Voici un lien qui dcrit en dtail chaque journe de notre voyage pour savoir o nous en sommes rendu clic sur voyageitinraire. Bonne lectueIl reste 8 jours...
Monthly Archives: January 2010
An English Man in New York
DAY 433Firstly everyone many apologies for the picture on our last blog sometimes we have a busy interesting day and do not take any photographs which happened on this day so when time came to upload the blog we had a situation of a photo less entry and in this case Caroline decided to take a picture of Misha the little dog and Rocky the Kelpie.Today was an important day for us we both have
Work and figuring out our workshops
Buenos Noches Well I was wrong about today. Yesterday we worked very hard digging out the hole mixing cement and moving loads of stuff. I then went to the gym please see pictures attached its like rocky 2. One of the girls made the silo wall collapse so I went in and sorted it out and finalised the depth and breathe of it its really pained me to do so. Rewarding none the less. We laid some
5 Tips for What to Do If You Get Sick on Honeymoon Vacation
Getting a cold or the flu is bad enough but when it strikes less than 24 hours before getting on the planemdashor worse while you're flyingmdashpanicking won't speed up your recovery. Rather than succumbing to a sneezy fate take immediate action by following these top five tips en route.1. Check all your bags. Keep yourself free of things to haul and save energy by checking whatever bags yo
Tarragona Spain
Friday 15.1.210 day 92Tarragona SpainWe were very sad to leave Andorra as it is fantastic so we headed to the beach town of Tossa De Mar it was a fantastic drive along sweeping roads with fantastic views and Temps got up to 22 up until today 10 is the highest temp we have had in Europe while we have been here. On the way to the beach we saw I saw what looked like 3 of the test team for BMW testi
Travel advice and destination reviews
My blog has advice on travelling with everything from what to take to reviews of European cities and exotic destinations in the Caribbean and Asia take a look at httpciaranjones.wordpress.com
Experiences of south America Visiting a Mens Prison of Quito in Ecuador
Visiting Menrsquos Prison of Quito in EcuadorWhile visiting friends in a hostel in the mariscal area which is the new town in Quito I read on the information board that it was possible to visit a womanrsquos and menrsquos prisons and it was pretty straightforward so on a Saturday in September I went alone and gave the taxi driver the address he seamed surprised and asked if I was visiting
The French Don’t Work…They Have Kids.
The French donrsquot workhellipthey have kids.Today we had class like any other daymdashit started at nine at the institute with each of us presenting some sort of French article that we found for homework. Today Carlrsquos article was about how the French had ldquolost its reputationrdquo as the place where the least amount of work was done. Although it was still up theremdasho
Counting down the days
Today trudging through snow a few days from now it'll be sand under my feet. Ironically they both sound similar under foot.It's been snowing in Manchester on and off since before Christmas. Luckily I escaped the worst of it by dissappearing to India for a few weeks over Xmas NY.I'm now counting down the days to my flight to Sharm El Sheikh on 311. An hour drive north and I'll be in Dahab wh
Andorra
Thursday 14.1.210 day 91AndorraWe drove to Andorra today. Andorra is the second smallest country in the world 464 sq km 2 times smaller than Paris. It has the best skiing in the Pyrenees the lifts can get 95000 people up to the ski fields an hour the population of the country is 76900. It has great hiking and motorcycle riding in summer. There are no taxes in Andorra so petrol food and alcoh
Soria Spain
Wednesday 13.1.210 day 90Soria SpainWe got up had bfast and headed off to Spain. Today was our last day in Portugal so our last chance to use our favourite Portages word lsquoFuckerrsquo Knife being Australian we had been thinking that we would use it in the crocodile Dundee style lsquothatrsquos not a fucker this is a fuckerrsquo but sadly we did not even get to ask for a fucker at
peso da regua
Tuesday 12.1.2010 day 89peso da reguaWe got a 10 am bfast served in our room and we slept so well it was so nice to have a full European bfast with fantastic Portuguese very nice Coffee. The locals told as that this is the most snow they have had in Portugal in 70 year Lucky we got to see it We decided to have a look at Porto the home of port. One thing my driver learnt is that our lsquosat
Merida
Monday 11.1 2010 day 88Merida We both woke up feeling very cold and sick. Although Merida Spain is a world heritage town with lots of roman things including a Dina temple that looks like the one we saw a few days ago in Portugal in faced the whole city look very much like Evora At one point we took a wrong turn and was on an identical turn around that we had done in Evora. There where Roman glad
Gibraltar
Sunday 10.1.2010 day 87Gibraltar We checked out of our resort and drove to Gibraltar where we had to go in and out of immigration but they did not put a new stamp in my passport 61516 I loved Gibraltar it is so exciting every little boys dream lots of forts and tunnels and ship even monkeys. The airport goes over the main road so you get to drive over the airport run ways on your way in and out
Portugal dinner out
Saturday 9.1.2010 Day 86Portugal dinner outWe did some work on the internet book some more accommodation had to decide what we are doing in the next few weeks as there is so much snow about we think we will stay away from it for a bit longer. We had some drinks at the bar and had a bit of a rest day today. Then after being well rested we went out for dinner for my friendrsquos birthday at this g
Portugal
Friday 8.1.2010 Day 85PortugalWe did our washing and went for a walk to a fort along the cliffs it was a fantastic view we forgot the camera but we could not get to the fort by the cliffs so we went back and got the car it was not a very good fort and had been turned in hotel maybe by the government as they do that here some times. There is a bull fighting ring walking distance to our resort and
Evora
Thursday 7.1.2010 Day 84Evora We went to Evora a world heritage site it has lots of roman things like the Diana temple and the aqueducts for carrying water. We went to the Capela dos Ossos or chapel of the bones it is made up of hundreds of bones and has a great sign on the top of is saying we who are here are waiting for you to join us. We saw peacocks in the park. We then went to the Prehistor
Portugal fort
Wednesday 6.1.2010 Day 83Portugal fortWe wanted to go to the fort near our hotel but each time we went to go out it started raining so we went shopping again. We meet the club people here who tried to get us to by their shares in holiday club.
Markets Tavira Olhao Faro
Tuesday 5.1.2010 Day 82Markets Tavira Olhao FaroWe went to the mouthy markets and got some nice fresh pine nuts. There is a lot of pine nuts farms and orange farms around here. We then drove to Tavira a little fishing village we went up to the castle. We then drove on to Olhao that has roman and Arab fortresses we then drove to Faro.
Is breech vaginal delivery safe?
Between 3-4% of babies begin labor in the breech (bottom first) position, increasing the risk of neonatal morbidity and mortality. Pre-emptive C-section has become the preferred method of delivery for breech babies, but now some are questioning this recommendation. The controversy is fueled by differing appraisals of the danger and by differing assessments of the whether any risk of neonatal death can be justified in the age of the safe Cesarean.
The best conducted and most important study comparing breech vaginal delivery with elective C-section is the Term Breech Trial (TBT) conducted by Mary Hannah and colleagues. It is the only randomized control trial of its kind.
… [W]e found that the fetuses of women allocated planned caesarean section were significantly less likely to die or to experience poor outcomes in the immediate neonatal period than the fetuses of women allocated planned vaginal birth. Although some of the deaths in the planned vaginal birth group were related to difficulty with vaginal breech delivery, others were clearly associated with problems during labour. Thus the avoidance of labour and vaginal breech delivery could have contributed to better outcomes with planned caesarean section…
A more recent trial, the PREMODA (PREsentation et MODe d’Accouchement: presentation and mode of delivery) study produced different findings and as a result, some obstetricians have been calling for a re-evaluation of the standard recommendation for C-section delivery of a breech baby.
The groups [planned vaginal delivery vs. planned C-section] did not differ significantly for the combined outcome of fetal or neonatal mortality or serious morbidity (odds ratio [OR] = 1.10, 95% CI [0.75-1.61]. Of the criteria included in this combined variable, only a 5-minute Apgar score less than 4 was significantly more frequent in the planned vaginal group (n = 4 vs n = 1, OR = 8.9, 95% CI [1.00-79.8]). Of the other individual outcomes, the following were significantly more frequent in the planned vaginal than in the planned cesarean group: 5-minute Apgar score less than 7 (OR = 3.2, 95% CI [1.9-5.3]), total injuries (OR = 3.9, 95% CI [2.4-6.3]), and intubation (OR = 1.8, 95% CI [1.08-3.1]).
The authors of the PREMODA study acknowledge that their trial was not randomized and that the results must applied with caution. Nonetheless, the authors concluded:
In centers where planned vaginal delivery remains a widespread practice and in complying with rigorous conditions before and during labor, we did not find a significant excess risk associated with planned vaginal delivery compared with planned cesarean for women with a singleton fetus in breech presentation at term. There may be a slightly higher neonatal risk associated with planned vaginal delivery but it is very different from that reported in the only published large randomized trial….
In light of the PREMODA study, some obstetricians have been calling for a return to breech vaginal delivery. The NNT to prevent neonatal death from breech is 111. That translates to 110 unnecessary (in retrospect) C-sections for every baby saved. What are the risks of those C-sections? They include hemorrhage, transfusion and possible hysterectomy. Maternal mortality after elective C-section is so rare that many contemporary studies of C-section focus exclusively on morbidity.
So why not simply explain the controversy to patients, as well as the differing findings and let them choose? Putting aside the issue of the magnitude of the risk, are patients capable of giving informed consent to a procedure that will, if widely offered, lead to preventable neonatal deaths? Obviously consent ultimately rests with the patient, but can it be truly informed consent?
Let’s assume for the moment that The Term Breech Trial is correct and the excess risk of neonatal mortality in breech vaginal delivery is 9/1000. That sounds like a small number and many women will reason that the number is so small that they need not worry that their babies will die.
However, 9/1000 means that approximately 9 babies per 1000 WILL die. In the US approximately 140,000 babies each year present as breech at the onset of labor. Not all will meet the eligibility criteria for vaginal delivery (approximately 35% of breech babies are in an unfavorable position for vaginal delivery, and others will exceed the weight criteria or have other contraindications), but even if only half were eligible, that would mean 70,000 attempted breech vaginal deliveries. At an excess rate of neonatal mortality of 9/1000, we could expect that 630 babies would die from preventable neonatal deaths each year.
This is a relatively small number. Indeed, it would barely impact overall neonatal mortality figures (approximately 18,000 neonatal deaths per year), since the bulk of neonatal mortality is due to prematurity and congenital anomalies. On the other hand, that is quadruple the number of deaths we would expect in an otherwise low risk group. Most importantly, that number represents 630 sets of bereaved parents who would have had a healthy baby had they opted for elective C-section. Would those parents accept a preventable death philosophically, or would they be shocked and bewildered that the baby actually died? Would they simply try again or will they look for someone to blame?
Can the excess risk of neonatal mortality can be reduced somewhat by making the eligibility criteria more strict as the authors of the PREMODA study suggest? Only a randomized trial can provide that information, and unless the excess neonatal mortality rate could be reduced dramatically, we would still anticipate the preventable death of hundreds of babies per year.
C-section is not a trivial procedure, but it is an extremely safe surgery, reducing risk to the baby and only slightly elevating risk to the mother. Even though the risk of breech vaginal delivery is small, the outcome can be catastrophic. A lot of unnecessary (in retrospect) C-sections are being done. Do we think that is too high a price to pay to save several hundred babies each year?
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