Article first published online: 22 DEC 2003
BJOG: An International Journal of Obstetrics & Gynaecology
Volume 110, Issue 4, page xxi, April 2003
How to Cite
Thornton, J. G. (2003), Editor's Choice. BJOG: An International Journal of Obstetrics & Gynaecology, 110: xxi. doi: 10.1046/j.1471-0528.2003.51104.x
- Issue published online: 22 DEC 2003
- Article first published online: 22 DEC 2003
Forceps or vacuum again
Much of the debate about the relative merits of the forceps or vacuum extractor (some people prefer to call it the ventouse) for instrumental vaginal delivery has gone on in the pages of this journal. Over the last 20 years, we have published 3 of the 10 randomised comparisons between the two types of instrument, as well as innumerable reviews and commentaries. This month we not only report two more cases of serious fetal injury following instrumental delivery (Inusekar and Olah, pages 436–438), but also report yet another trial. Let me summarise the story so far. Opinion had been both divided and strongly held, until a systematic review of the randomised trials appeared to show that the vacuum was less likely to cause severe maternal injury. Because there was little clear evidence of any other differences, opinion leaders started to recommend the vacuum, and within a short time a substantial shift away from forceps occurred in the United Kingdom. Nevertheless, some advocates of the forceps remained unconvinced. They argued that the assessment of perineal injury in the trials had been conducted mostly by the doctors who performed the delivery themselves. Because they knew the trial allocation, they may have been biased. These sorts of claims received a boost four years ago when a five year follow up of women recruited to one of the largest and best-conducted trials appeared to show no long term differences in outcome. In the places where I have worked recently this led to a small swing back towards the forceps, and in Dublin it has provoked yet another trial which we report this month. Fitzpatrick et al. (pages 424–429) have tested the hypothesis that use of the vacuum as the first instrument of choice reduced maternal fecal incontinence at three months. It does. I doubt this will be the last comparison of these two instruments; concerns about fetal safety for both instruments remain and many experts still wonder whether the benefits of the vacuum apply to all the situations where both instruments could be used. Any future trials should ensure that data on head level, position and moulding, as well as the presence or otherwise of fetal distress, are collected pre-randomisation so that unbiased subgroups can be analysed separately. In the meantime, I predict yet another swing of the pendulum towards use of the vacuum.
Second generation endometrial ablation
The other randomised trial in this issue concerns the relative efficacy of thermal balloon and laser ablation of the endometrium. Such trials are notoriously difficult to do well. Timing is problematic. If the trials are done too soon, surgeons may be relatively unskilled, but if left too late, the moment for evaluation may pass. A one year follow up is pretty much the minimum, but is often difficult to achieve. Co-interventions such as the agents used for endometrial preparation, or use of hysteroscopy leading to differential post-randomisation exclusions can easily muddle the interpretation. Ray Garry's Middlesborough team is to be congratulated on the success of the study they conducted before his recent move to Australia, and which they report on pages 350–357 (Hawe et al.). The two techniques appear to be broadly equivalent, but there is room to improve case selection. No less than 9 of the 77 women followed up for a year had either undergone hysterectomy or were listed for one by that time. However, the paper from Leeds (Wright et al., pages 358–363) suggests that predicting such poor results will be difficult. Psychiatric morbidity usually improves after endometrial ablation, even in those whose objectively measured menstrual loss was normal pre-operatively.
Magnetic resonance imaging
There are two papers on magnetic resonance imaging in this issue. In adult women, magnetic resonance imaging of the brain provides a non-invasive way to evaluate the cerebral changes in diseases such as pre-eclampsia (Rutherford et al., pages 416–423). The metabolic changes detected are intriguing, albeit based on small numbers. The second magnetic resonance imaging study in dead babies is relevant to recent debates about paediatric autopsy. The organ retention scandal in Alder Hay hospital in Liverpool and the subsequent discovery that many other hospitals were also retaining fetal organs without informed parental consent has led increasing numbers of parents to decline postmortem examination of their babies. Paediatric pathologists are looking at alternative diagnostic methods, such as magnetic resonance imaging. Among pregnancies terminated for fetal abnormality, we already know that magnetic resonance imaging is reasonably accurate in the diagnosis of neurological abnormalities. In this issue, Alderliesten and her colleagues from the Academic Medical Centre in Amsterdam report their experience in a series of pregnancies that ended in spontaneous fetal death. The results are only fair. Careful external inspection would have detected some of the abnormalities missed by magnetic resonance imaging, but not all. The message for parents is the same as it has always been. Non-invasive imaging such as magnetic resonance imaging is pretty good, but if you really want to maximise the chance of finding the cause of death, you need a full postmortem.