Clinical controversies: applying evidence in practice

Abstract

What does knowledge of current evidence from published research offer clinicians at the bedside? The answer may seem obvious. One needs to know the efficacy, risk of adverse consequences, and treatment options. Two articles in this issue summarize the current evidence on controversial topics today: induction of labor with misoprostol and vaginal birth after cesarean (VBAC-TOL). After I read these articles, it struck me that I need more information before I can apply this in practice. Alisa Goldberg, MD, MPH, and Deborah Wing, MD, review the efficacy and risks associated with the use of misoprostol for induction of labor. This article coincides with the release of the American College of Obstetricians and Gynecologists Committee Opinion1 summarizing the 2002 Food and Drug Administration (FDA) labeling requirements for use of misoprostol in pregnancy. These publications reassure me that induction of labor with misoprostol is safe for women who have not had prior uterine surgery. Effective doses and dosing intervals have been determined, and although the most catastrophic adverse effect is uterine rupture, the incidence is so rare that randomized trials with large enough numbers to determine risk cannot be performed.2 Misoprostol is associated with a small increase in hyperstimulation (with and without fetal heart rate changes) and a possible increase in meconium stained amniotic fluid.2 Although it is a relief to finally have this important information summarized and guidelines available, each individual setting has unique concerns that are equally important but not addressed in these documents. Does the woman have a fetus that appears healthy? Do I have the time and resources available to monitor her and the fetus following administration of this drug? Are my collaborating partners comfortable with this plan considering the caseload we are handling today? Similarly, the article by Nancy O'Brien-Abel, RNC, MN, on risk of uterine rupture in women undergoing VBAC-TOL summarizes the complex issues that some controversial clinical scenarios present. Thus, my second thought after “thank you for this information” is “what more do I need to know?” Ms. O'Brien-Abel reviews the risk of uterine rupture in relation to maternal history and events that develop during the intrapartum period. However, before I offer VBAC-TOL to an individual, I need to tell her both the risk of uterine rupture and her probability of having a successful VBAC. The risk of uterine rupture is presented in this issue. The chance of having a successful VBAC involves analysis of a different set of data. Did she have the previous cesarean birth electively for a breech presentation, or following a 6-hour second stage? More importantly, who should provide her with this information? Should the midwife who is managing her labor, the physician who might have to perform a cesarean birth, or both of us have a formal discussion with her before proceeding? We have a commitment to empower women with knowledge and to offer safe care. Knowledge of current evidence is the first essential step and I thank the authors who contributed to this issue for sharing information all clinicians seek. Every clinical scenario takes place in a setting with resources that are specific to that setting. Practices that are considered safe in a tertiary care center may not be safe in a level 1 community hospital. An intervention that might be safe at noon may not be safe at midnight. Each woman brings her own strengths and vulnerabilities that must also be considered. And, because any clinical scenario in which the management is controversial may require participation from collaborating partners, plans for management must involve these providers. Every day I have to ask, “Is it safe for me to offer this care to this person in this setting at this time?”