Letters to the Editors

What is a laborist?
TO THE EDITORS: We read with great pleasure the article by Olson et al1 in the August 2012 issue. According to their denition, I am a part-time, full-service hospitalist. My time as a laborist is 5-37% of my weekly hours in the hospital. We share the belief that it is too early to pass a judgment on the effects of the laborist model on efciency, processes, outcomes, patient and provider satisfaction, and medical education and that further studies are needed. As exposed in the article, this model is the culmination of a change in the professional climate, the practice of the specialty, paralleled by a generational shift.2 The variation among laborists is wide for a number of reasons. Many obstetricians became laborists by choice; however, many others became laborists by default. We believe that the variations among practicing laborists due to individual, institutional, and societal/contextual differences should be attenuated to allow a better delineation of laborist model effects. We propose that the current efforts to dene this model should lead to the establishment of an Inpatient-Obstetrics/ Laborist Fellowship in which the Fellow not only would be versed in the practice of the clinical duties that were well-numbered in the article (including maternal acute and critical care) but also would be trained in protocol writing, human-factors engineering, simulation, team training, evidence-based medicine, and clinical research. Because outcome is affected by training and volume and because the Maternal-Fetal Medicine subspecialty has shifted away from inpatient obstetrics and lost its rst M,3 Inpatient Obstetrics deserve a formal framework similar to that of other subspecialties in the hope that it would decrease cesarean delivery rates, improve the skill sets that are

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needed to perform forceps assistance and repair fourth-degree lacerations, and decrease error and harm, just as examples. In the beginning of understanding, there are denitions. A better denition of laborist can be fostered through training and not only would mitigate any variations that affect outcome but also would improve outcome through concentration of experience and standardization of practice. We share with the authors the promise of this model and believe that bridging the gap between the ideal and the real model should be the next step. f
Fouad Atallah, MD, FACOG Program Director Departmental Quality Improvement Woodhull Medical and Mental Health Center Department of Obstetrics and Gynecology Brooklyn, NY fouad.atallah@woodhullhc.nychhc.org
The author reports no conict of interest.

REPLY DECLINED
REFERENCES
1. Olson R, Garite TJ, Fishman A, Andress IF. Obstetrician/gynecologist hospitalists: can we improve safety and outcomes for patients and hospitals and improve lifestyle for physicians? Am J Obstet Gynecol 2012;207:81-6. 2. Phelan S. Generational issues in the Ob-Gyn workplace: Marcus Welby, MD, versus Scrubs. Obstet Gynecol 2010;116:568-9. 3. DAlton ME. Where is the M in maternal-fetal medicine? Obstet Gynecol 2010;116:1401-4. 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2013.01.001

Is early amniotomy in nulliparous labor induction really efcient?

TO THE EDITORS: Thank you for publishing an article about the concept of early amniotomy in nulliparous labor induction.1 It is really a special interest topic in the eld of obstetrics that most of us considerably encounter in clinical practice every day. I also congratulate all the authors who contributed to this successfully and rationally designed article. However, there seems to be something wrong with the statistical analysis performed in the study. According to the statistical analysis, nearly 290 well-randomized patients who experienced normal spontaneous vaginal delivery were needed to complete the research. However, in Table 3, approximately 40% of both the early amniotomy and standard therapy groups had undergone cesarean delivery. This means that nearly 60% of 290 patients (calculated as approximately 177 patients) experienced normal spontaneous vaginal delivery, which is not enough in terms of patient number to calculate perfectly according to the methods of this 418
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study; as mentioned, they needed 290 patients who had undergone spontaneous delivery per group. Also, 22 women who were assigned randomly to early amniotomy group experienced rupture at 4 cm of cervical dilation, and 13 women who were assigned randomly to standard treatment group experienced rupture at 4 cm of cervical dilation. As all we know, early spontaneous rupture of membranes occurs naturally without any control. However, in my opinion, if the rupture of membranes is spontaneous then you should exclude these cases according to the study design; iatrogenic and full controlled amniotomy had been performed to all other patients. In conclusion, I suggest that the authors should better perform the statistical analysis of this study anew according to the new sample size because it will be smaller. The delivery time and proportion of induced nulliparous women who deliver within 24 hours will probably be different and possibly statis-

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tically insignicant. Also, the neonatal outcomes will be different from the present results with the calculation for 177 patients. I hope this unfortunate error in this well-designed randomized trial will be addressed in order to prevent other f major misconceptions.
Taner Kasapoglu, MD Department of Obstetrics & Gynecology Hacettepe University Faculty of Medicine Ankara, Turkey tanerkas18@yahoo.com taner.kasapoglu@hacettepe.edu.tr
The author reports no conict of interest.

Letters to the Editors

First, he has some concerns about our sample size as it relates to one of the primary outcomes: proportion of women delivered with 24 hours. I believe that he assumed that this was limited to those women who delivered vaginally. In fact, this primary outcome included women who both delivered vaginally and by cesarean. Dr Kasapoglus second point relates to postrandomization exclusions for spontaneous rupture of membranes in the control arm. This study was analyzed with the intent-to-treat principle, which means that, once a patient is randomly assigned, the data were analyzed according to that assignment. We do believe that this is the proper approach to analyzing clinical trial data. f
George A. Macones, MD Washington University in St. Louis School of Medicine St. Louis, MO maconesg@wudosis.wustl.edu
The author reports no conict of interest.

REFERENCE
1. Macones GA, Cahill A, Stamilio DM, et al. The efcacy of early amniotomy in nulliparous labor induction: a randomized controlled trial. Am J Obstet Gynecol 2012;207:403.e1-5. 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2013.01.003

REFERENCE

REPLY
We thank Dr Kasapoglu for his interest in our article on the role of early amniotomy in nulliparous labor induction.1 Dr Kasapoglu raises 2 points in his letter.

1. Macones GA, Cahill A, Stamilio DM, et al. The efcacy of early amniotomy in nulliparous labor induction: a randomized controlled trial. Am J Obstet Gynecol 2012;207:403.e1-5. 2013 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.ajog.2013. 01.004

Trends in the rate of invasive procedures after the addition of the intrauterine tamponade test to a protocol for management of severe postpartum hemorrhage
TO THE EDITORS: We read with interest the recent article from Laas et al.1 This was a really interesting study concerning a new treatment of a main cause of maternal death. We want to congratulate the authors for evaluating the efciency of the intrauterine tamponade test by Bakri balloon in severe postpartum hemorrhage. Literature about Bakri balloon tamponade is limited to case reports or a few retrospective series. Moreover, the efciency of Bakri balloon tamponade alone was not demonstrated clearly in the literature. In most studies, this procedure has been associated with invasive surgery (surgical artery ligation or compressive uterine sutures).2 We have 2 major concerns with the current study: First, we were surprised by the low rate of embolization in this study. Indeed, during the control period, only 16 patients of 820 who experienced postpartum hemorrhage required embolization. This represents an embolization rate of 2%, which is not in accordance with the French register of embolization published by Bartoli et al (5.1% in the same French area).3 Our Department is also a French reference center in the same area, and 80% of the patients who are treated for postpartum hemorrhage come from other hospitals because of persistent bleeding after the administration of sulprostone. The embolization rate for severe postpartum hemorrhage that is unresponsive to sulprostone in our institution decreased from 33-22% between 2005 and 2010.4 Second, we would like to highlight the potential danger of inating a Bakri balloon after cesarean delivery. When hemorrhage occurs after cesarean delivery, insertion of the Bakri balloon by the authors was transvaginal. Indeed, even with abdominal ultrasound scanning, we cannot have a safety control on uterine scarring. Finally, we thank the authors who demonstrated that tamponade by Bakri balloon is effective and can reduce the embolization rate. Bakri balloon tamponade could also be an effective tool that will allow a safer transfer for patients in referral f centers with an embolization unit.
Delphine Hquet, MD Sophie Lubrano, MD Emmanuel Barranger, PhD Obstetric and Gynecology Unit University Paris Diderot, Sorbonne Paris Cit, AP-HP, Hpital
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