Literature / Littérature

Can J Rural Med vol 2 (2):146

© 1997 Society of Rural Physicians of Canada


This month's search of SDILINE (MEDLINE's subsection covering the most recent full month of citations) revealed several items of interest. Together, they are further evidence of the growing interest in the level of care that can be provided in rural settings. The first article, and the one that takes this concept the furthest, describes a pilot project in South Africa. The second article provides further descriptive evidence of the safety of vaginal births after cesarean section (VBAC) in rural settings.

The Cardiothoracic Outreach Programme -- a pilot project.
Klein M, Ramoroko SP, Jacobs AG, Bomela MD, Mokhobo KP, Mohlala ML. S Afr Med J 1996;86(12):1533-5.

The "cardiothoracic outreach" of the title refers to the transport of a complete cardiothoracic team into 2 small rural hospitals with "no conventional ICU facilities" and staff who had no "experience of high technology or complex theater work."

Thirty-five major procedures were performed, including 20 cardiopulmonary bypasses. There was 1 intraoperative death, 2 major intraoperative episodes of morbidity (a cerebrovascular accident and an episode of temporary heart block) and 1 late complication (a cerebrovascular accident due to embolism).

Major benefits flowed to the community hospitals involved and to their patients: the elimination of the need for remote referral, an increase in community confidence in the hospital and lower transport costs. The project, which demonstrated the safety and cost-effectiveness of cardiothoracic surgery "under primitive conditions," was judged a "resounding success" by the authors.

Although a similar project is unlikely in the North American context, the demonstration that technology is mobile and can safely be brought closer to rural residents should be encouraging to Canadian rural hospitals that are considering expanding the services they provide locally.


Induction of labour for trial of vaginal birth after caesarean section in a remote district hospital.
Kumar S, Maouris P. Aust N Z J Obstet Gynaecol 1996;36(4):417-20.

Although the numbers in this study of VBAC were small (33 women who had previously undergone cesarean section and who agreed to a trial of labour), the success rate was 88%. Only 4 (12%) of the 33 women had to undergo repeat cesarean section.

In this series, labour was induced in 29 of the 33 women, and it is of interest that the issue of induction of labour is currently under discussion by the obstetrics committees of the Society of Rural Physicians of Canada, the Society of Obstetricians and Gynaecologists of Canada and the College of Family Physicians of Canada. The aim of these discussions is to create guidelines for, among other things, the practice of obstetrics in the absence of local cesarean section availability (see also the Letters section, page 118). Future plans include tackling the issue of appropriate settings for VBAC, for induction and for VBAC with induction.


Table of contents: Volume 2, Issue 3