Tuesday, October 23, 2012

Word of the Day: Iatrogenic

Quick & dirty definition, on the off-chance you don't already know: "caused by treatment."

By & large, I quit hanging around mainstream parents during my first pregnancy.  Lacking the gene to not question and not research made a lot of what my fellow moms were doing seem just odd to me. 

Pregnancy and childbirth, for most women, simply aren't dangerous.  There are, of course, exceptions.  I've made no secret of my two surgical births.  They were both for what (to me) is a good reason: footling breech presentation.  Babies who present like this can be born vaginally, but there are heightened risks, and a doctor inexperienced with breech births (which is almost all OBs these days) increases those risks.  It was riskier for me but much healthier for my daughters for them to be born via a method the doctors knew something about.

The uncomfortable truth a lot of women never learn is this: there are many complications of birth that are made manifestly more likely by obstetricians.  This has been true as long as physicians have been involved in birth: one of the reasons germ theory was developed was because a doctor in (I believe) Paris noticed that when the doctors at his hospital had a horrific record compared to the midwives, and the significant difference was their habit of going straight from the morgue to the delivery ward.

We are not quite at that level of stupidity anymore, but some things do come close.

For instance, induction of labor nearly doubles the risk of amniotic fluid embolism.  Make no mistake, it is a rare complication, but it is a very real one and is often deadly.  So you'd think inductions would be pretty rare...but by and large they aren't.  Actual numbers are impossible to pin down because of the huge variation by hospital, but up to 40% of labors are induced, and only 19% of those inductions are due to a medical reason.  Induction also doubles the risk of c-section, which a lot of women don't seem to realize is major abdominal surgery(The WHO, by the way, recommends a c-section rate of 10% - 15%; the US has an overall rate of 31%.  You can find doctors with much lower rates here and there, and for the most part these are doctors who do not push inductions.)

What frustrates me as a parent and a patient is how many women credit their doctor with saving their baby...without any realization that the only reason their baby needed saving is that the doctor first endangered its life.

True story, and very recent:

Woman is pregnant with twins.  Woman is told twins should be born at 37 weeks, because waiting longer does not improve their outcomes.  (There are reasons for this other than the seemingly-obvious, including that when one twin dies in utero, induction of the other is often put off as long as possible to improve its chances of survival--so there is an artificial bump in stillbirths at 38 weeks.)  Woman trusts her doctors, because that's what most people do, and reports for her induction the day she hits 37 weeks.  Because she's already contracting, they simply augment with Pitocin, and because she's been told it's for the best, she gets a very early epidural.

Time passes.  She's dilating very slowly.  This happens, especially when you are induced just because and when you've been given an injection known to slow down labor.  Mom is stuck in bed because her epi's so high she can't feel a thing.  Baby A is pretty high up in her pelvis--not what we call engaged. 

After a few hours, the decision is made to try to hurry things along.  One of the ways this is very commonly done is to break the amniotic sac.  So they break Baby A's water and leave the room...Only to come running back in minutes later and rush her off to emergency surgery.

So, what happened?

Did you catch up there where I said Baby A's head was not engaged?  It's actually really, really important NOT to break the water when this is the case.  See, if the baby's head isn't pressed down against the cervix good, there's a chance the cord will come out first and be compressed by baby's head, cutting of the infant's supply of oxygen.  The death rate from this is 91/1000.  (Here I am forced to note that the mother wound up with a complication that has a higher risk of death than waiting for her twins to be born naturally would have offered.)  According to the RCOG, Britain's version of ACOG, about 50% of cases are preceded by obstetric manipulation, and "planned artificial rupture of membranes, particularly with an unengaged presenting part" is one of the interventions most frequently preceding cord prolapse.

So, her baby's life was heroically saved...but not before being endangered by the very people who saved it.

The whole damn thing makes my head hurt.

(As a sort of side note: she's lucky she was contracting already.  They had planned to induce her with Cytotec, a drug which both the FDA and the manufacturer have been warning against using for this purpose for at least a decade now.  It's absolutely amazing to me that a drug whose product info includes the sentence "A major adverse effect of obstetrical use of Cytotec is hyperstimulation of the uterus which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophrectomy, or amniotic fluid embolism)" is still regularly used for this.)

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