A Continued Rise in Caesarean Deliveries
A new study finds than the Caesarean section delivery rate may be increasing even faster than critics believe and the single most significant factor driving the trend is greater reliance on repeat Caesareans.
Those conclusions--certain to disappoint health workers and organizations trying to reduce the surgical birth rate--come from the same group of researchers at the National Institutes of Health who last year found the Caesarean rate to be rising at a discouragingly rapid rate. Last year’s study found that between 1979 and 1984, a period in which major health organizations had been trying to discourage unnecessary Caesareans, the rate rose instead, from 14.1% to 19% of all births.
Working with a different set of data on Caesareans, the same team now has found significant evidence that the increase was even greater--with Caesareans accounting for 21.2% of births in 1984. The earlier conclusions were based on a survey of hospital obstetrical departments. The new findings came from other, independently collected, hospital data.
The new study, published in the journal Obstetrics and Gynecology, found the incidence of breech presentation of the fetus--previously a major reason for Caesarean--has actually declined, even while the rate has gone up. On the other hand, more than a third of Caesareans now are done on women who had already had one--despite repeated findings over the last decade that many women who have a first child by Caesarean can deliver vaginally subsequently.
In fact, in a separate study published in the American Journal of Obstetrics and Gynecology, a team in Mineola, N.Y., found that vaginal birth is a productive approach in women with two or more previous Caesareans. Among 57 such women, 77% were able to deliver vaginally. Contravening this observation, though, the NIH team found that only 4% of women in the United States overall gave birth vaginally after a Caesarean in 1984, but that probably just 2.5% intended to have vaginal birth after a Caesarean. The others would have preferred another section--or, at least, their physicians would have.
Osteopathy Challenge
Osteopathy--which has managed in the more than 90 years it has existed to blunt allegations of quackery and become a branch of legitimate medicine--has always held philosophically that a physician’s touch alone can diagnose much of what may be wrong with a patient.
But this central tenet of osteopathy--a field that has its roots in faith in musculoskeletal manipulation as effective therapy for disease--is coming under challenge from the research community within osteopathy itself.
The latest forum is the Journal of the American Osteopathic Assn., which has just published a study of palpatory diagnosis--the use of touch to determine the nature of disease. The study found doctors using it “did not demonstrate any increased diagnostic accuracy” compared with physicians who didn’t. The study was based on attempts by five osteopathic physicians to diagnose 100 different patients.
But while the finding flies directly in the face of the teachings of Andrew Taylor Still, the founder of osteopathy, the journal issued a calm call for additional research. An editorial argues that osteopathy must get to the root of the issue and determine the scientific validity--or lack of it--of this basic osteopathic concept.
Dr. George Northup, the journal’s editor, observed in a telephone interview from Mesa, Ariz., that the scientific confirmation for much of osteopathy’s root philosophy “is not as firm as we would like.” He said he still believes that subsequent research will confirm the role of touch in diagnosis--a concept physicians in all branches of medicine routinely embrace. The question is: How important is touch alone? “Medical research should never end,” Northup said, “because it’s very dangerous to say we know all we know and there is nothing more to know.”
Laser Heart Surgery
Of all the established and potential uses of lasers in medicine, possibly the most captivating is the prospect the Buck Rogers devices can be used to clear clogged arteries near the heart--replacing conventional bypass surgery. But so far, though there have been extensive experiments with lasers in coronary surgical applications, the use of the light beams in heart operations has not proved safe or effective--largely because lasers tend to burn through the surrounding artery while they remove the plaque inside.
Because the anticipation of this use of lasers is so great, every new research report stands a chance of exciting ever greater interest in laser heart surgery. Now, in the American Heart Journal, a team of physicians at the Cleveland Clinic, the Massachusetts Institute of Technology and at a private laboratory in Irvine report possibly promising new results in use of the argon laser to remove coronary artery fat deposits.
The work was done on human coronary artery specimens obtained from patients who had died. Using new techniques to control the diameter of the laser beam, the team reported success in removing only the plaque without damaging the surrounding arterial wall. The argon laser, the team concluded, “should be effective for laser angiosurgery.”
But Michael Berns, head of UC Irvine’s Beckman Laser Institute and the president of the American Society for Laser Medicine and Surgery, said a careful review of the new conclusions doesn’t change the previous reality. “The bottom line is that all of the major questions are still unresolved and anyone who says differently is not presenting an accurate picture,” he said. “I think there’s still promise. But we’re a long way from going up into a human’s coronary system, where one mistake may be fatal to the patient.”
Coin Rubbing Alert
Among the community of Vietnamese refugees, traditional folk medicine remedies linger--one of which holds that a variety of illnesses in children can be cured by rubbing coins (usually copper ones) on the child’s body. Coin rubbing, though, may leave black and blue marks on the child--and doctors, police officers and school teachers who don’t recognize the marks for what they are may inappropriately institute a child-abuse investigation.
The issue has been a concern in the Vietnamese community for a decade--especially in portions of Orange County where many Vietnamese refugees have settled, but in places as far afield as Mississippi, too. Now, a physician in Pascagoula, Miss., has published a warning to other physicians to be aware of the folk practice and a Vietnamese-born pediatrician in Fountain Valley agrees that while medical personnel and many law enforcement officials have learned to recognize coin rubbing when they see it, many teachers are still ignorant of the practice and its intended purpose.
Dr. Quynh Kieu of Fountain Valley said coin rubbing marks usually appear parallel to the ribs and that while Vietnamese parents have slowly reduced their use of the folk remedy, it remains a custom in many quarters and is likely to remain common for many years to come. Social workers familiar with Vietnamese practices can often avert child abuse prosecutions, she said, but some embarrassing incidents still occur.
