obstetrics

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Study Of 80,000 Birthing Moms Suggests Epidurals Safer Than Thought

(archibald jude via Compfight)

(archibald jude via Compfight)

I subscribe to the dentistry school of birthing babies. That is, I wouldn’t want to get a tooth filled without Novocaine, and I wouldn’t want to have a baby without an epidural.

I know that opinions — strong ones — vary on this, but for those of my ilk who’d like yet another data point to support the pain-relief side, here it is: A national study, one of the biggest yet, of complications from epidurals has just been presented at the annual conference of the American Society of Anesthesiologists now under way in New Orleans. And it suggests that epidurals are even safer than previously thought, with rates of the most-feared complications well under 1 percent.

Dr. Samir Jani, a senior resident in anesthesiology at Beth Israel Deaconess Medical Center, presented the findings, gleaned from a giant national database of anesthesiology cases, the National Anesthesia Clinical Outcomes Registry.

He found that among more than 80,000 cases of anesthesia during labor and delivery, 2,223 involved complications, for an overall rate of 2.78 percent. But most of those concerned medication errors — over-dosing, under-dosing, or use of expired drugs.

The rate of the complications that many women fear most — nerve damage or an excruciating “spinal headache” — were even lower than previously estimated, Dr. Jani said: .2 percent — that’s 2/10 of one percent — for the headache; .002 percent for spinal nerve damage and .14 percent for damage to other nerves.

“So it’s well under 1 percent for the kinds of complications that I think a lot of women worry about,” he said, not the 1-2 percent that he’s been quoting his patients based on textbook teachings.

An awkward question: But don’t anesthesiologists tend to be pretty pro-anesthesia? Mightn’t that bias the results?

“Actually,” Dr. Jani said, “Whenever I talk to all my patients, I tell them, ‘I’m not here to sell you an epidural. it’s your ultimate decision.’ And I think that that’s the mentality that almost all of us have. We aren’t ever going to force on a patient what they don’t want. But in that informed consent process, it’s important we quote not only possible complications but the rates to the best of our knowledge. At the end of the day, it’s good to be able to tell your patient that this is a safe and efficient method to be able to control labor pain.”

And what about the common belief that getting an epidural can hinder the pushing process in labor? Continue reading

When One Twin Baby Lives But The Other Dies

(stitches1975 via compfight)

(stitches1975 via compfight)

By Dr. Karen O’Brien
Guest contributor

Never before in my obstetric practice have I taken care of so many twin pregnancies. What I witness in my own office is part of a nationwide trend: Over the last two decades, the twin birth rate in the United States rose 76 percent, from 19 to 33 per 1,000 births.

And never before have I taken care of so many twin pregnancies with complications.

The specific complication that has given me pause in the last year or two is the loss of one twin, either during or after pregnancy.

This doesn’t happen often, but I have taken care of a number of patients recently who have lost a twin during or shortly after pregnancy. And I’ve learned that though outsiders might see a glass half full, this experience is uniquely devastating, both emotionally and medically.

We must all understand that the life of one twin does not eradicate grief for the sibling who died.

The hope and anticipation of bringing home two healthy babies comes grinding to a halt. The joy of delivery is clouded by sibling loss.

As early as 18 weeks, Melissa’s identical twins showed signs of a complication called twin-to-twin transfusion syndrome, which occurs when one of the twins essentially donates blood to the other.

At 19 weeks, Melissa underwent surgery to try to correct the problem. Unfortunately, two days after the surgery, one of the twins passed away. Melissa remained pregnant for 13 more weeks and ultimately underwent cesarean section at 32 weeks.

She and her husband were able to hold the deceased twin for several hours after delivery. Her live twin did well; she spent a few weeks in the neonatal intensive care unit (NICU) and is now home and thriving.

Samantha’s twins were not identical, and were conceived through in vitro fertilization. At 14 weeks, we found that one of the twins, a boy, had several serious abnormalities. Even at that early gestational age, we knew that he would not live for long after birth, and might pass away during the pregnancy. The other twin, a girl, appeared normal throughout the pregnancy. Continue reading

Childbirth Complications: Some Hospitals Have 5 Times More, But Which Ones?

(pumicehead/Flickr)

(pumicehead/Flickr)

By Richard Knox

The risk of a major complication of childbirth can be up to five times higher at one hospital versus another, a new study finds. But there’s no way expectant mothers can tell the high-risk hospitals from the low — at least, not yet.

A study in this month’s Health Affairs is the first ever to examine hospitals’ childbirth complication rates on a national basis. Authors looked at a representative sample of more than 750,000 deliveries that took place in 2010 at hospitals large and small, urban and rural, including both teaching and community institutions.

Major complications include hemorrhaging, infections, vaginal lacerations and blood clots. Unlike major complications from, say, cardiac surgery, these obstetrical glitches are not generally life-threatening.

On the other hand, as Dr. Laurent Glance, the study’s lead author, tells CommonHealth: “The vast majority of women of childbearing age are fairly healthy people. They can reasonably expect to have a baby without any complications.”

The study found that for women delivering vaginally, the risk of a major complication can be more than double at a “low-performing” hospital (23 percent) than a “high-performing” institution (10 percent).

When it comes to cesarean deliveries, the disparities are even greater — 21 percent at a low-performing hospital versus a little over 4 percent at a high-performing obstetrical unit.

The study doesn’t provide Massachusetts-specific complication rates, but the researchers found no significant differences between Northeast hospitals and other regions. “It’s reasonable to assume there is a similar amount of variation [among Massachusetts hospitals], but we can’t say for sure,” Glance says.

If you think of the results in a big-picture way, it means that among the roughly 4 million American births a year, hundreds of thousands of women could avoid childbirth complications if somehow low-performing hospitals could raise their outcomes to those of their betters. Extrapolating from the new study, about 520,000 new mothers suffer a major complication.

The wide disparities in childbirth complications care are especially striking when you consider how big a slice obstetrics represents of the total health care pie. Continue reading

Study: Pregnant Women Hungry For Better Info Earlier On

Pregnancy test (Wikimedia Commons)

Pregnancy test (Wikimedia Commons)

The “+” sign pops up on your pregnancy test. You call the office of the obstetrician you’ve chosen for just this eventuality, and the receptionist congratulates you and sets you an appointment four or six or eight weeks away.  “But,” you think, “I have so many questions now!” The books aren’t enough. So you turn, of course, to Google, and navigate the thickets of information alone.

If this was your pregnancy experience and it struck you as odd or off or wrong, you’re not alone, according to a recent small study that likely reflects a far broader opinion. Writes one pregnant friend: “My docs are wonderful and insanely knowledgeable, and I call them for the big stuff. However, there’s so much little stuff when you’re pregnant, especially for the first time. It’s constant googling, is this normal? Everything from symptoms, food, exercise routines, massages, whether to dye your hair – it’s endless.”

And some things you need to know early, she notes. “I did have the books – I found the Mayo Clinic guide to a healthy pregnancy to be quite good. But, not so easily searchable, especially when you’re at dinner and you’re like, ‘Can I eat xyz?’ My husband downloaded a few apps right away that allow you to search what you can eat, what to avoid. Some are obvious: alcohol, sushi, some way less so – um, lunch meat?”

From the study’s press release:

Pregnant women are using the Internet to seek answers to their medical questions more often than they would like, say Penn State researchers.

“We found that first-time moms were upset that their first prenatal visit did not occur until eight weeks into pregnancy,” said Jennifer L. Kraschnewski, assistant professor of medicine and public health sciences, Penn State College of Medicine. “These women reported using Google and other search engines because they had a lot of questions at the beginning of pregnancy, before their first doctor’s appointment.” Continue reading

Research: Could Birth-Canal Bacteria Help C-Section Babies?

From a poster at the recent Boston meeting of the American Society of Microbiology. (Courtesy Dr. Dominguez-Bello)

From a poster at the recent Boston meeting of the American Society for Microbiology. (Courtesy Dr. Dominguez-Bello)

The usual drill is to wipe the effluvia of birth off of newborn babies, cleaning them up and readying them for snuggling.

But in a fascinating departure, researchers have begun to experiment with the opposite: collecting birth-canal bacteria and wiping them onto babies after birth.

Why in the world? For good reason: to explore whether it might help babies delivered by C-section to restore some of the vaginal bacteria that they would have been exposed to if they’d gone through the birth canal.

Why do that? On the theory that altered bacterial populations could help explain why C-section babies tend to have higher odds of asthma, allergies, obesity and other health risks.

Dr. Maria Gloria Dominguez-Bello, an associate professor in the Human Microbiome Program at the NYU School of Medicine, presented some preliminary results on that research at a recent conference of the American Society for Microbiology here in Boston. Those initial findings suggest that indeed, using gauze to gather a mother’s birth-canal bacteria and then impart them to babies born by C-section does make those babies’ bacterial populations more closely resemble vaginally born babies — though only partially.

Many questions remain. But the research sounded so intriguing — and the intervention so simple, if it gains medical approval — that I asked Dr. Dominguez-Bello to discuss it. Our conversation, edited:

Your poster reports that there were six vaginal births, seven C-sections and four C-sections in which the babies also received the ‘inoculum’ of vaginal bacteria. But it wasn’t clear to me: To what extent did the mothers’ bacteria restore a more normal balance of bacteria in the C-section babies? A little or a lot?

When we analyzed the sharing — how many microbes any site of the baby’s body share with their mom’s vagina — we doubled the number of bacteria that the C-section babies were exposed to. But the vaginal process was six times as much. So the vaginal delivery still exposes the baby to a lot more.

In other words, if we got one bacteria in the C-section baby that is associated with the vagina, we got two in the inoculated C-section but six in the vaginal births. So those C-section babies still don’t have the full exposure of the vaginal babies.

That’s logical because during labor, the baby is rubbing against the mucosa of the birth canal for a long time and bacteria start growing even before the baby is out — growing and colonizing the baby during birth. In half an hour, you get multiplication of bacteria. If the baby gets one cell, an hour later the baby has probably four of those cells and five hours later, it’s exponential.

Also, C-sections involve antibiotics. There is no C-section without antibiotics, and we don’t know what the effect is of that gram of penicillin. If it’s good enough to kill strep B, I’m sure it’s killing a lot more than that community of bacteria.

If your research pans out, using this gauze technique for C-section babies would seem to be such an easy intervention. I imagine there might already be women saying, ‘I want to do that.’ Possibly even, ‘I want to schedule a C-section and do that.’ What would you say to them?

I would say labor is a very complex process and labor is far more than inoculating the baby. And it’s a process that we don’t fully understand — what’s its adaptive value, why is it important? Continue reading

True Birth Wisdom: 10 Pearls You Won’t Find In Your Pregnancy Guide

(Wikimedia Commons)

(Wikimedia Commons)

Any pregnant woman wants a how-to manual on her nightstand — and for good reason. But for all their usefulness, books like “What to Expect When You’re Expecting” can’t speak to the infinitely intimate, lived experience of labor and delivery.

As Dani Shapiro puts it in an essay that’s part of a new anthology, Labor Day: True Birth Stories by Today’s Best Women Writers, “the inner life of a woman about to give birth is a world textured and complex and all its own.”

Here, editors Eleanor Henderson and Anna Solomon share 10 lessons taken from these writers’ harrowing and sometimes hilarious stories, which range from delivering twins to a 10-pound baby, from scheduled C-sections to a birth in the back of a car.

1. Your birth experience is unlikely to match up with your birth “plan.”

Julia Glass (courtesy)

Julia Glass (courtesy)

Even when labor and delivery go smoothly, there will be bumps, surprises and probably setbacks you didn’t imagine. Julia Glass looks back on the birth of her second child and sighs: “I should have known better than to make any plans.” But if you can be open to what you or your baby wind up needing, you may find your laboring self far more flexible than you imagined. As Susan Burton, who wanted but didn’t get a drug-free birth, puts it, “the IV fluids I hadn’t wanted were better than ice chips.”

2. Choice can be empowering. But it can also paralyze you.

We’re lucky to live in a time and place of such endless options, but the options can be overwhelming –and can often come to feel like ethical and political choices. As Marie Myung-Ok Lee writes: “People espoused breathing techniques, epidurals, the Bradley Method, the narcotic Stadol, doulas, a morphine drip. Each person’s feedback took on the fervency and faith of a Moonie wedding; it was thus hard to know what was ‘normal.’ You have to get an epidural. Don’t get an epidural; they cause C-sections. Make sure you––” Try not to let the chorus drown out your own voice. What do you really want?

3. Understanding what your body is actually doing during labor really can help — if not with the pain, then with the fear. Continue reading

Tragically Wrong: When Good Early Pregnancies Are Misdiagnosed As Bad

An ultrasound of a pregnancy at six-and-a-half weeks (meaning that it was done two-and-a-half weeks after the woman's missed period.) The pregnancy sac  is outlined by four short arrows within the uterus and the embryo is within the pregnancy sac. (Courtesy P. Doubillet)

An ultrasound scan of a normal pregnancy at six-and-a-half weeks (meaning that it was done two-and-a-half weeks after the woman’s missed period.) The pregnancy sac is outlined by the four arrows and the embryo is within the pregnancy sac. (Courtesy P. Doubilet)

A beautiful, supremely talented young friend of our family recently fell victim to a terrible medical mistake. Newly married, she was having some pelvic pain and bleeding, and the doctor who saw her diagnosed a probable ectopic pregnancy — an embryo that develops outside the womb. Concerned that such pregnancies can turn life-threatening, the doctor prescribed the standard treatment: methotrexate, a drug used for chemotherapy and to help induce abortions.

When our friend returned to be checked a few days later, the imaging revealed that in fact, the pregnancy had not been ectopic; it was in place, in her uterus. But because she had taken the methotrexate, a known cause of birth defects, her pregnancy was doomed.  She soon miscarried. What may have been a perfectly healthy pregnancy had been ended by well-meant medical treatment.

I assumed her horrifying case was an exceedingly rare medical fluke — until now. A paper just out in the prestigious New England Journal of Medicine shows that such misdiagnosed pregnancies are part of a pattern — a pattern that needs to be changed. “Considerable evidence suggests that mistakes such as these are far from rare,” it says.

When I told our friend’s story to the paper’s lead author, Dr. Peter Doubilet, he responded that he knows of “dozens and dozens and dozens of similar cases that have come to lawsuits, and that’s probably the tip of the iceberg.” There is even a Facebook group, Misdiagnosed Ectopic, Given Methotrexate, run by a mother given methotrexate whose daughter was born with major birth defects.

The New England Journal of Medicine paper stems from a panel of international experts who resolved to change medical practice to stop such misdiagnoses. I spoke with Dr. Doubilet, who is senior vice chair of radiology at Brigham and Women’s Hospital and a professor of radiology at Harvard Medical School. Our conversation, lightly edited:

Before we get into the nuts and bolts of the problem, what’s the upshot for women of child-bearing age? What’s your message to them?

When a woman gets pregnant, a number of serious complications can occur early in pregnancy, including miscarriage or ectopic pregnancy. When a doctor diagnoses these problems within the first two to three weeks after her missed period, it’s very traumatic to the patient and it’s critically important that the woman and the doctor are confident that the diagnosis is correct, because the steps that will be taken would harm a normal pregnancy if one is present.

Dr. Peter Doubilet (Courtesy)

Dr. Peter Doubilet (Courtesy)

It’s become apparent over the past two to three years that errors in diagnosis of miscarriage and ectopic pregnancy occur more frequently than they should, and that’s why we put together a multi-specialty panel of expert doctors from radiology, obstetrics-gynecology and emergency medicine to come up with new, more stringent guidelines for diagnosing these complications, taking into account the most recent research on the subject.

And just to simplify, when a woman in very early pregnancy has been told that it appears that she has an ectopic pregnancy or a failed pregnancy, it would very rarely be overly risky — and often be wise — to wait a couple of days and be sure of the diagnosis before acting?

Yes. That’s a very important message. In 2010,  I, together with Dr. Carol Benson, wrote an editorial in The Journal of Ultrasound in Medicine entitled “First, do no harm to early pregnancies,” and that was the key message: Unless the doctor is sure that the woman has a miscarriage or an ectopic pregnancy, the doctor should err on the side of waiting, as long as the woman is stable and shows no signs of serious internal bleeding.

If the patient meets definite criteria for a miscarriage or ectopic pregnancy, there’s no reason to wait, but if there’s any degree of uncertainty, the prudent thing is to wait. Continue reading

Response To High U.S. Birth Costs: You Get What You Pay For

pumicehead/flickr

pumicehead/flickr

What a quick point and counter-point! First, The New York Times published its latest feature on high U.S. health costs, headlined “The American Way Of Birth Is The Costliest in the World.”  It opens with the disturbing description of a pregnant New Hampshire woman whose health insurance does not cover maternity care, and who must shop around and haggle over each treatment and test. Ugly. Here’s a taste:

Midway through her pregnancy, she fought for a deep discount on a $935 bill for anultrasound, arguing that she had already paid a radiologist $256 to read the scan, which took only 20 minutes of a technician’s time using a machine that had been bought years ago. She ended up paying $655. “I feel like I’m in a used-car lot,” said Ms. Martin, a former art gallery manager who is starting graduate school in the fall.

Now, Slate has just published a riposte, headlined: Yes, Childbirth Is More Expensive In The U.S. But You Get What You Pay For. It’s the tale of two women, both doctors, who get pregnant, one in the U.S. and one in Canada. The subhead sums it up:

“The Canadian woman couldn’t get her first appointment for eight months, although it was free. The American got an appointment right away, but it cost a fortune.”

To wit: The American shelled out more than $12,000 for an ever-available OB. And by the way, the Canadian did manage to finagle some obstetric care earlier than the 8-month mark.

Readers? Which would you choose? I’m thinking neither system is sounding very appealing at the moment…

Is It ‘Unethical’ To Prescribe Bed Rest For Pregnant Women?

(cscott2006/flickr)

(cscott2006/flickr)

It seems so intuitively right. You’re facing the risk of delivering your baby early and the doctor prescribes bed rest. What could be more cozy and safe? Why wouldn’t you endure a little extra annoyance (you’re pregnant, after all) if it would help keep your tiny, oh-so-vulnerable fetus floating inside the fortress of your womb as long as possible? Even the words “bed” and “rest” feel so inherently soothing and therapeutic.

Think again.

Bed rest, a growing body of research suggests, may be bad for you.  And for physicians to blithely prescribe it is, in a word, “unethical,” argue a trio of doctors from the University of North Carolina School of Medicine.

In a paper called “‘Therapeutic’ Bed Rest in Pregnancy: Unethical and Unsupported by Data” recently published in the journal Obstetrics and Gynecology, Dr. Christina A. McCall and her colleagues make a powerful case against the practice many perceive as cuddly and innocuous.

They cite the medical paradox in which bed rest remains widely used despite no evidence of benefits and, on the contrary, “known harms.” They further suggest that in its current form, strict bed rest should either be discontinued or else viewed as a “risky and unproven intervention” requiring rigorous testing through formal clinical trials.

“If we have anything to learn from the history of medicine it is that instincts and good intentions are a highly fallible compass without the check of scientific controls.”

In an email exchange, Dr. McCall clarifies that she is talking about strict bed rest here and adds:

“If a woman feels that increasing her daily rest lessens anxiety or improves symptoms (whatever they may be), then we are not suggesting this should be discontinued. We are merely suggesting that every woman receive INFORMED CONSENT regarding the literature on bed rest and the autonomy to make her own decision.”

Research suggests that the potential harms for women on bed rest (a broad term that can include everything from total inactivity to limits on strenuous endeavors like household chores, exercise and sex) can be significant. They range from potentially dangerous blood clots and bone demineralization to muscle and weight loss, financial harship due to restrictions on working and a range of psychological suffering, notably depression. Continue reading

What Not To Say To Parents Of Twins

“Did you do IVF?”

“You had a C-section, right?”

“Are they natural?”

Questions that may seem odd—even offensive — to some new mothers. Unless you are the mother of twins. Then you’re used to them.

The “babyrazzi” can be relentless, and the appearance of multiples in public can create an instantaneous barrage of questions. Earlier this year, I was in line at the Mothers of Twins sale (a huge biannual event in Winchester that is akin to the running of the bulls) comparing notes with other moms. Some of the more seasoned moms were used to the forward questioning, while the rest of us were still adjusting to the public’s keen interest in our multiples and our pregnancies.

Here’s my favorite. Upon seeing my boy and girl twins, “Are they identical?”

So when the hilarious cartoon above appeared in my Facebook feed on Mother’s Day, I didn’t mind the peering grandmothers at Costco later that afternoon. It captures just about every inquiry I’ve ever received and somehow it was validating to know that I’m not alone. I must say, all in all it’s a pretty special club.

Readers, any other cringe-worthy twin questions or comments you’d like to share?