Academic OB/GYN

Given that cesarean delivery is the second most common surgery performed in this country, it is somewhat surprising that as a profession we can’t seem to settle on what the best way to do it is.  We argue about how we should open, what we should close on the way out, and how we should close these layers.  Some have even argued that we shouldn’t even enter the peritoneal cavity in doing the surgery, which leads to a radically different approach.

Of all the variations on this surgery, one element that has been up to a great deal of discussion is how many layers we should close the uterus in.   Like many things in surgical and clinical technique, the answer to this question seems to have changed over time, and has even gone back and forth.   When I was training in the late 90’s, we were closing the uterus with a single layer of chromic gut suture.  Towards the end of my training, we slid towards a double layer of gut, and now we are seeing some movement back towards a single layer, but now with polygalactin 910 (Vicryl or Polysorb.)

There have been two separate areas of concern with how many layers we should close with.  One of these concerns have been the immediate effects of how we close the uterus on patient factors such as immediate postop pain, infection rates, blood loss, and surgical time.  The second concern has been the effect of closure technique on uterine rupture rate in subsequent VBAC attempts.

Like all areas of controversy, there are surgeons that are passionate on either side.  There are also groups of non-physicians that have taken strong stands on this issue, which to surgeons can seem a little out of place given the heterogeneity of the data and the variable interpretations of that data.
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In this month’s Green Journal, ACOG published Practice Bulletin #111 “Inherited Thrombophilias in Pregnancy”.  This practice bulletin was an attempt to coalesce the available evidence on thrombophilias in pregnancy and to make some evidence based recommendations for how obstetricians should deal with the issue.

This is all well and good, but what happened next was not.  A few weeks after publication ACOG retracted the Practice Bulletin.  Though we don’t know for sure, this was likely due to an outcry the many MFMs who don’t agree with the published recommendations.  As of now, it is no longer available online, and exists only in the pages of the printed journal.  Per ACOG, a new version will be out this summer.

So why did this happen?

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While the NIH Conference on VBAC behind us, the blogosphere continues active discussion of this important issue.  I’ve been involved in this discussion a bit over at Science and Sensibility.

Here’s the message I am getting from a lot of folks strongly in favor of VBAC rights and availability.

The choice to VBAC is an informed refusal of a intervention.  There should be no “right” required to have it.  Hospitals should not be allowed to refuse VBAC attempts, as this is the same as requiring a woman to have an elective surgery.

I hear a general feeling that the risk of uterine rupture is overstated, as is the likelihood of a severe adverse outcome if a rupture occurs.

I hear a general feeling that the short and long term risks of repeat cesarean deliveries are overstated.

I think these are good messages.  I agree with women should be be free to refuse repeat cesarean delivery, even in hospitals that do not have 24 hour anesthesia access and 24 hour OB coverage.  As long as this refusal is informed, it should be a woman’s right.  I also agree that the risks of VBAC are overstated by many, and the risks of repeat cesarean are understated by many.

The problem is liability.

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I had the opportunity to do an abdominal cerclage with one of my MFM colleagues this week, which was fantastic.   This is a procedure that is rarely done, and for me is something pretty new.  I had the opportunity to do a few of these in residency, but hadn’t done one for over 5 years and never in a pregnant woman, so that was a great envelope-pushing experience for me.

For my colleagues that haven’t had the opportunity to do one of these procedures, I want to lay out how its done.  In short, the goal is to place a cerclage between the ascending and descending branches of the uterine arteries, at the connection of the lower uterine segment and internal cervical os.  When you’re done it should look something like this -

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Dr Onyeije

By Nicholas Fogelson, M.D. and Chukwuma Onyeije, M.D.

Early reports described the story of Tracy Hermanstorfer as a “Christmas Miracle”. It has also been described as  inspiring, heartwarming, and “wonderfully appropriate for the season.” Others have referred to her saga as a nightmare with a happy ending.

On Christmas Eve 2009, Ms. Hermanstorfer was admitted to Memorial Hospital in Colorado Spring, Colorado after her water broke.  Ms. Hermanstorfer suffered a cardiac arrest during labor with her child Colton.  After immediate resuscitative efforts failed, nearby Maternal Fetal Medicine physician (Dr Stephanie Martin) performed an emergency cesarean section.  In the minutes following the delivery, Ms Hermanstorfer regained circulation and breathing, and is now doing well. Her infant also went on to survive and is apparently well.

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There has been some discussion recently in the blogs and the twitterverse about VBAC.  Some have expressed a concern that not enough women are being offered VBAC, and that not enough doctors are supportive of it when the facilities are available.   I have a few thoughts on this.
VBAC, or Vaginal Birth after Cesarean, is something that gets a lot of discussion, because any discussion about VBAC is basically a discussion an inverse interplay between fetal and maternal well being.

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There are times in our medical careers where we see a shift in thought that leads to a completely different way of doing things.   This happened with episiotomy in the last few decades.  Most recently trained physicians cannot imagine doing routine episiotomy with every delivery, yet it was not so long ago that this was common practice.

Episiotomy was supported in Medline indexed publications as early as the 1920s(1), and many publications followed in support of this procedure.  But by as early as the 1940s, publications began to appear that argued that episiotomy was not such a good thing(2).  Over the years the mix of publications changed, now the vast majority of recent publications on episiotomy focus on the problems with the procedure, and lament why older physicians are still doing them (3) (4).  And over all this time, practice began to change.

It took a long time for this change to occur, and a lot of data had to accumulate and be absorbed by young inquisitive minds before we got to where we are today, with the majority of recently trained OBs and midwives now reserving episiotomy only for rare indicated situations.

Though this change in episiotomy seems behind us, there are many changes that are ahead of us.   One of these changes, I believe, is in the way obstetricians handle the timing of cord clamping.

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When I was an intern in Charleston, SC, I quickly learned the importance of the labor curve.  When checking out with my chief, I was often asked the question “Is she on the curve?”  Quickly I learned the idea that women that “fall off the curve” were in a dysfunctional labor pattern, and were more likely to require a cesarean delivery.  I dutifully listened to all this, and did many a cesarean for active phase arrest.  As a junior level I did the cesareans, and as chief I called them.  But at the same time, I had doubts about all of this.
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Throughout my career heard so many reasons why the fern slide didn’t fern in the apparently ruptured patient.

“She’s only 19 weeks, they don’t fern this early.”

“There’s blood in the sample, that makes it not fern.”

“She has chorio, that makes it not fern.”

Over the years, this has driven me a bit crazy, because the real reason that the slide is not ferned is not any of these reasons.  The reason there is no fern on the slide is because the fluid on the slide is not amniotic fluid.

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I was recently on call and we had 2 patients on our board having second trimester inductions, one for ruptured membranes at 17 weeks and another for fetal anomaly.  Both patients were being treated with what seemed like a strange regimen of misoprostol, 400 mcg miso vaginally _and_ 400 mcg orally, every 4 hours.  I had never heard of this regimen, and was wondering where it came from. None of the residents seemed to know, only that it had been passed down through some route to them.

It struck me as odd that people are using misoprostol in all kinds of different ways,  despite the large amount of available evidence in the literature.  In fact, it may be one of the most thoroughly studied topics in obstetrics, having been the subject of many randomized trials, a standard of research rarely achieved in our field.  Studies have included both pharmacokinetic and clinical data.  For better or for worse, abortion is the single most common procedure performed for women worldwide, and the patient population tends to be appreciative and willing to participate in research.  Sadly, the mammoth amount of data available seems overlooked by the majority of practicing obstetricians, given the wide variation in practice I have observed.  As such, I want to review a few of the major articles here.

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