Trial of labor or repeated cesarean section. The woman's choice.

OBJECTIVE: To develop recommendations for the preferred delivery method for a pregnant woman who underwent a previous low transverse cesarean section and who has no contraindications to labor. DATA SOURCES: MEDLINE searches and the references from retrieved articles yielded 759 citations. Search terms included trial of labor (TOL), trial of scar, vaginal birth after cesarean section (VBAC), and uterine rupture. STUDY SELECTION: Articles with primary outcomes data contrasting TOL and elective repeat cesarean section (ERCS) were analyzed. Studies from developing countries or before 1980 were excluded. DATA EXTRACTION: Data from 292 articles were extracted independently by at least 2 team members using a structured form. DATA SYNTHESIS: Outcome data were combined using commercially available software and are presented as absolute differences per 10,000, with 95% Bayesian confidence intervals. Maternal outcomes showed that TOL increased the risk for uterine rupture (23.9 [0.24%]); ERCS increased the risk for infection (522 [5.22%]) and bleeding (58.6 [0.59%]). Infant outcomes differed only for 5-minute Apgar scores of less than 7, which were more likely for infants whose mothers underwent TOL (85 [0.85%]). Other outcomes (eg, disability), patient preferences, and cost data did not lend themselves to meta-analysis and were examined separately. While two thirds of women desired TOL, one third preferred ERCS. Costs were 1.7 to 2.4 times greater for ERCS. CONCLUSIONS: A woman should be given information on both delivery methods and encouraged to undergo TOL, but her preference for ERCS should be respected.

Skull x-ray examinations after head trauma. Recommendations by a multidisciplinary panel and validation study.

The value of skull radiography in identifying intracranial injury has not yet been satisfactorily defined. A multidisciplinary panel of medical experts was assembled to review the issue of skull radiography for head trauma. The panel identified two main groups of patients--those at high risk of intracranial injury and those at low risk of such injury--and developed a management strategy for imaging in the two groups. The high-risk group consists primarily of patients with severe open or closed-head injuries who have a constellation of findings that are usually clinically obvious. These patients are candidates for emergency CT scanning, neurosurgical consultation, or both. The low-risk group includes patients who are asymptomatic or who have one or more of the following: headache, dizziness, scalp hematoma, laceration, contusion, or abrasion. Radiographic imaging is not recommended for the low-risk group and should be omitted. An intermediate moderate-risk group is less well defined, and skull radiography in this group may sometimes be appropriate. A prospective study of 7035 patients with head trauma at 31 hospital emergency rooms was conducted to validate the management strategy. No intracranial injuries were discovered in any of the low-risk patients. Therefore, no intracranial injury would have been missed by excluding skull radiography for low-risk patients, according to the protocol. We conclude that use of the management strategy is safe and that it would result in a large decrease in the use of skull radiography, with concomitant reductions in unnecessary exposure to radiation and savings of millions of dollars annually.

Cardiopulmonary resuscitation in rural community hospitals.

Carson-Tahoe Hospital is a 77-bed hospital serving a large rural area. During 22 months cardiopulmonary resuscitation was carried out 89 times in 79 persons. Of these resuscitations, 56 were done in the emergency room and 25 on inpatients. Resuscitation was successful in 46 percent of the patients at least once, and 30 percent of the patients lived and were released. These figures compare favorably with those from larger, urban centers, despite problems unique to smaller hospitals.