Archive for the ‘Obstetrics’ Category

Delayed Cord Clamping Grand Rounds

January 30, 2011 263 comments

I recently gave Grand Rounds on Delayed Cord Clamping.  If you have an interest and a spare 50 minutes, take a look!

Categories: Obstetrics

Academic OB/GYN Cases: The House of Twins

January 2, 2011 5 comments

This is a nice photo of a diamniotic/dichorionic placenta, part of a pregnancy involving two separate embryos in the same uterus.

Note the thick intervening membrane and lack of blood vessels traveling between the two placental discs, both characteristic of a di/di placenta.

Traditional Healers, External Fetal Monitoring, and the NICHD

August 12, 2010 17 comments

Continuous fetal heart rate monitoring is at its core an almost laughable idea.   We are checking a single vital sign and using that vital sign to extrapolate a host of ideas and meanings.  OBs that have read strips for years can make some sense of them, but would we give so much meaning to any other single vital sign?  Would we do it with an adult?  Of course not, but there are people who do.  In fact, there are entire countries where this is a major methodology for determining the etiology of illnesses.

But the people doing this are not physicians – they are the healers of various cultures.  Throughout the world there are practitioners who claim to divinate illness through feeling a person’s pulse for several minutes.  This is particularly prominent in Asia.  They describe using the rate, strength, and character of the pulse to make all manner of determinations.   This practice is fairly laughable to physicians, as it seems crazy to get so much meaning from feeling someone’s pulse.

But is this so much different than EFM?  In fact its quite similar.   Given that traditional healers are probably hit and miss with their diagnoses, its no surprise that EFM technology is similarly lacking.

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Categories: Obstetrics

Academic OB/GYN Podcast Episode 24 – The Preemie Primer and Reproductive Infectious Disease Part 2

August 7, 2010 6 comments

In this episode we talk to Dr Jennifer Gunter about her new book “The Preemie Primer”.  I also pick Dr Gunter’s brain about some difficult problems in reproductive infectious disease. 

Academic OB/GYN Podcast Episode 24 – The Preemie Primer and Reproductive Infectious Disease Part 2

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
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