Federation Internationale de Gynecologie et d'Obstetrique
International Federation of Gynecology and Obstetrics
Secretariat: 70 Wii London W1G SAX Unii
Telephone: +44 2l Fax: +44 2<
Email: 1 Website: http:/A
Parents in Action (RODA) Lug, Kneza Trpimira 52 10432Bregana Croatia
20 December 2002
Dear Sirs
I refer to your petition entitled 'My Childbirth, My Body, My Choice' which was forwarded to i International Federation of Gynecology and Obstetrics (FIGO) for comment by Dr Paul van Look the WHO.
Having circulated the petition to several members of the FIGO Advisory Panel on Maternal a Perinatal Health and Obstetrics, the following comments were made:
1.
Professor F van Assche - WHO
The WHO recommendations are for worldwide use, the Croatian hospitals differ in some way from the WHO recommendations.
If the WHO recommendations should be followed in all the delivery places (maternity units) in the world, it would improve perinatal care.
The standards in the developed world will be always higher than in the less developed world.
Croatia tries to compare its own situation with the WHO recommendations.
Croatia has also the intention to improve for some items, in other fields Croatia is maybe more advanced.
I do not see a real conflict.
2. em. Professor Dr Wolfgang Kim/el - Department of Obstetrics & Gynaecolog
University of Giessen
Further to your letter from 15. November 2002 I recommend that Parents in Action (RODA) shou go into a discussion with their local health authorities. It is neither a matter of FIGO nor a matter EBCOG. The items of the provided table could be interesting topics at the next FIGO world Congre in Chile. Most of them are not evidence based in both directions.
3. Professor Gian Carlo Di Renzo - Centre of Perinatal & Reproductive Median
Perugia, Italy
In reference to the document 'My Childbirth, My body, My choice' from the WHO about which y( asked my opinion as an expert, I can tell you as follows:
President; Dr S Sheth (India), Vice-President: The Lord Pats (UK(.
President-Elect; Dr A Acosta (Paraguay), Past-President: Professor M Seppala
[Finland] Treasurer Professc* S AnJkumaran (UK), Secretary General: Protessor G
Benagiano (Italy)
There are no clinical studies which demonstrate that a person close to a pregnant woman during labour may reduce the rate of caesarean sections.
Enemas and pubic shaving have been abandoned as a routine by most hospitals in Italy .The reason of their application in women has been proved to be factitious.
Early amniotomy and early oxytocin infusion are not a way of expediting labour
Routine episiotomy has been abandoned in all maternity hospitals in Italy.
Normal labour usually attended by a midwife. The decision to make an episiotomy is left to her and the rat<
has decreased inprimi gravida to as low as 40%.
Pushing the abdomen during the second phase of labour is a common practice in Italy (we call it 'Kristeller manouvre). Anyway it is limited to 1 or 2 pushing in case of a patient's suddei refractoriness to final pushing or sudden uterine hypocyinesia.
I do not comment the declaration from the TV show and from the daily newspaper because they an not substantiated by evidence based medicine.
If you look at Cochrane Library1 last reports, you may find further details that RODA may use fo ameliorating and modernizing the care during labour and delivery in their country.
4. Dr Usha Krishna - Consulting Obstetrican & Gynaaecologist, Breach Cand;
Hospital, India
I have gone through the RODA correspondence and the WHO recommendations. I agree that « woman should have empathetic support before and during labour. It is most essential that there i: presence of a person close to her before and during labour. A spontaneous onset of labour is desirable if the pregnancy has progressed normally and there are no indications for induction of labour . Then can be different views of doctors and the patients regarding enema, pubic shaving and birth givinj positions. There are patients who may prefer to have enema or lie on the back. However one shoulc encourage the woman to choose the position that suits her best and to move around during the labour Constant electronic monitoring (CTG) all through the labour is not necessary. However admissior test (CTG) is certainly useful even in normal patients and CTG can be used in intra partum perioc when there is prolonged labour or clinical signs of foetal distress.
Early amniotomy and early oxytocin infusion may not be routinely carried out to expedite labour bu there are situations where this procedure is desirable.
Regarding episiotomy, the obstetrician car decide the need depending on several factors and this should be left to the discretion of the obstetrician. Eating and especially drinking during delivery can be as per woman's wishes providec the obstetrician is not anticipating a Caesarian section. Non-pharmacological methods of reducing the labour pains is useful but pharmacological methods may be necessary when there is prolonged laboui or when the patient's pain threshold is low or the patient desires it. At times it may help to reduce hei tension and help progress of labour.
Obstetric practice needs excellent rapport between patient and doctor. Proper counseling is necessary before any intervention. There can be no thumb rules as every labour and every patient have different requirements. The obstetrician has to minimize intervention and allow physiological labour, but the patient must have full faith in her obstetrician and not suspect the reasons for intervention. The most important factor is congenial atmosphere and mutual faith to achieve the best results.
5. Professor T Eskes - Director, Institute Prevention of Birth Defects
Unfortunately your letter reached me too late. Nevertheless I appreciate to tell you that '. wholeheartedly support the letter of WHO to the Croatian authorities. I was not aware of the fact tha childbirth in Croatia resembles surgery. I am waiting for further action
6. Dr Patrick Duff - University of Florida
Enclosure 1
Paragraph 3: Paragraph 4: Paragraph 5: Paragraph 6:
Paragraph 8:
Paragraph 9: Paragraph 10:
Table:
Enclosure 4
Paragraph 1: Paragraph 3:
Paragraph 4:
Agree
Agree - no need for routine enema
Agree
(L) Lateral position optimises uterine blood flow. Alternatively pillow should b(under (R) hip
'Normal labor does not need to be expedited by pharmacological or invasiv<
methods' - Agree. However, abnormal (prolonged) labor should be promptb
corrected.
Agree - routine episiotomy is not indicated.
Clear liquids are acceptable - better not to eat solid food because of concern
About vomiting and aspirating matter
Pushing of the abdomen - According to WHO - harmful. - Agree
Shaving is appropriate for C/S but not for vaginal delivery
If labor truly is normal. AROM will not necessarily make it progress even mon
rapidly.
Actually, published data show that episiotomy is associated with more vaginal
An perineal lacerations. No data confirm that episiotomy reduces the subsequent
risk or urinary stress incontinence or fecal incontinence.
In the light of these observations by a group of experts, I would suggest that
you approach tb Croatian Society of Gynecologists & Obstetricians, which is a
member society of FIGO, in order ti discuss any ways in which the experience of
childbirth might be improved for Croatian women.
Yours sincerely
Giuseppe Benagiano Secretary General