal head engagement and station during labor. Ultrasound Obstet Gynecol 2009;33:320–5. 3. Repke JT. What is new in labor management? Best articles from the past year. Obstet Gynecol 2014;124:1207–9. Editor’s Note: Dr. Repke declined to respond.
that a great number of so-called indicated premature deliveries can be avoided by more intensive management of the conditions complicating pregnancy. Secondly, a more intensive and comprehensive approach to prevention is possible. Regarding the administration of multiple dosages and the association with decreased fetal brain growth, I would be interested in knowing what else may have contributed to the apparent lack of growth. Knowing that this may happen with repeat dosing, I would suggest proactively using the agents that may counter such consequences. Low-dose aspirin and eicosapentaenoic acid have been shown to improve fetal growth. I believe that our attitude toward prevention must be changed and that we must overcome the fear of being sued lest we make a misstep. I believe that lack of progress in prevention of premature birth is due to reluctance of getting out of our comfort zone; “lack pizzazz,” as some put it. Premature births are preventable in a majority of cases. Financial Disclosure: The author did not report any potential conflicts of interest.
Stefan Semchyshyn, MD Jonesborough, Tennessee
REFERENCES 1. Liggins GC, Howie RN. A controlled trial of antepartum treatment for prevention of the respiratory distress syndrome. Pediatrics 1972;50:515.
Appropriate Use of Antenatal Corticosteroid Prophylaxis
2. Goldenberg RL, McClure EM. Appropriate use of antenatal corticosteroid prophylaxis. Obstet Gynecol 2015;125: 285–7.
To the Editor:
3. Semchyshyn S. Patients made key to successful prenatal care. Innovations. Philadelphia (PA): The American College of Physicians; 1993:231.
One wonders whether Dr. Goldenberg and Dr. McClure can answer why it took so long1 to recognize the value of antenatal corticosteroid administration.2 Is it so difficult to discern good news from bad information? Just think how many patients were denied beneficial therapy under the pretense of being cautious. I agree that this mode of prophylaxis is one of the most important interventions, and the most important in prevention of premature birth. Prevention of premature birth is possible more often than you think.3 From my own practice of maternal–fetal medicine for nearly 30 years I can conclude
In Reply: In his letter, Dr. Semchyshyn confuses prevention of preterm birth with prevention of the complications of preterm birth. Antenatal corticosteroids reduce complications but not the risk of preterm birth itself. Preventing preterm birth is complex. With the exceptions of progesterone for some indications, perhaps cervical cerclage, and reducing inappropriate inductions and cesarean
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
