CORRESPONDENCE 1101

retardation is a self-fulfilling prophecy”. However, there is no doubt that this is implicit in our own findings. Equally, and more importantly, it seems to emerge directly from Fay and Ellwood’s own observation of “increasing incidence of asymmetry with declining birthweight”, unless they believe (which is most unlikely) that all of their babies with a birthweight below the 10th centile were abnormal.

Professor T. Chard Department of Reproductive Physiology, St. Bartholomew’s Hospital Medical College, West Smithjeld, London EClA 7BE

Reference Chard T., Costeloe K. & Leaf A. (1992) Evidence of growth

retardation in neonates of apparently normal weight. Eur J Gynecol Reprod Biol45, 59-62.

The predictive value of outpatient hysteroscopy in a menopause clinic Sir, The paper by Downes et al. (December 100, 1993) on the predictive value of outpatient hysteroscopy in a menopause clinic made interesting reading. The growing attention paid to menopause by society at large may be due to the fact that close to 10 million people in the UK population (1 5 %) are menopausal. It would seem controversial to suggest subjecting all these women to hysteroscopic examination before commencing them on hormone replacement therapy (HRT). Despite the immense benefit that could accrue from the use of HRT, studies have shown that fewer than 8 % of menopausal women presently take oestrogen therapy (Wilkes & Mead 1991); the addition of a compulsory hysteroscopic examination may further reduce this number.

The effects of HRT are considered protective, with the questionable exception of breast cancer. As suggested by Studd (1992), it may be illogical to recommend extra monitoring for patients receiving acceptable regimes of HRT. The study showed that 47% of the women with bleeding complications on HRT had structural abnormalities within the uterine cavity; the use of hysteroscopy in all the women could still have missed close to a half of those likely to develop bleeding complications based on the finding of structural abnormality. Most of these complications could be identified by ultrasound scan, which is less invasive, cost effective, well tolerated and shown to be highly predictive of sinister lesions. In view of the above, it seems reasonable to suggest that hysteroscopy can be used, as is the current practice, for investigating those women who develop bleeding compli- cations while taking HRT or those, who prior to taking HRT, have episode(s) of postmenopausal bleeding.

A. Oladipo Department of Obstetrics and Gynaecology, Salisbury District Hospital, Salisbury SP2 8BJ

References Studd J. (1992) Complications of hormone replacement therapy in

postmenopausal women. J Roy SOC Med 85, 376-378. Wilkes H. C. &Mead T. W. (1991) Hormone replacement therapy in

general practice: a survey of doctors in the MRC’s general practice research framework. Br Med J 302, 1317-1320.

Author’s reply Sir, I agree with Mr Oladipo that in over 50% of women noncompliance with postmenopausal HRT regimens is due to the development of unscheduled bleeding. Thus our endeavour to understand this serious clinical problem centered around the use of outpatient hysteroscopy and endometrial biopsy. The incidence of structural abnormality was almost twice that in

women who did not suffer from abnormal bleeding patterns. This reflects a wider histogenetic problem of abnormal angiogenesis associated with fibroid formation and is relevant to the fact that irregular ripening of the endometrium occurs over areas of submucous fibroids. The assertion that ultrasound scan by whatever route is just as effective as hysteroscopy, is, however, naive and misses the point that in the majority of instances it is the benign lesion that causes the irregular bleeding, making women despair and discontinue the treatment, and not the sinister pathology. In our clinics we have demonstrated on many occasions several types of localised sinister pathology that were not only missed by ultrasound scan but also by curettage under general anaesthesia. Similar clinical cases have been reported previously and sinister endometrial pathology occurred in some (Leather et al. 1990). Having passed the learning curve, we find current practice no more invasive or uncomfortable than ultrasound scan by the vaginal route. We conclude that the only accurate and safe method to screen the uterus is by hysteroscopy and curettage under local anaesthesia.

F. Al-Azzawi Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, Leicester LE2 7LX

Reference Leather A. T., Sawas, M. & Studd .I. W. W. (1991) Endometrial

histology and bleeding patterns after 8 years of continuous combined estrogen and progestogen therapy in postmenopausal women. Obstet Gynecol78, 1008-1010.

Flexibility in training Sir, Obstetrics and gynaecology is potentially one of the most interesting, varied and satisfying of all the medical disciplines, but many doctors with commitments outside their work (usually, but not exclusively, women doctors with young families) find the long hours and long training period too demanding to pursue a career in this speciality. This problem was highlighted in the commentary by Dr Laura Cassidy (February 101, 1994), and it is encouraging that it is being actively addressed by reduction in hours of work for all junior doctors, by proposals for shorter but more structured training, and by schemes to facilitate part-time training.

It was disappointing that Dr Cassidy did not mention Northern Ireland, but she may not have been aware that part-time training has been available in Northern Ireland since 1978. The first part- time trainee is now a full-time consultant. One part-time trainee is an accredited senior registrar now working full-time. The trainee with whom she previously shared a job is continuing her training as a part-time senior registrar. Another trainee works part-time in a clinical job and part-time in research. There is also a part-time post recognised for DRCOG training.

Prospective part-time trainees in Northern Ireland face the same obstacles as trainees elsewhere. Until recently posts have been on adhoc basis, and funding has been a major problem. The Northern Ireland Council for Postgraduate Medical Education provided assistance for one trainee and continues to fund the part-time DRCOG training post, and job sharing also has helped. Recently, central funding from the Management Execu- tive has been allocated for one part-time senior registrar post which has been recognised for training by the RCOG Higher Professional Training Committee.

This is significant progress but more needs to be done, not only in Northern Ireland but elsewhere in the UK and in other specialities, in terms of guaranteed funding for part-time training posts and in providing recognition for more part-time training posts, not just for senior registrars but a t all levels, from house officer up. More part-time consultant posts with the prospect of a reasonable quality of life to look forward to might also encourage more trainees to complete their training.

1102 CORRESPONDENCE

Ann Harper & Harith La& The Royal Maternity Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BB

Author’s reply

Sir, I thank Drs Harper and Lamki for their up-to-date information about part-time training posts in Northern Ireland. It is heartening to see the numbers of part-time trainees increasing in this part of the country, and this is in no small measure due to the efforts of the Northern Ireland Regional Adviser of the Royal College of Obstetrics and Gynaecology, Dr Harith Lamki.

To date there is no formal system of applying for part-time training in Northern Ireland. There is no doubt that such a formal system of application has led to a dramatic increase in the number of trainees working part-time throughout the United Kingdom. Currently, 33 % of senior registrars training in England and Wales are female and of these, 31 % are training part-time. Although the Scots were committed to having 3 % of trainees at senior registrar level training part-time, it was only when a formal system of application for posts with guaranteed funding was introduced in 1993 that four separate part-time senior registrar posts in obstetrics and gynaecology were filled.

Aspiring part-time trainees in Northern Ireland should currently contact the Royal College of Obstetricians Regional Adviser or the Northern Ireland Council for Postgraduate Medical Education to register an interest in part-time training. The Management Executive in England and Wales in 1993 made available funding for 20 part-time consultant posts. With the general acceptance of part-time trainees, it is to be hoped that there will be more part-time consultant posts.

Laura J. Cassidy Department of Obstetrics and Gynaecology, Inverclyde Royal Hospital, Lurkfield Road, Greenock PA16 OXN

Induction of labour confers benefit in prolonged pregnancy

Sir, Thank you for the excellent review by John Grant (February 101, 1994) on induction of labour in prolonged pregnancy (Grant 1994). One comment, however, must not go unchallenged; “...there is little eviden ce... to support the practice of fetal surveillance after 41 weeks gestation.. . ”. Clearly, from available evidence, induction at this gestation will prevent up to three perinatal deaths per thousand births, and perhaps a slightly larger number of hypoxic seizures (Grant 1994). This is a total benefit of perhaps 1 YO. Given that there are other causes of death (0.3 per 1000) and seizure, it would take a truly gargantuan trial to prove any benefit of fetal surveillance. Meanwhile, for those women who prefer to take the risk of prolonged pregnancy, common sense dictates heavy emphasis on observation of fetal movement, backed up by at least cardiotocographic monitoring perhaps every couple of days. Such monitoring would also provide an antenatal tracing with which to compare an intrapartum monitoring.

Laurence Wood Walsgrave Hospital NHS Trust, Clrfford Bridge Road, Walsgrave. Coventry CV2 2DX

Reference Grant J . M. (1994) Induction of labour confers benefit in prolonged

pregnancy. Br J Ohstet Gynaecol 101, 99- 102.

Author’s reply

Sir, Laurence Wood is right when he implies that the effectiveness of fetal surveillance in the prevention of perinatal mortality “in

prolonged pregnancy” has been little researched. In the 11 randomised trials induction of labour was the experimental treatment with fetal surveillance the control. In each trial this method of induction of labour was clearly defined, while the method of fetal surveillance was not, being fetal movement counts, nonstressed cardiotocography, ultrasonic estimation of amniotic fluid volume, fetal biophysical profile, or a mixture of these. In my review I stated that obstetricians should recommend induction of labour in prolonged pregnancy as opposed to the present haphazard methods of fetal surveillance, and this statement is justified in the light of current evidence. The focus of future research should be the effectiveness of specific forms of fetal surveillance compared with induction of labour. The emphasis of the comparison has shifted, for now the method of fetal surveillance, clearly defined, is the experimental group with induction of labour the control.

Laurence Wood is also right when he says that such a trial will be large. If a particular method of fetal surveillance is to be successful one would expect it to prevent just as many perinatal deaths as induction of labour. The 1 1 randomised trials of induction of labour resulted in a perinatal mortality rate of 0.3 per 1000; a doubling of this perinatal mortality rate with a specific method of fetal surveillance may be considered un- acceptable. Such a trial would require at least 150000 women with prolonged pregnancy to be randomised-clearly an im- possible task. Other indicators of perinatal fetal hypoxia should be chosen as outcome measures, such as fetal heart rate abnormalities, caesarean section for fetal distress, time to establish first respiration, and hypoxic ischaemic encephalopathy.

John M. Grant Bellshill Hospital, North Road, Bellshill, Lanarkshire ML4 3JN

Labour following caesarean section Sir, In the short communication by Roberts (February 101, 1994) on labour following caesarean section, I find it unfortunate that the phrase trial of scar appears on a recurrent basis. I feel very strongly that the correct phrase should be trial of labour after a previous caesarean section, as stated by the Canadian panel in 1986. The term trial of scar would indicate that there was doubt about the mechanical soundness of the scar and, of course, if there was any doubt about this, then labour should not be allowed.

D. H. Gudgeon Torbay Hospital, Lawes Bridge, Torquay TQ2 7AA

Author’s reply

Sir, There are a variety of descriptive terms for the labour of a woman previously delivered abdominally. When compiling our ques- tionnaire we selected the term which, in our experience, is used most frequently (or recognised most easily) by consultants in obstetrics. Having phrased our questions in this manner, we felt it only correct to report the replies using the same term. Personally, I prefer the term vaginal birth after caesarean (VBAC), particularly when discussing the issue with patients, who may find the prospect of a trial of scar a daunting one. Whichever expression is used, I would say that the mechanical soundness of a scarred uterus is always in doubt. This doubt is not so great as to justify routine repeat caesarean section, but it should remain in the minds of all those supervising VBACs so that they are alert to the warning signs of dehiscence.

Lawrence J. Roberts University College Hospital, Huntley Street, London