User talk:Glenn Blanchette

Welcome to Wikipedia. I appreciate your interest in Caesarean Section but I have reverted the massive changes you have made to the article without discussion on the talk pages. The article is a collaboration of many experts (and non-experts) and your boldness in making these edits distorts the entire article. It is clear from your edits that you have a particular point of view about the safety of caesareans. There are problems with the term breech trial and in Australia maternal deaths and injuries are increasing which correlates with the rising caesarean rate. Thus your edits are somewhat one sided and do not meet the WP policy of neutral point of view. It would be helpful if you could discuss your proposed changes before making such major edits. Thanks Maustrauser 10:09, 16 November 2006 (UTC)

response (I hope this is going to the correct place).
Thank you for the welcome, yes you are right I am new to Wikipedia and unaware of the 'protocols' for editing a page. I am an obstetrician and probibly sound as arrogant as you expect. It comes from a life time of standing in pools of blood at 3am in the morning and being personally responsible and required to make potentially lethal decisions. (Don't take that the wrong way, I trust my patients and they have ultimate control, but in the end they also rely on me for my judgement and it is very difficult to condense 30 years experience into what might only be 2 mintues of precious time in the face of severe fetal compromise). For the first 1,000 it is still exciting, even after 5,000; at 10,000 you are starting to tire but by 20,000 a condition much like 'shell shock' sets in (I have seen more human blood than most soldiers will see in 10 life times) and then of course some idiot will turn to you and say "nature knows best".

I looked as far as I could at the backgroud of the contributors to the Caesarean Section page. But you like most of the others keep their backgrounds hidden - I could see no experts! - so if am wrong please let me know. As far as neutrality is concerned - your statement regarding the "Breech Trial" is certainly not neutral. I guess we all have an opinion, that is probably what makes us want to contribute. So let me see if I get this right - you are group of self appointed lay people who know nothing about the subject. And you are trying to inform the public from your view point of blindness. Well I could perhaps live with that ? - If I thought there was any hope of educating you (but there seems along way to go.)

I'll start more slowly. Lets just pick one topic for now and I can see what your response is.

'Apparent fetal distress' - you make it sound like it doesn't actually exist - I'll give you that the diagnosis is difficult to get right but unfortunately its also easy to get wrong (under diagnosis). 2-3 babies /1,000 births die or are severely brain damaged as a result of lack of oxygen in labour. It should be an easy figure for you to confirm for yourself. Go to your local maternity hospital, look at the statistics for a large obstetric centre close to you, read any obsteric journal, BrJOG, AJOG etc. I work in New Zealand the figures here are worse than in the USA or Europe, 4-5 babies / 1,000 births are damaged or die here in labour.

The problem is that in-labour (acute) Caesarean Sections are often too late. It takes half an hour to get the anaesthetist, or the midwife hasn't called you in time or worst of all its one of those moments in your life when you're made a mistake (I will admit to some). Thats why there isn't a good co-relation between rising CS rates and improving perinatal death rates. BUT there would be for elective pre-labour Caesarean Section. If you don't have a labour - it's very difficult to die during it.

Do you think it is reasonable to include this major risk of vaginal delivery on the page ? You raised the issue of neutrality & balance: - the risk of maternal mortaity from Caesarean Section is 1/70,000+ ("Why Mothers Die - The Confidential Enquires into Maternal Deaths in the UK" RCOG press 2001) - shouldn't you mention a major fetal risk of 1/300 ?

Yours, Glenn Blanchette.

A response to your response
Thank you Glenn for responding to my reverts and my welcome. You will find that WP is is an interesting place. Whilst expertise is valued, it isn't worshipped and it is expected that you don't bring your personal perceptions to the project but rather evidence. Many of the articles are poorly referenced and thus I very much appreciate your arrival and willingness to add some rigour to the Caesarean article.

Your comment that 'we' are all lay people who know nothing about the subject is both wrong, and from my point of view arrogant and insulting. I have four degrees, two of them post graduate. I am capable of reading and analysing data. Very few of us trumpet our expertise because our arguments should stand on the evidence that we bring to the debate and not on the number of degrees hanging on the wall. This is the first time I have mentioned my qualifications on Wikipedia in the two years I have been an editor here.

So that we are clear on our perspectives, I should say that my interest in birth comes from dealing with many women and men who are traumatized by their birth experience and particularly the damage done by caesarean sections, both physically but more often emotionally. That said, I recognize that a caesarean section can be a life saving event, but I also concur with the World Health Organisations view that only between 10-15% of women require caesarean sections. In Australia it is nearing 30% and in our private hospitals some are over 80% and rising. This discrepancy between WHO and reality to me is alarming.

I think it is indeed best that we do take some of the edits you propose one step at a time. And nut out either an agreement or agree to disagree but include our scientific references that back the data up.

Let's work on apparent foetal distress first.

You state that 2-3 / 1000 babies die or are severely brain damaged by lack of oxygen in labour. This must be a much more up to date figure than that quoted by Paneth and Stark (Am J Obstet Gynecol 1983:147(8):960-966) which states that 3-4 / 1000 babies are severely mentally retarded and 8% of these are perinatal in origin (giving a rate of 2-3 / 10000 babies. Thus my figure is a factor of ten smaller than your figure.  Which is correct?  Hall (BMJ 1989 279-282) concurs.  What has happened since the 1980s to increase foetal distress ten fold to get your figure?

With best wishes, Henry. Maustrauser 08:14, 17 November 2006 (UTC)

and the follow on
Dear Henry,

Several points to cover.

1) My manner I make no apologies – I don’t like a playing field where I am being open about my background and others stay hidden behind their names. I didn’t at any point assume you were unintelligent, in fact I hope the opposite. But I’m not just going to take you at face value – I want to know what your degrees are and something about your background. Also you said there were experts (I assume in obstetrics or midwifery or statistics) within this group – you haven’t provided any information to support that.

2) The WHO They made that comment more than quarter of a century ago (1985). It is completely out of date. What’s more - it was out of date at the time they made it. They employed a non-practicing paediatrician (probably the only person they could find to spout their political gibberish) to tour the world and try to discredit obstetricians in North America & Europe. The whole premise of their comment was the variation in Caesarean Section rates across Europe. Well it simply isn’t important and it certainly did NOT warrant them extrapolating an ideal Caesarean Section rate.

The world has moved on and their mistake is more apparent – They took their eyes off the ball! While they were toying with midwifery philosophy in the first world, the lives of their charges in the third world were stagnating.

Do you know how many women die in childbirth in Africa? 1 in 100 - ½ million each year (and you can double it – for under reporting) And the lives of the babies lost are not even counted!

You are obviously Australian – Do you know what the maternal mortality is in Australia? 1 in 50,000+? (the guess isn’t important – it’s the order of magnitude you should consider)

Why the difference? -	It’s not because of poor nutrition or those other nice epidemiological issues that they teach you about in medical school (in an effort to stop you thinking that medicine is actually of any use) – they make a minimal contribution -	It’s because of lack to transport: lack of transport to a place where there are medical or midwifery personnel and lack of those same personnel, that are capable of treating obstructed labour or post partum haemorrhage.

If you want to go back to a world with a Caesarean Section rate of 10-15% - you are welcome to it: no sane person would make the same choice.

3) Swapping Anecdotal Stories If your wife or friends have physical or emotional problems following Caesarean Section I honestly commiserate with you, on the substandard level obstetric care they received.

And I note - that it hardly makes you a neutral editor.

I am tempted to respond and fill the next 500 pages with stories about my patients – I know most would give consent to waive the privacy act – but it would unfair of me to use them.

4) Asphyxial Damage in Labour Yes - you are right - 1983! - your reference is out of the arc – it would have to be some sort of foundation article to still be relevant.

There are two major problems with it.

One - Paneth is looking at Cerebral Palsy in babies that survive labour. That doesn’t count the deaths - between 0.5 – 2 / 1,000.

Two – it’s an argument of mitigation. This is a difficult explanation – so just stick with it.

There is a ‘wonderful’ wall of mirrors put up by my profession to protect itself against criticism of its mistakes. Actually a lot of it originated on the East Coast of Australia. It’s the debate about fetal damage (cerebral palsy) – if it was an antenatal event (prior to labour), unpredictable, unpreventable – then no one could be blamed – particularly not the obstetrician overseeing the labour. You will know that obstetrics in the current climate of litigation is close to being unaffordable – just because of this single-issue fetal damage in labour. Consensus statements have been published about the criteria needed to make a diagnosis of in-labour damage: the type of cerebral palsy, the precursor events in labour, apgars, pH levels, fetal condition following etc …. they are all useful in court. I am sure that proponents of the antenatal event philosophy (like Paneth) honestly believe it.

BUT 8% !? - it’s not the truth. I know how much you like anecdote and ‘value’ experience but after 20,000 deliveries you’ll just have to lump it. We have mortality meetings every month, look at the CTGs and wonder why some one didn’t act sooner. You don’t have to be told it wasn’t an antenatal event. MRI scanning will detect pre-existing (antenatal) neural damage – its not there in most cases.

You can see that if 70-80% of Paneth’s 2-3 / 1,000 were in labour damage + the babies that actually die - the figures will be almost identical.

I’ll throw in a few references to keep you happy. Myles et al “Non-Invasive intrapartum fetal ECG” BJOG 2005 112: 1016-1021 Badawi et al “Antepartum risk factors for newborn encephalopathy” BMJ 1998 317: 1549-1553 Cowan et al “Origin and timing of brain lesions in term infants” Lancet 2003 361: 736-742

But don’t believe me - please do what I asked – look at your local figures or better still if your close to a tertiary centre – ring the NICU and speak to a neonatal paediatrician. Your doing a survey for something – “What are the local rates for asphyxial/hypoxic encephalopathy?” and “How many babies die in labour before reaching NICU?”.

5) Breech Trial I had hoped we’d be moving on. So I’m going to push it.

You don’t like the Breech Trial – Hannah et al “Planned caesarean section versus planned vaginal birth for breech presentation at term; a randomised multi-centre trial” Lancet 2000 356: 1375-1383.

I’d like to tell you that you’re on your own – but there are some other non-believers like Kotaska BMJ 2004 329:1039-1042. You’re certainly out on a limb though. I grant you it was a shame they felt ethically compelled to end the trial early – just 2000 patients - why couldn’t they have let those other babies die and then the statistics would be that much surer. Unlike you, the rest of the world (those of us who have been involved in over 300 vaginal breech deliveries) gladly accepted the trial results. Most obstetric research gets ignored for 5-10 years until it’s thoroughly validated by time and then practicing clinicians slowly accept it – it’s the way it should be. Not so with the breech trial –the practicing clinicians had known for years that vaginal breech delivery was sin against creation (I’m an atheist by the way). [Just a quick anecdote again – the most normal easiest vaginal breech delivery I was ever involved with - the baby died ten hours after birth – thank goodness for post-mortems – it popped an intracerebral AV malformation – wouldn’t have happened at caesarean section] Anyway within two months of the Breech Trial being published it was fully incorporated into clinical practice – across the whole world (or anywhere that maters – USA, Canada, UK, Europe, Australia, New Zealand).

Even in that bastion state of midwifery – the Netherlands. And that’s where the good news comes in. The Netherlands is one of the few countries in the world with a robust national perinatal database. They captured it on snapshot.

Rietberg et al “The effect of the term breech trial on medical intervention behaviour and neonatal outcome in the Netherlands: an analysis of 35,453 term breech infants” BJOG 2005 112: 205-209.

They looked at the 2 years before and after the trial results were published. The caesarean section rate shot up from 40% to 80% within two months and guess what the death rate of breech babies was halved and fetal trauma was quartered.

I can see you’re still unconvinced – So - population based studies related to the Breech Trial now total of 138,000 breech births - all showing a dramatic reduction in fetal death and damage with increased Caesarean Section rates.

Some of the studies Gilbert et al Obst Gyn 2003 102: 911-917 Herbst et al Acta Obs Gyn Scand 2005 84: 593-601 Krebs et al Obs Gyn 2003 101: 690-696 Guilani et al Am JOG 2002 187: 1694-1698

Best wishes, Glenn

A brief reply - more coming in the next week
G'day Glenn,

I only have time to deal with point 1. It will take me time to put my fingers on relevant data and look more in depth at the research you quote, but I shall reply within the week.

My degrees should make no impact upon this discussion. It is the research evidence that is important. However, my qualifications are in science, economics, politcs and law. I can read and interpret research data. Few editors on Wikipedia use their own name as to do so can encourage nutters to personally contact you. I will not tell you the background of other editors of the article because I do not believe their background is important - simply their ability to interpret research. You can make your own inquiries. I have revealed more of my background than I normally do and you have immediately suggested that because of it I am incapable of being a neutral editor. I'd hazard to suggest that same goes for you too. You understandably wish to defend your profession and practice against those who don't agree with you. We both have to tread carefully to ensure that we do write neutrally.

I shall respond in detail this week.

Have a good one.

Cheers, Henry Maustrauser 09:48, 19 November 2006 (UTC)

Dear Henry,

I see that while we have been having this polite conversation, you ± your fellow ‘expert editors’ have allowed several alterations of the page – including the following:

“a quick caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at 7 a.m. than to respond to nature's schedule and deliver a baby at 3 a.m.”

Where is your objective reference for this professional insult?

I have spent most of my life in delivery suite at 3 am in the morning it is the most convenient time for having a disaster, there are no elective lists and no meetings to get in the way.

Do you really feel you are doing a service to the people you are mis-informing?

Goodbye, Glenn

Comment
G'day Glenn,

I am sorry that you feel personally offended by what others write. Please don't take things so personally and please don't personalise this debate. It's the only way of staying cool on WP, otherwise you will do yourself in with stress. I have NO control over what other editors write on any WP page. If you look at my list of contributions, I spend vast amounts of time removing vandals and trolls comments from the encyclopaedia. Please feel free to make changes to the article that you do feel are appropriate. If you type (double curly bracket fact double curly bracket) the words "citation needed" will appear. This is a handy little way of alerting people that the statement made is not adequately referenced. It looks like this:


 * Kiwis cannot play cricket

I will ignore your last comment as it appears mightily like a personal attack to me, and that is against WP policy, so I imagine that I am dreaming it. I am still marshalling my references for your other questions.

Cheers,

Henry Maustrauser 06:59, 21 November 2006 (UTC)

Poor old Henry, trying to be an expert in a field he knows nothing about. Unfortunately, this is what makes Wikipedia an embarrassing joke. I agree with Henry - publish whatever rot you feel like. Glenn, ignore Wikipedia pages - they are full of garbage.