Vaginal birth after cesarean and trial of labor after cesarean: what should we be recommending relative to maternal risk:benefit?

Trial of labor after cesarean (TOLAC) delivery is currently a hot obstetrical topic owing to the acute rise in the rate of cesarean deliveries, both primary and repeat. When the physician and patient are considering TOLAC, several factors should be considered: risk of uterine rupture, contraindications, minimizing risk and morbidity, choosing the appropriate candidate and whether or not to induce. Each patient has her own set of individual risk factors that may decrease her chance of successful vaginal birth after cesarean delivery or increase her risks with TOLAC. Once all things are considered, the risk:benefit of TOLAC should be weighed up before a decision is reached. Each of these factors is discussed in respect to maternal risk:benefit, with the focus on evidence presented in the current literature.     

Should the capability approach be applied in Health Economics?

This editorial questions the implications of the capability approach for health economics. Two specific issues are considered: the evaluative space of capablities (as opposed to health or utility) and the decision-making principle of maximisation. The paper argues that the capability approach can provide a richer evaluative space enabling improved evaluation of many interventions. It also argues that more thought is needed about the decision-making principles both within the capability approach and within health economics more generally. Specifically, researchers should analyse equity-oriented principles such as equalisation and a 'decent minimum' of capability, rather than presuming that the goal must be the maximisation of capability.     

Do tort reforms impact the incidence of birth by cesarean section? A reassessment

Investigations into the existence and impact of defensive medicine in obstetrics have produced mixed and often conflicting implications. The most widely-cited and accepted results in this literature find that less severe malpractice environments cause an increase in the use of cesarean section. This has been interpreted as “offensive medicine”; taking advantage of lenient malpractice environments by providing unnecessary services in order to raise revenue. In this article we show that an assumption concerning births with an unknown method of delivery, which is not explicitly stated in the literature, is pivotal in obtaining these results. Using data on tort reforms and birth outcomes from 1989 to 2001 in 24 US states, we show that for the 98.4% of births with a confirmed method of delivery, the estimated effects of tort reform on C-section rates are insignificant. Therefore, without this assumption, there is little evidence to support an interpretation of offensive medicine.     

How safe is vaginal birth after cesarean section for the mother and fetus?

Compared with planned repeat low-transverse cesarean section, vaginal birth after cesarean section (VBAC) is not associated with increased risk of maternal or neonatal mortality (strength of recommendation [SOR]: B). Morbidity is slightly increased, as evidenced by higher uterine rupture rates and some neonatal outcome measures (SOR: B).     

Quality of life in a broader perspective: Does ASCOT reflect the capability approach?

Purpose

Economic evaluation of services and interventions in care services tends to focus on quality of life(QoL) based on health-related measures such as EQ5D, with a major focus on health and functioning. The Capability Approach (CA) provides an alternative framework for measuring QoL and challenges some of the conventional issues in the current practice of measurement of QoL. The Adult Social Care Outcomes Toolkit (ASCOT) aims to measure social care-related QoL in a broad sense. This article investigates whether and, if so, how the ASCOT addresses issues put on the agenda by the CA.

Methods

Literature analysis concerning theoretical assumptions and arguments of CA and ASCOT.

Results

The Capability Approach (CA) puts three issues on the agenda regarding QoL. First, the focus of evaluation should not be on functioning, but on freedom of choice. Second, evaluation should be critical about adaptive preferences, which entail that people lower expectations in situations of limited possibilities. Third, evaluation should not only address health, but also other domains of life. Our analysis shows that freedom of choice is reflected in the response option ‘as I want’ in the ASCOT questionnaire. The problem of adaptive preferences is countered in the ASCOT by developing a standard based on preferences of the general population. Third, the ASCOT contains several domains of life.

Conclusions

We conclude that the CA and the ASCOT contribute to the discussion on QoL, and that the ASCOT operationalizes core assumptions of the CA, translating the issues raised by the CA in a practical way.

     

Do capability and functioning differ? A study of U.K. survey responses

A core feature of the capability approach is that a person's capabilities (what they are able to do and be in their life) can differ from their functionings (what they actually do and are in their life). However, the degree to which capability and functioning differ in practice is unclear. This paper investigates this issue, focusing on capability and functioning differences (CFD) across different aspects of life and different individuals. In the study, the ICECAP‐A capability questionnaire was modified to measure both functionings and capabilities and was completed by U.K.‐based convenience sample of 943 people. Around one third of people reported CFD in at least one area of their life, most commonly in terms of their “achievement.” People were more likely to report CFD when they had a degree‐level education and when they had impaired health. An additional finding was that capability varied more with education whereas functioning varied more with health status. This finding needs further examination, but it suggests that the choice of evaluative space may influence how priorities are set for public spending.     

Primary care managers’ perceptions of their capability in providing care planning to patients with complex needs

Objectives

The aim of this study was to investigate primary care managers’ perceptions of their capability in providing care planning to patients with complex needs. Care planning is defined as a process where the patient, family and health professionals engage in dialogue about the patient’s care needs and plan care interventions together.

Biobanks and the ‘well-being’ of humanity: integrating consent to research with the capability approach

Among the important ethical challenges that biobanks raise, the shortcoming of the traditional acceptation of informed consent is one of the most debated. The protection of research participants’ autonomy is a central theme in current ethical reasoning on biomedical research. In this article, I argue that moral philosophy offers the opportunity to broaden the debate raised by the shortcomings of the established doctrine of informed consent when applied to biobanking activities. The capability approach and deliberative democracy theories are particularly interesting in analyzing biobanks and informed consent because they shift the focus from the relationships patient/physician and participants in research/investigator–the bioethics focus–to the well-being of research participants and their ability to self-determination understood as a mean by which individuals participate in the societal arrangements that underscore biobanks’ regulation, thus fostering the democratic deliberative process. My claim is that many ethical issues raised are better understood and eventually solved if a broader definition of the notion of autonomy as put forth by moral and political theory is integrated in the discourse of biobanking and informed consent.

Philosophy is like this: eternally unsettled and only occasionally disturbed by new facts

Matt Ridley, Nature via Nurture, p.23     

Longitudinal assessment of anti-Müllerian hormone after cesarean section and influence of bilateral salpingectomy on ovarian reserve

ObjectiveThis study aimed to compare longitudinal changes in ovarian reserve markers after cesarean section (CS) with and without bilateral salpingectomy (BS).Study designWe prospectively enrolled women >35 weeks’ gestation scheduled for CS alone or CS + BS and obtained blood samples for anti-Müllerian hormone prior to surgery and at 3 and 6 months after surgery. At the 3-month visit, we similarly performed transvaginal ultrasound for antral follicle count.ResultsWe enrolled 50 women; 30 underwent CS only and 20 underwent CS + BS. Although anti-Müllerian hormone level increased over 6 months of follow-up in both groups, no clinically important differences in the geometric mean (interquartile range) (ng/mL) were observed at any timepoint (baseline [0.69 {0.36?1.21} {CS only} vs 0.49 {0.32?2.10} {CS + BS}, p = 0.64]; 3 months [1.35 {0.58?3.13} vs 1.45 {1.04?2.25}, p = 0.79]; and 6 months [1.74 {0.93?4.45} vs 2.60 {1.41?5.10}, p =0.27]). Similarly, we detected no difference in antral follicle count.ConclusionBS at the time of CS does not have a negative impact on ovarian reserve 6 months after surgery.ImplicationWhile our results provide reassuring data that bilateral salpingectomy for permanent contraception at the time of cesarean section does not impact ovarian reserve, longer adequately powered studies are needed.     

Does intravenous fentanyl affect Apgar scores and umbilical vessel blood gas parameters in cesarean section under general anesthesia?

The administration of opioids during induction of general anesthesia is a matter of challenge in obstetric anesthesia. The aim of this study was to investigate the effects of intravenous fentanyl before induction of general anesthesia on the"1st and 5th minutes' Apgar scores" in neonates with elective cesarean surgery. In a double blinded randomized clinical trial on 60 parturients undergoing elective cesarean surgeries under general anesthesia in Vali-e-Asr Hospital, in Tehran, Iran, were divided randomly into two groups; the intervention group and the control. In intervention group, intravenous fentanyl 1μg/kg was administrated three minutes before anesthesia induction. The induction route, laryngoscopy and tracheal intubation were the same in the groups. The blood pressure (BP) and heart rate (HR) measures were recorded before anesthesia induction (as baseline measures) and so during laryngoscopy and intubation. The 1st and 5th minute's apgar scores and the pH of umbilical cord arterial and venous samples were compared in two groups. The systolic and diastolic blood pressure, mean arterial pressure and heart rate changes before and after induction and in various times after intubation showed significant difference between two groups (P<0.05). The 1st and 5th minute's Apgar scores of the neonate and umbilical cord arterial and venous blood gas analysis were not statistically different between two groups (P>0.05). Based on the results of this study, the administration of 1 μg/Kg intravenous Fentanyl, three minutes before induction of anesthesia for cesarean section can lead to a stable hemodynamic situation in mother and showed no effects on neonate`s outcomes. Fentanyl showed no effects on Apgar scores and on umbilical cord arterial and venous blood gases analysis and it probably can be used safely in elective cesarean surgeries. More studies are required to obtain a clear view.     

From anatomical ‘competence’ to complex capability. The views and experiences of UK tutors on how we should teach anatomy to medical students

Developments in clinical education have recently challenged the identity of anatomy teaching and learning, leading to high profile debate over the potential implications for the competence levels of new doctors. However, the emphasis remains on methods of teaching, rather than a review of what well-rounded anatomical learning actually entails, and how teaching can address contemporary learning needs. This paper identifies and addresses some of these issues, drawing on expert views captured in qualitative research with anatomy tutors at twenty different medical schools in the UK. Three main themes emerging from our analysis are described: anatomy as a subject matter, the challenges of teaching or learning anatomy, and the use of teaching methods. We also detail how inductive analysis generated new hypotheses worthy of further consideration. These fall into two key categories: (1) improving anatomy curriculum design and (2) advancing anatomy education research.     

Relationship between habitual physical activity,motor capacity,and capability in children with cerebral palsy aged 4–5 years across all functional abilities

Background

Children with cerebral palsy (CP) have lower habitual physical activity (HPA) than their typically developing peers. There are limited studies of HPA in young children with CP under the age of 5 years.

Evaluation of the immunogenic capability of the BCG strains BCGΔBCG1419c and BCGΔBCG1416c in a three-dimensional human lung tissue model

Tuberculosis (TB) still remains as an unmet global threat. The current vaccine is not fully effective and novel alternatives are needed. Here, two vaccine candidate strains derived from BCG carrying deletions in the BCG1416c or BCG1419c genes were analysed for their capacity to modulate the cytokine/chemokine profile and granuloma formation in a human lung tissue model (LTM). We show that the clustering of monocytes, reminiscent of early granuloma formation, in LTMs infected with BCG strains was similar for all of them. However, BCGΔBCG1419c, like M. tuberculosis, was capable of inducing the production of IL-6 in contrast to the other BCG strains. This work suggests that LTM could be a useful ex vivo assay to evaluate the potential immunogenicity of novel TB vaccine candidates.