Belly Tales

One week after our historic election of Barack Obama as the 44th president of the United States, here’s a very interesting article on what his presidency might mean for Women’s Health (of the non-”airquotes” variety), namely improved access to birth control and sex education (i.e. the federal government no longer funding abstinence-only programs), a reversal of the “conscience” legislation which is now allowing doctors, nurses and pharmacists to legally refuse to perform any service they morally object to, including prescribing birth control, and stopping the global gag-rule which prohibits federally-funded health clinics in foreign countries from performing abortions or even referring women to other facilities that will. It’s all good stuff, and worth checking out (with a nod to Women’s Health News who found the article in the first place).

South Dakota’s Measure 11 was soundly defeated: “South Dakotans have affirmed by their votes tonight that no vague law can account for every individual circumstance. And that is precisely why women and families, not the government, should make these personal healthcare decisions,” said Sarah Stoesz, President and CEO of Planned Parenthood Minnesota, North Dakota, South Dakota.

The New York Times, in the midst of all the election craziness, published an article on new links between depression and premature delivery which have been recently reported in the Journal of Human Reproduction. The study interviewed 791 women and ultimately gave them scores based on how many depressive symtoms they exhibited–the higher the score, the worse the depression. The study found that the higher the score, the greater the risk of preterm delivery, even after controlling for prior preterm deliveries, miscarriage, socioeconomic status, education and other variables. This is particularly fascinating considering that so little is known about how depression affects pregnancy, and vitally important since depression during pregnancy (and the mental health of women during pregnancy in general) are so often overlooked in prenatal care.

The New Space for Women’s Health (formerly Friends of the Birth Center) is having a fundraiser on November 18th at Babeland called Women Come First. The event, which is co-sponsored by Ricki Lake and The Business of Being Born, offers an opportunity to not only raise money for the new free-standing women’s health and birth center in New York City but an exclusive cocktail party and shopping opportunity. Sounds like a lot of fun! I’d be there if I wasn’t already working that day…

Finally, I’m sure this is going the rounds on the internet, but I think everyone, everyone, needs to watch Keith Olbermann’s special comment on Proposition 8:

Last night was a very strange night. It wasn’t that busy, and yet, somehow, neither the other midwife nor myself were able to take a break. The pace was very steady. We kept expecting it to settle down, but it never did. Just as we were thinking “oh, as soon as this woman is discharged, we’ll be able to rest for awhile”, then another woman would walk through the door.

There were two deliveries. One was a grand multip (G6P5005) who came in 9 centimeters dilated with a bulging bag of waters. The other midwife ruptured her membranes at 3:40 am and she delivered at 3:41 am. I love deliveries like that! It’s always amazing to me how QUICKLY a baby can actually exit the human body, when all the conditions are right. It’s as if they’re on a greased slide, and they just whizz on out. If only all births were so quick and easy.

The woman I delivered was 16 years old, having her first baby. She was newly immigrated, and the father of the baby was back in Santo Domingo. She had her mother and grandmother with her, though, and they were a tremendous support team for her as the contractions were picking up, fanning her face and feeding her ice chips. She progressed remarkably fast for a first baby. We forget, sometimes, that teenager’s bodies are meant to give birth, and probably more so at this age than at any other time in their lives. Even though they might not be emotionally ready, their bodies are, and they often open up through labor as if it were the easiest and most natural thing in the world. This girl was having a labor like that.

When I came on at the start of the night she was 4 centimeters dilated and in a lot of pain. We discussed her pain options, but she didn’t think she needed anything just yet, and carried on with the support from her family. Two hours later, she was ready for something for the pain, and was thinking that she wanted an epidural. However, when I checked her, she was a whopping 8 centimeters dilated, and the head had moved down to zero station. I told her she was a superstar, she was doing amazing work and the birth would be really, really soon. I told her that she could have an epidural if she really wanted one, but that by the time she got it she would probably be fully dilated and ready to push, and that an epidural would just slow down the birth in the long run. She didn’t believe me (I can’t really blame her….the contractions were pretty intense at this point), but her mother and grandmother exchanged a look, and both of them rolled up their sleeves. We coaxed her into a sitting position, and her grandmother went behind her, rubbing her back, while her mother continued to fan her face. Less than half an hour later, she was fully dilated (there is a Russian doctor at our hospital who likes to call this moment “fully delighted”), and was pushing beautifully.

The baby came down quickly and was delivered 11 minutes after she was fully: a beautiful little girl with a really tight nuchal cord which had to ultimately be clamped and cut in order to allow for the birth, and a compound right hand that extended as the baby delivered and unfortunately tore the girl’s left labia, leaving a tender, open gash. The pediatricians were there to check on the baby due to the moderate meconium which had been in her amniotic fluid, but the tracing had been overall reassuring (we’re calling this Category II now…has anyone else moved onto the new NICHD guidelines? Our hospital has finally made the switch officially, despite the fact that these guidelines have been around and endorsed by nearly everyone [ACOG, AMA, ACNM etc. etc.] since 1997, but I must admit, I’m still finding it a bit strange) and the baby came out vigorous and screaming, waving her little pink arms around. An altogether beautiful and uneventful labor and birth, which took less than 5 hours in total. You couldn’t have asked for a nicer first birth than that.

The eventful part came next, unfortunately. Everything was looking good. I was checking her perineum (intact! the only tear was the labial laceration) and waiting for the placenta when there was suddenly a pretty forceful gush of blood. I figured it was a sign that the placenta was starting to seperate, so I gave a gentle tug on the cord, and the placenta quickly began to descend. Instead of coming out with the shiny, fetal-side showing first (Shultz presentation) it came out maternal-side first (Duncan presentation) and I immediately noticed that the membranes had been completely sheared off on one side. There was a thick tendril of trailing membranes which were still firmly attached somewhere up in the uterus, and were taut and unmoving when I tried to gently tease them out by spinning the placenta a bit. Rather than tearing the membranes and losing them, I cut the placenta away and put a ring forceps on the trailing end of the membranes, so that at least we had them. I quickly inspected the placenta and saw that there were hardly any membranes present, only the cotelydons of the placenta, and the cord. Which meant that most of her membranes were still inside, either retained or trailing, I wasn’t sure which yet. And all the while she was gushing blood.

We moved pretty quickly. I called the attending doctor, we asked the family to step out a moment, and started the IV pitocin running. I gave fundal massage and felt absolutely no fundus! I couldn’t find it anywhere (later on, the attending pointed out that that is exactly what an atonic uterus feels like…as if there’s nothing there). The attending began to remove the rest of the membranes by traction, gently teasing and working them down. We administered methergine, then hemabate, and finally 1000 mcg of cytotec rectally. We started a second IV line and used a catheter to help quickly drain her bladder. I was doing firm fundal massage all this time, and finally, after what seemed like quite some time, but was really about 8 minutes, I began to feel a hard, firm fundus balling up under my hand, and the bleeding had slowed down to a trickle. The doctor had managed to extract what looked like the rest of the membranes, and his sonogram later confirmed that the uterus was empty. And then, just as quickly as it had started, the bleeding stopped. The total loss was estimated to be between 800 - 1000 cc. But once the trailing membranes were finally out, and the fundus was finally firm, she was absolutely fine. I repaired the labial laceration, cleaned her up, and helped her breastfeed her beautiful girl.

Her hemoglobin and hematocrit dropped pretty precitously when we checked her CBC four hours later, but it was still in the range of normal (10.0/ 30%), so in the end she didn’t need any kind of blood transfusion. In fact, I’m still kind of astounded by the entire thing. It’s as if a huge emergency had been averted, and yet, at the same time, it felt really routine. We drill our hemorrhage protocol pretty regularly on our unit. It was really nice to see that when push came to shove, we were able to go down the steps of the protocol one by one, and amazingly (or perhaps not), they worked just the way they were supposed to, and lo and behold, the bleeding stopped! Nobody panicked, the nurses were prepared, the doctor was calm. Everyone knew what they were supposed to do, and we just did it.

Afterwards I was waiting for the shaky post-adrenaline terror feeling that often comes after emergencies, but it never came. It made me think about how far I’ve come in my first year as a new midwife. A year ago, this would have probably left me crying or near tears, shaking in the chart room, totally freaked out. Instead, I finished the paperwork, checked her bleeding again (it was fine) and carried on with the rest of the non-stop night. I guess this is what midwives do. They don’t panick, and they stop the bleeding, and that’s that. It was just a hemorrhage kind of night.

Sometimes, briefly, you feel like you’re making progress, that midwifery outreach is making a difference, that people are becoming more educated and informed, and then you read an article like this one, over at Time Magazine, and you realize that you exist in a small bubble where your philosophy on birth is far different than the majority of the country, and no matter how much you talk yourself hoarse educating people about the issues, they’re still going to buy into the myths of birth, hook, line and sinker.

Cesarean births are not “safer”. Numerous studies have demonstrated, again and again, that cesarean births carry more risks than vaginal delivery, and these risks multiply with each cesarean birth. Sure, the woman in this article had a “safe” and uncomplicated primary cesarean, but no attention is given to what happens when this same woman comes back for her second or third repeat cesarean—how difficult it is to perform surgery on the same site, to cut through scar tissue, how the risks for abnormal placentation such as placenta previa or placenta acreta increase exponentially with each cesarean, how the risk of hemorrhage increases dramatically. There’s also no discussion about how painful recovery from a cesarean is compared to recovery from a vaginal delivery, and how statistics have shown that this poorly affects bonding and breastfeeding rates in women who’ve given birth by cesarean. (Not to mention the fact that the motivation for elective cesareans for many women is a fear of pain, and in fact, the entire process is often much more painful, for a much longer period of time, post cesarean).

Vaginal delivery can, for example, lead to future incontinence and pelvic damage, while babies born by C-section may suffer from respiratory problems because of not being exposed to certain hormones during the birthing process.

Where is the author, Alice Park, getting this information from? How come there are no articles or references cited? I thought we were well beyond the argument that cesareans prevent pelvic floor damage. While injury to the pelvic floor can and does occur during vaginal delivery, it’s often caused by practices such as episiotomy, vacuum-extraction, forceful pushing and lithotomy position during deliveyr, all of which can be (and are being) minimized during vaginal birth. Routine episiotomy, for example, is now by and large a thing of the past. Furthermore, there is no conclusive evidence which demonstrates that cesarean section prevents pelvic floor damage. To quote from What Every Pregnant Woman Needs to Know About Cesarean Section (2006), published by the Maternity Center Association:

Is vaginal birth in and of itself harmful? It is common to hear that “vaginal birth” causes pelvic floor problems. Of hundreds of studies examined, however, not one attempted to avoid or limit the use of practices that can injure a woman’s pelvic floor to try to determine whetehr vaginal birth itself plays a role. It is wrong to conclude at this time t hat the cause of pelvic floor problems is giving birth through the vagina….

Is “vaginal birth” the culprit in the high levels of incontinence that women experience later in life? Studies that take a longer view find that new problems with urinary incontinence that appear after birth lessen over time. These problems tend to completely disappear by the time of menopause. Older women experience high rates of incontinence, but this appears to be due to other factors. For example, excess weight and smoking play a role.

Does cesarean section prevent incontinence? Routine cesarean section would only prevent continuing symptoms of incontinence in a small portion of birthing women. For most women, it would pose numerous risks without benefit. And it would offer no protection against experience incontinence in later years. As no research has found that vaginal birth itself causes incontinence, there are more sensible ways to prevent these problemss: 1) avoid when possible the use of birth interventions that can injure the pelvice floor, and 2) focus on keeping a healthy weight, avoid smoking and other risk factors.

(Still not convinced? Check out the following studies:

[1] Shorten, A, Donsante, J. & Shorten, B. (2002) Birth position, accoucheur and perineual outcomes: Informing women about choices for vaginal birth. Birth, 29(1), 19-27.

[2] Terry, R, Westcott, J, O’Shea, L., & Kelly, F. (2006). Postpartum outcomes in supine delivery by physicians versus nonsupine delivery by midwives. The Journal of the American Osteopathic Association, 106(4), 199-202.

[3] Soong, B., & Barnes, M. (2005) Maternal position at midwife attended birth and perineuam trauma: Is there an association? Birth, 32(3), 164-169.)

The point being, I can’t believe such a mainstream publication could write such an imbalanced, one-sided and poorly researched article. I think I feel a letter to the editor coming on!

Forget the Oscars (well, not entirely: Go, Juno, go!); the movie I really want to see is A Walk To Beautiful. Having already won several awards at film festivals around the world, the film follows five courageous women as they travel to the Addis Ababa Fistula Hospital in Ethiopa to find a cure for the obstetric fistulas they suffer from. Fistulas are an opening between the vagina and rectum or the vagina and urethrea which occurs after days and days of obstructed labor. In developed countries around the world, fistulas have become a thing of the past since the advent of cesarean birth (the last U.S. fistula hospital closed its doors in 1895), but in developing countries around the world, it’s still a very grim reality. Incontinent, with either feces or urine dripping from their vaginas, women with fistulas are often shunned by their communities, ostracized and forced to live lives of isolation. The cure for fistulas is a simple surgical procedure, but with access to modern health care often hundreds of miles away, the cure might as well exist on another continent. Just check out some of these facts:

• For every woman who dies from pregnancy-related complications, 20 women survive but experience terrible injuries and disabilities.
• In Ethiopia, there are 59 OB/GYNs and 1,000 midwives for a population of 77 million.
• One woman dies from pregnancy-related complications every minute worldwide; 95% of them live in Africa and Asia.
• More than 99% of The Fistula Hospital patients are illiterate. (The hospital teaches all patients the Amharic Fideles and the Oromiyffa alphabets.)
• Number of patients treated at the Addis Ababa Fistula Hospital every year: 1,200
• Number of obstetric fistula cases occurring in Ethiopia alone each year: 9,000
• Number of new obstetric fistula cases resulting from childbirth occurring worldwide each year: 100,000
• Number of new obstetric fistula cases resulting from childbirth occurring in the U.S. each year: 0.

The movie is playing at the Quad Cinemas in New York City right now, and has recently been extended through February 28th. I’m hoping to see it on Wed., and I’ll certainly write a review afterwards. Good stuff.

(Go Juno, go!)

Sometimes birth is not normal. Sometimes there really are complications and problems which need to be dealt with in a hospital setting. Sometimes a medical approach to birth is exactly what’s needed. Sometimes interventions during birth ARE lifesaving. Yesterday was a perfect example of that. I was helping to take care of a woman who was incredibly high risk and had the odds stacked against her in terms of her chance of having a normal, uncomplicated delivery. She was severely anemic, and had been throughout her pregnancy; and not just the usual anemia of pregnancy—no, this was a woman who had a hemoglobin of 6.5 at one point during her 3rd trimester, and a hematocrit of 19%. (To put that in perspective, bear in mind that normal is a Hemoglobin of 12-13 or greater, and a hematocrit of 32-33% or greater.) She had been seen by Hematology several times during her pregnancy and had had numerous anemia work-ups. It all pointed to iron-deficiency anemia, and she was taking iron replacement therapy, but there’s only so much that this can do. At one point during her pregnancy she had been offered a blood transfusion, which she had refused. When she was admitted, her hemoglobin was 7.8 and her hematocrit was 21%—numbers which didn’t demand an immediate transfusion, but which were very concerning given the fact that she was going to give birth, and giving birth means losing blood, and if you’re severely anemic you don’t really have any blood to lose. Our professor used to say that if a woman is severely anemic, she “can’t tolerate” a hemorrhage…which is what…a polite way of saying that she’ll die?

In addition to the severe anemia, she was also preeclamptic. Her baby had oligohydramnios, probably caused by the preeclampsia (unchecked hypertension and poor placental perfusion can lead to intrauterine growth restriction and oligohydramnios, both of which are not good signs). She had protein in her urine, was hyper-reflexive, and was starting to have toxic symptoms (blurry vision, headaches, visual changes, epigastric pain, edema). She was admitted for an induction of labor immediately on account of the oligohydramnios and preeclampsia. To my way of thinking, this was the right call. With preeclampsia, you don’t want a patient sitting around at home with skyrocketing blood pressure—it can lead to siezures if untreated, and the only cure is birth. Similarly, oligohydramnios indicates chronic, long-term insult to the baby, which sadly means that the womb is no longer the best environment for fetal well-being.

This was her second baby. Her cervix was 3 centimers dilated at the start of the induction, so rather than using a cervical ripening agent like cytotec or cervadil, pitocin was started instead. Because she was preeclamptic, she was also started on Magnesium Sulfate, which prevents preeclamptic seizures by causing systemic smooth muscle relaxation. Mag is an awful drug. It makes you weak and hot and sweaty, and it often complicates inductions because it’s hard to induce contractions when a woman is receiving a medication which is causing all of her muscles to relax. Pitocin and magnesium are always at odds with each other. I think a lot of preeclamptic inductions fail because of the magnesium.

Anyway, maybe it was because of the magnesium, maybe it was because her first labor was also a very long, drawn-out labor, but in any case, her progress was very slow. I admitted her on Friday, and she was still in labor when I came back 12 hours later, on Saturday. She hadn’t made much progress; she was only 4 centimeters dilated when the doctor checked her that morning, and was still 4 centimeters when the doctor checked again 3 hours later. Her bag of water was broken by the doctor, an intrauterine pressure catheter was inserted to measure the actual strength of the contractions, and the pitocin was duly increased. And increased, and increased. It got as high as 28 miliunits/min., which was as high as I’ve seen it in a long time. Her contractions were adequte (because of the IUPC, we were counting montivideo units, and yes, they were adequate), but they were always irregular. When I checked her again 3 hours after the IUPC had been placed, she was only 5 centimeters dilated, and it was a tight 5 (I was worried that I was being too generous, and that the doctor would come behind me and check her again and decide that she was still only 4 centimeters, that she hadn’t made any progress, and that she would therefore need a cesarean for failure to progress).

I was really worried about this woman and this baby. I was worried about a severe hemorrhage. She had so many risk factors leading up to it; she was on magnesium, which relaxes the uterus and makes postpartum uterine atony more likely. She had been on pitocin for almost 24 hours, which tires out the uterus and makes postpartum uterine atony more likely. And because she was severely anemic, she couldn’t hemorrhage. She had no blood to loose. I was worried that after another three hours of little or no progress, she would give birth by cesarean, which means that her blood loss would be at least 800 cc. She didn’t have 800 cc to lose.

At least the tracing was always reassuring. I’m sure that if, at any point the tracing had begun to look anything other than beautiful, there would have been an immediate cesarean. Her urine output was always good, her magnesium levels were always on target (never too high or too low), and all of the medications we were giving her seemed to be doing their jobs. The woman seemed to be taking everything in stride, as well. I was amazed by her strength. She never panicked, even when she first found out that she had preeclampsia and would need to be induced. She had an epidural and was comfortable. She slept for several hours at a time, as did the rest of her family (her partner and grandmother, both in their chairs with their mouths open, snoring). She asked a few questions here and there, but for the most part, she seemed to trust that things would be okay. She must have known something that I didn’t. I was worrying plenty for the both of us.

Three hours after my last exam, I was unsure of what to do. I didn’t want to check her again and have to be the one to discover that she was still only 5 centimetrs dilated, and then have to notify the doctor and watch the entire thing get written off as “failure to progress”. On the other hand, we’re supposed to round on the women we’re taking care of every 2 hours, and I was trying very hard to be on top of things; it was already an hour past when I was supposed to check her and write a note. I called my preceptor on the phone and discussed the situation with her. We decided to write a note on her well-being, lab values and fetal status, but defer the exam for another hour, if possible. I hung up the phone and walked to the room, only to discover that the doctor was already there, and had just checked her. She was fully dilated.

I didn’t even have time to marvel over how she’d managed to go from 5 centimeters to fully in 3 hours…not that this is an impossible thing at all (many 2nd time moms do the entire labor in 3 hours or less), but she had been making such slow progress, and her body was battling the magnesium every step of the way. I was so incredibly, pleasantly surprised! I barely had enough time to get my gloves on before the baby’s head was crowning. He wasn’t a very large baby. She pushed him out in 6 minutes, and he began to scream and wave his arms around. Her partner cut the cord. The pediatricians were there on account of the prolonged magnesium exposure in the baby, but everything was fine.

The placenta came out 4 minutes after the baby, and we began to massage her uterus immediately. It wasn’t firm right away, but it firmed up with massage. We ran 40 units of pitocin in 1 liter of IV fluid (we couldn’t give her methergine because her blood pressure was too high, since methergine can cause a stroke if given to hypertensive women) and…please, no heavy bleeding…please, no hemorrhage…please, let it stop….and it did. She lost blood, but a normal amount. She had a small, first degree laceration which we quickly repaired so that it wouldn’t bleed very much.

And that was it. All of those risk factors, all of those hurdles to overcome, and in spite of it all, a normal birth. Even with the doctor in the room. Even with multiple IV lines, and packed units of red blood cells ready and waiting in case she hemorrhaged. Even with an induction that lasted 28+ hours, and heavy medications competing against each other. Even with a midwife that was worried about so many things that could have potentially gone wrong, which didn’t. Even in high risk situations, with all sorts of complications, even with a prenatal course and labor which is anything but normal….normal birth can and does still occur.

The BBC has put together an amazing series of articles on birth and maternal mortality in developing countries. This year, at the half-way mark towards the Millenium Goals set for 2015, we’re not even close to reaching the desired 75% reduction in maternal mortality. These articles explore the reasons behind these failures: everything from lack of US funding for the United Nations Population fund (ostensibly because the UNFPA doesn’t outlaw abortion) to the low status of women in developing countries, the low priority given to women’s health issues, unsafe drinking water, lack of access to medical facilities and skilled birth attendants, infection, poor nutrition and low birth weight.

“These women are dying not because we don’t have the means to save them, but because we (the world) have not determined whether they are worth saving.”

Why women still die to give birth

Action needed on maternal deaths

“They thought I was cursed” (article on maternal fistulas)

In pictures: fighting maternal mortality

Check out the older articles from 2005 and 2006 as well. Really excellnt, but really sobering reading.

After signing off yesterday, I had some lunch then promptly attended three educational sessions in a row, two of which I paged. The first was entitled Cervical Ripening: What We Know and Why A Paradigm Shift is Needed for Reducing the Incidence of Preterm Birth, which focused on how our preterm labor treatments (tocolytics) are very utero-centric and concerned only with stopping contractions, while cervical ripening is often a much predictor for preterm labor. There is a lot of new research in this area, and new therapies aimed at counteracting cervical ripening might be more effective in stopping preterm labor than simply stopping contractions (which may, but often does not stop cervical ripening in any way). The speaker was very knowledgeable on her topic, which was her area of research and interest, but aside from presenting her own research, which is microscopic tissue analysis of the cervix under ultrasound to assess for markers of tissue disruption and increased water retention (precursors to ripening), there was not much which was immediately applicable to take away from her lecture. You get the sense, however, that in another 5-10 years, there will actually be drugs and assessment tools and treatments available to combat this aspect of preterm labor, which is very exciting.

The next educational session I went to was on sexual dysfunction, presented by a doctor who has spent years heading up a sex clinic in downtown Chicago and mentoring other medical and nursing students in sex therapy. While she had many, many (often sad, often hilarious) fascinating stories to relate, she really didn’t get into the nuts and bolts of sexual dysfunction in any great detail, at least not in any way that is immediately clinically applicable in terms of helping, counselling and treating couples with dyspareunia, anorgasmia, vaginismus, unconsummated mariages and premature ejaculation (although apparently you can use SSRIs, which notoriously have libido-killing side effects, to help delay and slow down men who have rapid ejaculation problems). Still, it was overall a fascinating topic, and really made me realize how little I know about sex therapy and sex counselling, which is indeed something a midwife should be pretty well versed in. While I certainly feel comfortable asking women about their sex lives, and discussing all aspects of sex and a person’s sexuality, specific treatments and counselling techniques are not at all in my repertoire, which is something that can be fixed with a little bit of reading and education.

The third educational session I attended was Menopause: Case Studies of Hormone Therapy, which was fabulous. I was astounded by how well the researchers knew the material. They made the very valid point that even though the Estrogen/Progesterone arm of the Women’s Health Initiative (WHI) was ended in 2002 due to the alarming increase in the rate of breast cancer, the other arms of the trial continued, and information is still pouring in from all sides, as well as from other studies that are now in progress. One of the speakers (Mary Brucker, CNM) termed it “research sushi”: after a large randomized control trial such as the WHI, you’re often left with more questions than answers, and in the ensuing years different aspects of the larger study are often chopped up (like sushi) into more specific questions and newer, smaller studies are mounted to try to tackle all of the questions raised. With hormone replacement therapy (HRT) at the moment, we’re apparently very much in the research sushi phase. It’s still a very grey, very unclear and ambiguous area, with very few clear guidelines or answers. While the WHI did a great job of scaring people so much that HRT is now often avoided at all costs (even when it can be very beneficial on a short-term basis for symptomatic relief of menopause), some of the information gleaned from WHI is actually, surprisingly saying the opposite. While the combined estrogen/progesterone arm increased the risk of breast cancer, apparently the estrogen alone arm of the study actually had no increased risk in breast cancer among the women treated with estrogen , and and a nearly significant decrease in risk (28% in the estrogne-alone arm, v. 34% in the placebo arm), which raises the question of whether all hormones are bad, across the board, period, end of story, or whether some hormonal therapy might actually have a very valid place in symptomatic relief (it also raised the question of what to do about women receiving unoposed estrogen without progesterone to balance it out, which has been shown to increase the risk of endometrial cancer). As you can see, very confusing stuff. They also delved into alternative treatments, such as the use of soy and phytoestrogens, Tibolone (which is used in Europe and actually had a worse Relative Risk for developing breast cancer than the combined and estrogen alone arms of the WHI), and compounded, bio-identical hormones, which also might not be the be-all-end-all cure that they are often touted as. Really, really fascinating stuff. I wish I was better versed in all of this, too, but I still find menopause and HRT very confusing.

Today started bright and early after a fairly late night dinner with a few other student midwives from Florida and North Carolina, mostly spent comparing our program experiences, mutually stressing about the board exams, and reviewing test questions that one of the students had from the test prep workshop she’d attended earlier that day. This morning I attended a great lecture on the Social Marketing of Breastfeeding, and how commercial marketing techniques can be very effectively used to market breastfeeding, especially when you break it down in terms of product, pricing, placement and promotion. She had all kinds of examples of ads from formula companies, which we then deconstructed in the class to root out the hidden, and often very sneaky and damaging hidden messages in them. Again, realizing how important language is: using the word “breastmilk repleacement” instead of “formula”, which makes it sound like a far inferior version of breastmilk, rather than a special, carefully planned, secret recipe which is just as good as breastmilk. We also talked about the importance of not only talking about the benefits of breastfeeding, but the risks involved with not breastfeeding. Again, none of this was new to me, but it was a very well put together and very concise presentation, full of good tips and suggestions, and it has really inspired me to work harder on my breastfeeding promotion and education (”selling” this amazing product—breastmilk!).

The schedule got a bit messed up, there are a few announcements on room changes and cancellations and switching of times, so the lecture on hormonal contraception counselling which I really wanted to attend, I missed. Instead, I ended up in a fascinating discussion panel on the horrific health disparities which still exist in our country, and the ways that midwives can work harder to amend these. We watched a small section of an upcoming PBS special entitled “Unnatural Causes: Is Inequality Making us Sick?”, which will air this winter in a 7 part series, and was incredibly eye-opening and terrifying in many of its implications. For example, the clip we watched demonstrated again and again that the areas of a county or city or state which have the lowest socioeconomic standing (which goes hand in hand with the highest crime rates) also have the highest rates of heart disease, pre-term birth, infant mortality, death by diabetes, hospitalization for asthma, lowest environmental standards, highest pollution and toxin exposure…the list went on and on. From the PBS website on the series:

Former U.S. Surgeon General Dr. David Satcher and his colleagues calculated that in 2002, 83,570 African Americans died who would not have died if black-white differences in health did not exist, a rate of 229 “excess deaths” per day. That’s the equivalent of one Boeing 767 being shot out of the sky and killing everyone on board every day, 365 days a year. And they are all Black. According to a by-now landmark study by Dr. Colin McCord and Dr. Harold Freeman, African American males in Harlem are less likely to reach age 65 than men in Bangladesh.

There are by now thousands of studies tracing the pathways by which racial and socio-economic status affect health. But there is virtually no popular media—no print, TV, nor web—that translate this research into forms that can build public understanding of how social policies are de facto health measures. As a result, the ‘common-sense’ wisdom remains that the poor and peoples of color get sick because they have unlucky genes, or they are just too lazy and undisciplined to to eat right, exercise and abstain frm drugs and booze. Similarly, it’s still widely believed that top executives who are dropping dead from heart and artery disease when in truth it’s their subordinates.

After watching the clip, we then moved into a very fascinating, (and very encouraging!) roundtable discussion. Midwives have always traditionally worked with underserved, indigenous populations, and it was amazing to hear about some of the changes and work that is being done around the country right now. You could feel the energy building in the room as people continued to come to the mircophone to speak. By the time the sesssion ended, the conversation had barely gotten started. Because the session is going to be repeated tomorrow, it was suggested that rather than starting over, we simply pick up the conversation again where we left off, which may or may not happen depending on how many people from today’s lecture attend the session tomorrow. In any case, though, I would watch the PBS documentary when it comes out, because it is going to raise A LOT of questions, and cause a media-world storm to descend on this long ignored issue.

Which now brings me to the present moment.  Time to find some lunch, and then sit in on an afternoon session review of the 2006 STD Guidelines (because, while I’m here, might as well attend lectures which will be useful on our board exam).  Tonight is the opening ceremony and dinner, followed by the long-awaited opening of the Exhibit Hall.  I can feel my money disappearing already.  Can’t wait!  Much more to come!

I’ve been meaning to post this post for ages, but was never able to finish it during the school year last year. All of this comes from the research project that I worked on last year for 2 semesters as part of my research class, and even though I had to radically alter the goal and purpose of my research proposal in the end, along the way I had the opportunity to do some of the research I was really interested in doing in the first place, and it definitely needs to be shared. This is rather a long post, and it gets somewhat technical in places, but bear with me; a lot of the information here can help you fend off an unnecessary induction or cesarean, so it’s well worth reading. And with that, here we go:

Premature rupture of membranes (or prelabor rupture of membranes, aka PROM) occurs when a woman’s water breaks before she actually goes into active labor. It can happen to women at any point in their pregnancy, and when it happens to women who are still preterm, the danger to herself and her baby is much higher, as are the risks of infection (and many studies have demonstrated that in fact, preterm PROM, aka PPROM, is often caused by infection in the first place). However, the majority of PROM occurs in women who are at term gestation (37+ weeks)—90% of all cases, in fact (Zamzami, 2005), and it’s pretty common, too: PROM at term occurs in 8% of all births. (Hannah et. al., 1996)

In our hospitals today, there is sort of an unspoken rule—let’s call it the 24-Hour Rule. It goes something like this: if you haven’t delivered your baby within 24 hours of breaking your water, something is going to have to be done. In many cases, this something is induction, and in many cases, waiting a full 24 hours before inducing is something that never happens. Providers are often way too impatient and antsy for that, and will generally talk a woman into induction long before the 24 hours has passed. Many providers have the policy of immediately inducing a woman with PROM, either by using prostaglandin gels like cervadil followed by IV oxytocin (pitocin), or by just starting on the pit right away. The rationale for this type of management (often called active management) stems from research that was done in the 1960s (Shubeck, 1966; Rusell & Anderson, 1962) which found that the longer a woman was ruptured, the greater the chance of infection, chorioamnionitis (an acute infection of the chorion, which is part of the placenta), and maternal and/or fetal sepsis.

These early studies advocated immediate induction, and were the beginning of active management. The idea that the length of PROM is responsible for maternal infection is something which has sort of been hard-wired into modern obstetrical practice right now, and in my own experience, I have seen the 24-Hour Rule in effect many a time. Providers often use it to justify the need for an induction or augmentation, i.e. “we need to get your labor moving along, because you’ve been ruptured now for 8 hours…12 hours…18 hours…and you’re still not in active labor”, and as studies have shown, inductions and augmentations, especially for PROM, often lead to cesarean (Mozurkewich & Wolf, 1997; Grant et. al., 1992; Tan & Hannah, 2001). I have seen this deadline held over women’s heads before, and in my most humble opinion, it does absolutely NOTHING to help a woman relax, labor effectively, and have a vaginal delivery. (What’s that old Bradley joke about telling a man he better orgasm soon or else his penis will have to be cut apart to get to the sperm? No pressure, now!)

The thing is…the research from the ’60s, which forms the basis of the 24-Hour Rule, has more holes in it than swiss cheese. For one thing, these studies were retrospective, instead of prospective, which means that they relied on going back and looking at records after the births had already occurred, and never tried to control for any of the gazillion variables that might have affected these birth outcomes other than PROM. Similarly, these early studies were non-randomized, meaning that there might have been selection bias at play which could have muddied the findings. Additionally, both term and preterm pregnancies were mixed together when examining the effects of PROM, which seriously confounds results since preterm infants are much more susceptible to infection, and as I mentioned above, preterm PROM often occurs because of infection in the first place (McGregor & French, 1997). These studies had very imprecise definitions for infection, and the management protocols used were neither uniform or clearly discussed. And of course, NICUs and antibiotic therapy have improved so much in the past 40 years that many of the babies that died of infection in these early studies probably wouldn’t have died if they had been born today. So, as you can see, the studies from the 1960s had a lot of problems, and the fact that modern obstetrical practices are still based in part on the findings in these studies is an even BIGGER problem.

What have more recent studies shown? Well, many studies have shown that strict adherence to active management is often unnecessary, and in some cases, does more harm than good (seems to be a repeating theme when you start to look at obstetrical research—funny, that. And here is where it gets very technical. I’m putting the rest of this behind a cut, for those of you who are interested.)

(Read on …)

The strangest vaginal exam I’ve ever had so far happened two nights ago, on my first night-shift clinical rotation, when a woman in early labor came to triage. She was full term, she’d had some light spotting, hadn’t felt the baby move as much as normal in the past 24 hours, and was contracting about every 5-10 minutes. I took her history and started my physical exam. We were most concerned about the lack of movement, since this is often an indicator of fetal distress, and the tracing didn’t look that hot. I palpated her abdomen and I had a difficult time figuring out where the baby’s head was, but I assumed it was vertex (head down) because we were auscultating the fetal heart below the woman’s belly button, which is usually a good sign that the head is down. I’m a student and my Leopold’s maneuvers aren’t expert by any means, so I figured it was due to my poor Leopold’s that I wasn’t able to tell for certain where the head was.

We moved on to the vaginal exam. My preceptor checked first per usual, and smiled at me as she pulled her hand out and said “this is going to be a great vaginal exam for you.” I began my exam cautiously, figuring the woman was 2-3 centimeters dilated, and wondering what my preceptor was talking about. I felt the cervix right away, and indeed, she was 2 centimeters dilated and about 80% effaced….but where was the head? I didn’t feel the head anywhere. My preceptor told me to put my fingers inside the cervix and feel the bag of waters….and OMG, what is that???! Not a head at all! Some kind of strange, small, hard little thing bobbing up against the intact bag of waters, clear as day. I almost gasped in surprise (but managed not too, thank goodness!). What in the world is that? My preceptor mouthed the word “foot” to me, and suddenly it all clicked in to place. It was indeed a foot, I could feel the outline clearly, I could tell where the heel was and where the toes were….I was basically tickling the baby’s foot, and she was in a footling breech position. An ultrasound scan quickly confirmed what we’d felt, and the head, rather than being in the fundus (or over the symphysis pubis), was actually way off to one side, almost transverse more than anything else. The woman said the head had been down at her last check-up a few days ago, so I wonder….did the baby flip all of a sudden, and is that why the woman thought the baby wasn’t moving as much as normal, because all of a sudden she wasn’t feeling the usual movements in the usual places?

She was committed to having a vaginal delivery, so we referred her to the physicians on the floor, who offered her an external cephalic version in the operating room. As they were trying to turn the baby, though, the heart rate decelerated, and she ended up giving birth by cesarean. To be honest, the tracing, even in triage, never looked fabulous…there were never any accelerations, and the variability was occassionally flat, and as it turns out, there was a cord wrapped very tightly around the baby’s head. So everything happens for a reason, and I do think that sometimes babies have a mind of their own when it comes to how they want to be born. This little one wanted to come out foot-first!

One of the greatest concerns with a breech delivery is that the cervix will not be open enough to allow the large head to pass through, even though the smaller body might have already been delivered, and then you end up in the dangerous situation of a body fully born with a head entrapped by the cervix. While vaginal deliveries may be possible for other breech presentations, like a frank breech or complete breech, because at least the breech (i.e. the rump) is hard enough and unyielding enough to press against a cervix and help it fully dilate, with a tiny little foot presenting, the chances of the cervix opening fully are very small. Because of this, footling breech presentations are the most dangerous type of breech presentation to deliver vaginally, and I’m really glad this woman came in when she did and was able to give birth via cesarean, expecially once it became clear that a version was impossible and that the baby wasn’t doing that well with her tight nuchal cord. So, here’s to cesareans done for a good reason; they really can be lifesaving when they’re truly indicated. And as for me…I will never forget this vaginal exam for the rest of my life!

Two studies have recently come out which highlight the risks of cesarean birth for both mothers and babies, particularly primary cesareans with no medical indication. A recent study printed in Birth: Issues in Perinatal Care found that neonatal mortality rates were higher in babies born by cesarean, even after the statistics had been adjusted for congenital malformations, socioeconomic and medical risk factors. This is especially significant given that the focus of the study was on low-risk mothers who had no medical indication for cesarean, and the sample size was quite large (311,927 low risk women were analyzed). The NY Times picked up the story in last Tuesday’s paper (Voluntary C-sections Result in More Baby Deaths).

And then, it never rains but it pours: Nabbed from Milliner’s Dream, who saw it first, a recent French study also found that having a cesarean more than triples a woman’s risk of death when compared to the risks associated with a vaginal birth. (Postpartum Maternal Mortality and Cesarean Delivery) The increased risk of death was found to stem from complications from anesthesia, puerperal infection and venous thromboembolism, all of which are risks associated with surgery.

So, how…vindicating. There is now a sudden spurt of evidence which suggests that cesareans aren’t nearly as safe or benign as common practice would indicate. Now the question is: how long will it take for the medical community to absorb this new information and begin to cite the risks involved to the women trying to schedule a primary cesarean when there is absolutely no medical indication for one? It took years for the medical community to acknowledge that routine episiotomy can cause more harm than good, but practic is finally beginning to change. And, I wonder who will be the first to try to refute these findings?

(By the way, have you noticed how chock-full of good stuff the September issue of Obstetrics & Gynecology is? In addition to the above French study on maternal mortality and c-sections, check out ACOG’s Committee Opinion on the HPV vaccine).

ADDENDUM:

ACOG’s press release on the results of the French study in this month’s Obstetrics & Gynecology :

Though rates of maternal death in most developed countries are relatively low—US women have a 1 in 3,500 chance of pregnancy-related death—incidences of maternal mortality have not significantly decreased in the last two decades. These study results suggest that mode of delivery may be a modifiable risk factor, and in some cases, choosing vaginal delivery over non-medically indicated cesarean delivery could help lower maternal mortality rates.