Archive for the ‘Obstetrics’ Category

The Myth of the Unnecessary Cesarean

nec·es·sar·y: being essential, indispensable, or requisite

One thing I have learned by being active in the obstetrics and birthing blogosphere is that there are a whole lot of people out there that think that most cesarean deliveries are unnecessary. While most of them will admit that some cesareans are medically required, its pretty rare that the ones that have had a cesarean looks at their cesarean that way.

A popular term bandied about is “Unnecesarean”, a catchy little phrase that implies the underlying belief that most cesareans are unnecessary. Frequently, commenters state that they had a cesarean that they didn’t want, and that at some point later in their life someone let them in on the secret that their cesarean wasn’t really necessary, and this is completely accepted as fact. In some cases, people believe that they were robbed of the vaginal birth they were destined to have, or even that they were somehow raped by the their physician.

Frankly, I am tired of it.

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Green Journal – Vertical vs Transverse Skin Incisions for Emergent Cesarean

Junes’s Green Journal had an interesting article on vertical versus transverse skin incisions for emergent cesarean deliveries that seemed worth some comment.

The point of the article was to look at a large retrospective cohort of emergent cesarean deliveries, stratify them by vertical or transverse skin incision, and then look at operative times and patient and fetal outcomes.  This dataset was drawn from recorded data from many different centers, as part of the MFMU Network system of studies.

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A look at the data on hysterotomy closure – how many layers?

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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Categories: Obstetrics

Thrombophilias and Insurance Companies: The problem with ACOG’s recent Practice Bulletin

April 26, 2010 7 comments

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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Micro Tort-Reform: A potential solution to the VBAC Liability Issue

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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Academic OB/GYN Cases: Abdominal Cerclage How-To

February 27, 2010 74 comments

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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An Obstetrical Analysis of “The Christmas Miracle”

January 10, 2010 35 comments

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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Categories: Current Events, Obstetrics

Ten Thoughts on VBAC

December 17, 2009 143 comments

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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Categories: Obstetrics

Delayed Cord Clamping Should Be Standard Practice in Obstetrics

December 3, 2009 307 comments

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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Protracted thoughts on protracted labor…

November 8, 2009 108 comments

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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