Attitudes of the New Generation of Canadian Obstetricians: How Do They Differ from Their Predecessors?

Background: Attitudes drive practice, perhaps more than evidence . The objective of this study was to determine if the new generation of Canadian obstetricians has attitudes differing from those of their predecessors. Methods: Employing a cross‐sectional, Internet, and paper‐based survey, we conducted an in‐depth study of obstetricians responding to the Canadian National Maternity Care Attitudes Survey. Results: Of the 800 Canadian obstetricians providing intrapartum care, 549 (68.6%) responded. Participants were stratified by age less than or equal to 40 years compared with those over 40 years; 81 percent of those 40 years or younger were women versus 40 percent over 40 years of age. Younger obstetricians were significantly more likely to favor use of routine epidural analgesia and believed that it did not interfere with labor or lead to instrumentation; were more concerned and feared the perineal and pelvic floor consequences of vaginal birth compared with cesarean section; and were significantly less supportive of vaginal birth after prior cesarean section, home birth, birth plans, routine episiotomy, and routine electronic fetal monitoring as providing maternal or fetal benefits. They were less positive than the older generation about a range of approaches to reducing the cesarean section rate, the importance of maternal choice and role in their own birth, and peer review, and they were more likely to believe that women having a cesarean section were not missing an important experience. No significant generational differences were found for ambivalent attitudes to vaginal breech birth. Conclusions: Younger obstetricians were more evidence‐based for some issues and less for others. In general younger obstetricians were more supportive of the role of birth technology in normal birth, including routine epidural analgesia, and they were less appreciative of the role of women in their own birth. They saw cesarean section as a solution to many perceived labor and birth problems. Results suggest a need to examine how obstetricians acquire their favorable attitudes to birth technology in normal birth. (BIRTH 38:2 June 2011)     

Cardiomyopathy of Unknown Etiology: Barth Syndrome Unrecognized

This is a report of a child who died at 20 months from what was clinically thought to be cardiomyopathy of unknown etiology. Barth syndrome, an X‐linked mitochondrial cardioskeletal myopathy, was diagnosed by genetic testing at autopsy. Barth syndrome presents in infancy or childhood with cardiomyopathy, hypotonia, growth delays, and cyclic neutropenia. Other associated laboratory findings can include hypocholesterolemia, relative monocytosis, low prealbumin, low plasma carnitine, and lactic acidosis. The classic echocardiogram finding is left ventricular noncompaction, although not always present. Until recently, the most reliable biochemical finding has been 3‐methylglutaconic aciduria. However, quantitative analysis must be specifically requested for results to be reliable. Recently, a confirmatory tetralinoleoyl cardiolipin high‐pressure liquid chromotography‐tandem mass spectrometry blood test has become available. Genetic testing is also confirmatory and details the underlying mutation. Diagnosis is often missed or delayed and early diagnosis improves survival. The purpose of this case report is to encourage physicians to include Barth syndrome in the differential for cardiomyopathy of uncertain etiology in males, especially in the presence of growth delays, hypotonia, neutropenia, and/or family history of pediatric male death of unknown etiology.     

Airway abnormalities in patients with Arnold-Chiari malformation

OBJECTIVES: The goal was to determine the incidence and types of airway abnormalities in patients with Arnold-Chiari malformation (ACM). METHODS: The study was a retrospective chart review of 24 patients with ACM who were evaluated and treated between November 1991 and August 1997. RESULTS: Eighteen (75%) and 6 (25%) of the 24 patients had types I and II ACM, respectively. Three (12.5% of 24 patients) of the type II ACM patients had vocal cord impairment: 1 bilateral paralysis, 1 bilateral paresis, and 1 unilateral paralysis. None of the type I ACM patients had vocal cord impairment. Tracheotomy was necessary in 3 of the 24 patients and all in patients with type II ACM. Central sleep apnea was found in 5 of 6 type II ACM patients, but not in any of the type I ACM patients. CONCLUSIONS: Vocal cord impairment and sleep apnea were found in 12. 5% and 21%, respectively, of this ACM population. When type II ACM patients were considered separately, the incidences of vocal cord impairment and sleep apnea were 50% and 83%, respectively. Type II ACM patients tend to have a higher incidence of airway abnormalities and other neurologic dysfunctions. Flexible fiberoptic laryngoscopy is recommended in the airway evaluation of ACM patients. Early recognition, diagnosis, and management of these abnormalities may be lifesaving.     

An appreciation of Robert Moors Smith MD,an icon of pediatric anesthesiology

Robert Moors Smith M.D. passed away recently at the age of 97. During his chairmanship of the Department of Anesthesiology at Children’s Hospital Boston from 1946 to 1980 he gained world prominence for his contributions to the anesthetic care of children and the education of generations of pediatric anesthesiologists. His dedicated and earnest approach, reflected in tribute and in his own words, provide a window on pediatric anesthesia during its development into a recognized subspecialty in the 20th century.     

Exotic snakebite: Envenomation by an African puff adder (Bitis arietans)

We report an envenomation by the African puff adder (Bitis arietans), an exotic snake in the United States. The patient developed swelling and ecchymoses in the affected extremity, and cutaneous necrosis of the envenomated fingertip. There was no significant coagulopathy. He received 20 vials of specific antivenin (Schlangengift-Immunserum Behring Zentralafrika, Behringwerke, Marburg, Germany) and debridement of devitalized finger tissue. The only permanent sequelae were cutaneous scarring and permanent loss of the fingernail on the envenomated finger. Exotic snakebite is a rare presenting problem in emergency departments. The initial approach to a patient envenomated by an exotic venomous snake is discussed. Use of antivenin and supportive care are emphasized.