Sunday, February 28, 2010

How did we let these barbaric doctors get away with it?

I wrote this to a friend today: "I thought I'd heard it all, but no, there's more...". I'd just read a story in the Irish Herald highlighting new horrors that women have been subjected to during 'normal' vaginal deliveries in hospital.

I knew what an episiotomy was, of course. I also knew I wanted to avoid one. But a symphysiotomy? That was a new one on me, and here's what I learned today:
Note: More information in this SOS (survivors of symphysiotomy) press release

What is a symphysiotomy?
*A drastic operation to widen the pelvis in obstructed labour...
*It was performed on nearly 1,500 women around the time of birth, leaving many of them incontinent, in pain and suffering from depression for the rest of their lives
*The procedure, which dates back to the 18th century, was reintroduced into Ireland in the mid-1940s at a time when it was dying out in medicine in the developed world.

*...young and vulnerable women were put through a barbaric surgical procedure around the time of childbirth for dubious reasons."
*So far, around 110 victims of symphysiotomy have come forward, and there may be many more suffering in silence."
*Symphysiotomy was reportedly used to ensure women could continue to have several children, whereas a cesarean section might have limited the number of children they could bear.
*It was feared by some... that facing the alternative of repeated caesareans, women would turn to birth control.
*Those carrying out the procedure appeared to ignore its serious after-effects.

Remind you of anything?
I don't mean to suggest that the use of forceps, ventouse, episiotomy and other vaginal delivery interventions are as dangerous as symphysiotomy, but I do believe that comparisons can be drawn in relation to the final point above (regarding serious after-effects).

Women are simply not being warned about the true risks involved in planned vaginal delivery. Yes, if their outcome is spontaneous without morbidity for mother or baby, then I agree that (with hindsight) it has fewer risks than surgery. However, given that a spontaneous vaginal delivery outcome is neither predictable nor guaranteed, I simply cannot understand the justification for refusing a woman's request to deliver by planned cesarean surgery instead.

Improvements must come
The reporter for the Herald writes this about Ireland: "Some day, someone will properly psychoanalyse us as a nation and society to find out exactly why we put up with so much for so long."

I would make the same observation about some aspects of maternity policy and the disastrous outcomes that too many parents suffer: "Some day, someone will properly psychoanalyse expectant parents to find out exactly why we put up with so much for so long."

Unethical focus on reducing cesarean rates - another baby dies

This story, published in The Daily Mail on Monday this week, is a harrowing read and absolutely devastating (Why do doctors still use forceps when they killed our baby? by Jane Feinmann).

It sickens me when I hear about women whose legitimate cesarean request is being ignored or refused at antenatal meetings, and the stress and trauma that they have to suffer during their pregnancy, but when I read stories like this - where there was a clear and present danger to the baby, the parents are begging for a cesarean, and medical professionals choose a riskier course of action that results in a precious baby's death - I may have tears in my eyes, but my stomach churns in anger and resolve that something must be done to stop this unethical practice.

Maggie Blott, spokeswoman for the Royal College of Obstetricians and Gynaecologists, is quoted as saying: "If we are going to have normal deliveries, we have to keep on training obstetricians to use forceps."

My view: "I planned a cesarean delivery precisely because I did not want a 'normal' or 'natural' vaginal birth. I didn't trust Mother Nature, I wanted to avoid the unpredictability of a trial of labor, and I took comfort in the growing body of research that demonstrates far safer outcomes for babies with planned cesarean delivery at 39 weeks. I wanted a safe birth - not a normal one - and hospital policy should support this choice."

I would encourage you to read this article in full, but here are some of the main details reported as the investigation continues:
The outcome
- Baby Alexandra, born weighing 9lb 4oz, died when she was just three days old
- She died as a result of severe injury to her spinal cord inflicted during a forceps delivery that went wrong - 10 hours after her parents had repeatedly begged the obstetric team to deliver the baby by cesarean
- Parents Beatrix and Craig Campbell lost the daughter they had conceived through IVF after 5 years of trying (which had involved both parents undergoing surgery)

The birth
- June 2009, at the Royal Infirmary Edinburgh’s Simpson Centre for Reproductive Health
- Beatrix, a slight 5ft 2in, was past her due date with a large baby lying sideways
- 30 hours after induction started, exhausted and barely dilated, Beatrix told the midwife she wanted a cesarean. The hospital later admitted that this would have saved Alexandra, but the request was refused.
- It took 4 doctors 75 minutes to stitch Beatrix and she had to return a month later for surgery on the wound

What the parents say
- ...they believe she was the victim of medical arrogance and a determination to reduce the rising cesarean rate
- ...they are hoping there will be an independent investigation into Alexandra’s death
- They have begun their own investigation into forceps, discovering that deaths or serious injury are far from rare. ‘We were horrified to discover this is a frequent occurrence that no one seems to be monitoring,’ says Beatrix. ‘Craig has found local newspaper reports of ten examples of babies dying or being damaged during forceps delivery, with the coroners’ reports in many cases saying that a Caesarean should have been performed earlier.’

Informing women...?
Feinmann writes:
‘NHS websites talk about “the slight risks associated with forceps delivery”, citing temporary problems such as bruising or scratches,’ says Beatrix, 32, a researcher. In fact, studies since the Eighties have reported high rates of damage to mothers and babies through forceps use. Recent research confirmed this poses a higher risk of birth injury than other interventions, including Caesareans.

Over the past decade, there has been a decline in the use of forceps worldwide - the instrument is consigned to medical history in most U.S. maternity hospitals.

Using forceps safely requires a high level of skill and expertise, which ‘means that the outcome is always uncertain, even for experienced surgeons,’ says leading U.S. surgeon Atul Gawande, head of the World Health Organisation’s Safer Surgery initiative.

‘If you’re seeking the safest possible delivery of every baby, you have to take notice of the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received,’ he says.

Experts are particularly concerned about a type known as Kielland’s forceps, which were used to deliver Alexandra... Unlike most forceps, which are used to speed up the delivery of a baby that has become distressed or obstructed in the final stages of delivery, Kielland’s forceps are used to rotate an infant stuck in a sideways position, usually higher in the birth passage.

The procedure is so tricky, says Professor Nick Fisk, former consultant obstetrician at Queen Charlotte’s Hospital, London, ‘that even experienced senior consultants would not attempt a Kielland’s forceps delivery’.

Should forecps be used?
Feinmann writes: Phil Steer, Professor of Obstetrics and Gynaecology at Imperial College, London, is among the many who have abandoned forceps - they are a rarity in Chelsea & Westminster, where he is a consultant obstetrician, with Kielland’s forceps all but unknown.

Yet at least 31,500 babies a year are delivered by forceps - that’s one in 20. Some hospitals continue to use Keilland’s forceps; at the Royal Infirmary, where Alexandra was born, there are 170 such deliveries a year.

Tuesday, February 9, 2010

Study suggests: Infection and early birth linked to asthma

As someone who chose to have a cesarean delivery on maternal request, and supports other women who do so, I have always been slightly skeptical of studies that suggest I might have put my children at greater risk for asthma than women who plan vaginal deliveries. This is because most of the studies that suggest an association between cesareans and asthma contain mixed cesarean delivery types (e.g. emergency cesareans and planned cesareans for medical reasons; and the latter often take place prior to the advised 39 weeks EGA for maternal request cesareans).

The study referred to in the Los Angeles Times article below also points to premature birth as a likely risk for asthma, as opposed to the cesarean delivery itself, and adds weight to some of the points I made in my December 2008 blog, "Asthma has NOT been specifically linked with non-medical cesareans".

Article by Thomas H. Maugh II, on February 2, 2010:

An infection of the uterine cavity during pregnancy combined with premature birth doubles the risk that an African American child will develop asthma, researchers have found. The combination also increases risk for some other ethnicities, though less severely.

About 8% of pregnancies are marked by such bacterial infections, called chorioamnionitis, but it is not yet clear what proportion of asthma is induced by them, said the lead author, Dr. Darios Getahun of Kaiser Permanente's Department of Research and Evaluation in Pasadena. Nor is it clear whether the duration of the infection influences the risk and why different ethnicities respond differently, he said.

But blacks have about a 25% higher incidence of asthma and the new findings could account for a significant portion of that increase. Asthma incidence is also higher in American Indian and Alaskan Native populations, but the researchers were not able to examine that association.

About 14% of American children suffer from asthma, an inflammation of the airways that is marked by wheezing, shortness of breath, chest tightening and coughing. About half of such cases are believed to be of genetic origin, but the cause of the rest has been a mystery.

Many studies have looked at the risk of asthma related to caesarean sections, exposure to antibiotics and other factors related to delivery, Getahun said. "We were thinking that it was really exposure [in the uterus] that may predispose children to asthma later in life."

Getahun and his colleagues used the extensive electronic medical records of Kaiser's Southern California Medical Group, studying 397,852 births between 1991 and 2007.

They reported Monday in the journal Archives of Pediatric and Adolescent Medicine that chorioamnionitis had no apparent effect on the rate of asthma when the fetuses were carried full term.

But when the mother suffered from the infection and gave birth prematurely, the risk of asthma developing before the age of 8 was 98% higher in black children, 70% higher in Latino children and 66% higher in whites. No increased risk was observed for children of Asian or Pacific Islander descent.

Getahun speculated that the infections -- which can be caused by a broad variety of bacteria -- cause inflammation of the fetal lungs, either injuring the lungs or predisposing them to react more severely to future environmental insults.

Chorioamnionitis is marked by a fever above 100.4 degrees and may also be manifested as increased maternal or fetal heart rate, uterine tenderness, foul-smelling amniotic fluid and increased white blood-cell counts.

Study suggests: sutures safer than staples for cesarean

The article below appeared on the CBC News website on January 4th, and it is certainly a topic worth discussing with your OBGYN prior to your cesarean surgery.

Personally, I was given staples for both of my surgeries and was fortunate not to experience problems on either occasion; had I read about this study though, I'm sure I would have liked to discuss the risks and benefits of each beforehand.

CBC online article:
Women who had caesarean sections were less likely to suffer complications if their incisions were closed with sutures instead of staples, a U.S. study suggests.

When researchers randomly assigned more than 400 women who were having C-sections into either a staple or a suture group, they found staples were linked with a four-fold increase in risk of the wound separating compared with sutures.

Dr. Suzanne Basha, an obstetrician/gynecologist at the Lehigh Valley Health Network in Allentown, Pa., said she set out to test the difference after she noticed she was seeing more patients return with complications after staples but could not find any published research on the topic.

Wound data was available for 219 women who had sutures and 197 who received staples. They were interviewed by phone two to four weeks after delivery.

Use of staples resulted in:

•A higher rate of wound separation (16.8 per cent versus 4.6 per cent for sutures).
•Increased visits to doctors after the operation (36.0 per cent versus 10.6 per cent).
The average operating time was 49 minutes in the staple group compared with 57 minutes for those who had sutures.

The researchers concluded that sutures may be the preferred method for closing the skin for caesarean deliveries.

The findings were presented Thursday at the annual meeting of the Society for Maternal-Fetal Medicine in Chicago.