Dec 22, 2010

Twin Study

In 2007, the British Medical Journal (BMJ) reported that second-born term twins are twice as like to die at birth or shortly after birth as first born twins, if delivered vaginally. This finding reflects a relative risk, not an absolute risk which remains very small, and it was for term births only.

The Atlanta Journal Constitution (3/2/07) reported:
"'I would hate to see this study used as an excuse to have every mother with twins have a Caesarean section,' said Dr. F. Sessions Cole, the head of the neonatal intensive care unit at St. Louis Children's Hospital." Dr. Cole also that the study may apply more to Britain than the US, because we monitor twins better here.

Today, many doctors are all too willing to follow the lead author of the BMJ study, who concluded that: "the findings of this and other studies suggest that planned cesarean section may be beneficial for all twins."

The key word is MAY. Medical opinion is divided on whether cesareans are protective for all twin deliveries. Two French studies from 2006 and from 2003 showed excellent outcomes for vaginal deliveries of twins, regardless of presentation.

So why are so many doctors afraid to deliver twins vaginally? Because of a hostile legal climate in which a public expects a perfect birth and is unwilling to accept the very real risks of breech and twin deliveries, regardless of mode of delivery. When something goes wrong, when the doctor can show a cesarean was ordered, patients rarely complain.

Today, between 50% and 90% of all twins were delivered by cesarean, depending on their orientation (ie. headfirst or not). Yet roughly 60% of all twin pregnancies includes one twin who is not headfirst. This amounts to more than 80 thousand babies a year in the US, many if not all of whom will be delivered by cesarean.

Pregnant with breech twins in 2004, I had great difficulty finding a doctor willing to consider a vaginal delivery. Even though the studies were not conclusive in my case---for it was the second not the first twin who was breech---every single OB balked, even those in midwifery practices, even those who touted themselves as pro-vaginal delivery. Ironically, I delivered my twins an IVY league research hospital with the one obstetrician willing to deliver breech twins vaginally---at 26 weeks. None of the maternal fetal specialists at Harvard, Yale, or Northwestern I have since interviewed would have considered such a move. I still wonder if my twins success in the NICU had something to do with the well-known fact that labor and vaginal deliveries are known to hasten lung maturity?

It will be interesting to see what happens when the next generation of OBs and neonatologists take over, few of whom recall an era when any twins (never mind breech or preterm) were regularly delivered vaginally. For now, I hope that medical residents keep reading studies from other countries where doctors still perform vaginal deliveries of twins and breech babies, before these skills are utterly lost to history.

Jul 12, 2010

The delivery room at a district hospital in northern India was as crowded as the Palden Lhamo chapel during one of Ladakh's biggest winter festivals, the annual Spitug Gustor. It was only 10 am and it was standing room only. Dr. P, who had just gotten off the plane from Delhi that morning, waited as a woman whose bare thin calves poked out from under a bulky North Face jacket climbed up on the rusty steps to the delivery table. The jacket was a logical outfit. It was early April and nighttime temperatures inside the hospital might well sink into the 50’s.

Chime had arrived in early preterm labor at 3 am already 3 cm dilated and there was little the staff could do to slow the labor. There is only one doctor on call at night for a district hospital that serves a region one and half times the size of Denmark. In this case, the doctor, an internist with no experience in obstetrics or pediatrics was unfamiliar with the protocol for tocolytics to slow a woman's labor or prenatal steroids to help speed up fetal lung maturation. As a result, by the time Dr. P saw her, the patient was 10 cm dilated, 100% effaced, and her amniotic sac about to burst.

Which it did did as Dr. P performed her internal exam. She grimaced as the dark meconium stained fluid splashed over her pants and onto the floor. The color of the amniotic ‘liquor’ indicated possible fetal distress and were grounds for immediate delivery, she later explained. Yet she was concerned as the ultrasound from the previous night indicated a gestational age of 29 weeks and the patients’ chart suggested an even earlier date of 26 weeks.

P told Chime her baby had only a 15% chance of survival at this point and that the baby should be born as quickly as possible. I was reminded of my own precipitous labor almost 3 years earlier when I saw the terror in Chime's eyes. I, too, had found myself in a hospital in an emergency labor, with my waters broken, far earlier than I ever expected. I, too, was in labor when I was warned uncertain prospects my twins would face at 26 weeks. While I'm glad I was told the truth, I don't think there is any easy way to break this kind of news to a woman in preterm labor.

Dr. P immediately called for an IV and oxytocin, which might speed up the mother’s labor and also prevent post-partum hemorrhage, one of the most common causes of maternal death in both India and Tibet. A nurse placed the catheter, which failed to drip, until Dr. P noticed and cleared a dangerous bubble in the IV line, and then injected the syringe of synthetic oxytocin into the IV bag dangling above Chime’s head. The dose she administered---less than 1 mililiter of oxytocin per liter of IV saline----was lower than the standard US low dose oxytocin protocol that is used in over 70% of births in the US.

Yet even these protocols can be problematic. The Wall Street Journal 97/21/2006) reported that even insurance companies are trying to reduce the over-reliance on synthetic oxytocin or Pitocin in American obstetrics, as the drug is implicated in over half of all obstetric malpractice claims that involve birth trauma. These claims make obstetrics one of the most claim-ridden and costliest specialties in medicine from the perspective of insurance companies.

Chime tired after two hours of pushing ---for she been up the entire night in the throes of labor, then traveling to the hospital, never mind the panic of what must have felt like a horribly wrong time to be having this baby. But with Dr. P's encouragement and the nurses scolding, she managed at last to push her son out.

When her son was finally delivered, he was much bigger than expected at 1.6 kilos, but almost non-responsive. His color was dusky, he wasn't breathing, and had no obvious reflexes. His apgars of 2,4, and 6 at one, five, and ten minutes, reflected the concerted efforts of the hospital’s best obstetrician and pediatrician. He was transferred back to packed obstetric ward a half an hour after birth and given best treatment the Leh hospital had to offer---100% oxygen by improvised nasal canula, suctioning, and intramuscular antibiotics. Less than 24 hours later, he died of a brain bleed; his mother was discharged the same day.

Why write about this incident?

Because giving birth involves very similar and very different forms of suffering for women and infants, each and every day, depending on where they live on our crowded little planet. I honor the suffering that women in Ladakh experience who have no access to NICU's as much as I respect the difficulties that women in the US face, with some of the best medical care in the world.