Home Births and the Courts

My third child, Y, was born at home, at term, after such a gentle labor that the amniotic sac or caul was intact!  I was attended by two amazing midwives---my care during pregnancy, delivery, and postpartum was the best medical care I have ever received.  The unbroken sac is such a portent for good luck & special powers that midwives honor this type of birth and 19th century New England households used to keep these cauls in jars on mantelpieces in houses where their seafaring men were out to sea for safety. 

Y's home birth was at the center of a courtroom battle in 2017, with my ex-husband, Ashok, whose physical abuse was the cause of our divorce, and now our trial, as he had been abusive to our son K between 2014-2017, WHile I had 3 friends in the courtroom, Ashok had none, perhaps because he was too ashamed by the lies he would tell that day. Here is an account of what I said under oath and submitted in written testimony to Judge Simmonds of Berkshire Probate Court in 2017.

Y was born at home, at term, under the supervision of a trained and certified midwife (CNM) with 30 years experience. Our midwife who examined Y at birth and 24 hours later, found a healthy newborn with no jaundice.  At 48 hours after birth, a lactation consultant found Y to be jaundiced, but did not seem overly alarmed as jaundice affects 50% of newborns.  The midwife did return the next day to find the jaundice had progressed and advised that we take Yeshe to the local North Adams hospital to have the bilirubin levels checked. We did as asked and our pediatrician, Dr. Art, confirmed the jaundice and urged us to have blood test. The blood test confirmed that Y had hyperbilirubemia, due to a rare blood incompatibility with my blood type (called ABO incompatibility between MO and baby). 

After Y's blood test, we went home and waited for Dr. Art to call us with results on our home phone as we did not have cell phones yet in December 2007.  Yet Ashok had turned the ringer off our home phone as we were trying to get sleep and still had 3 yr old twins to care for, so we only checked the answering machine an hour after Dr. Art called.  I asked Ashok to drive me to the hospital immediately, but he wanted to wait till my mother arrived to stay home with our twins, because it was Jan 2 and -10 F outside that day.  When we arrived at the hospital, Ashok falsely blamed our delay on me.

In the courtroom, Ashok's attorney lied and implied that our home birth was the cause of the hyperbilirubemia, while exacerbating our lack of diagnosis and delayed treatment. She failed to mention that of the 200,000 cases of ABO incompatibility in the US each year--nearly 99% occur after the baby has been discharged from the hospital where it was born. In short, our home birth did not worsen nor cause Y's hyperbilirubemia.

First, ABO incompatibility affects less than 5% of all newborns in the US, and tends to manifest at 48 - 72 hours after birth. Indeed, most newborns with this condition are asymptomatic at birth. Second, most of the 4 million babies born in US hospitals were not routinely screened for ABO incompatibility in 2007. Third, if Y had been born in a hospital, we would have been discharged after 24-48 hours before hyperbilirubemia usually manifests. My midwife's son was born at Cooley-Dickinson hospital in Northampton with ABO incompatibility, and discharged one day after birth. At 2 days after birth the baby was brought back to the hospital yet nobody questioned the decision of the hospital that discharged them.

Finally, there was nothing about Y's home birth or the midwife's care that caused the jaundice. It was caused solely by the congenital ABO incompatibility that had nothing to do with mode or site of delivery, ie. the home.

Y was admitted to North Adams hospital,  given an IV to avoid dehydration, and phototherapy for two days. Upon discharge 48 hours later, we were given a home phototherapy device that we used a few more days. Y experienced no sequelae of this incident. Ashok's oral testimony was so full of confusion and lies that the Judge failed to understand that newborns born in hospitals do not routinely have their bili levels tested.  Ashok implied that I refused to have Y's billi levels checked at birth, which would not have been possible at home as a billi test requires taking blood as well as a sophisticated laboratory analysis that home birth midwives do not carry. Ashok's attorney asked, “did a doctor test Y's billi levels at birth?”, while failing to note that even hospitals do not test newborn bili levels routinely. The exchange implied that I was the obstacle, rather than admitting that both home and hospital births did not take blood from every newborn to test for bili levels in 2007.   

Ashok implied that when I breastfeed Y in the hospital, they were not getting the benefit of the billi lights--failing to recognize that breastmilk is lifesaving for a newborn, especially one under the bili lights which produce dehydration. Yeshe's IV had fallen out the first night in the hospital and so breastfeeding was the only way to keep this baby hydrated and alive. The first IV had taken 4 tries and another IV might have further side effects such as infection and stress.  I was told that if the second IV fell out, Yeshe might need a transfusion and transport to the Springfield NICU 2 hours away.  

There is only one major and deadly side effect of phototherapy treatment, dehydration.  If a newborn is not given an IV or breastfed, the phototherapy lights––so intense that newborns wears black foam glasses so as not to suffer retinal damage and routinely get sunburned––can be deadly for newborns whose systems are easily shocked by disturbances of warmth, hydration, and nutrition.  The nurses understood the urgency of my breastfeeding every few hours but Ashok implied that my breastfeeding was getting in the way of Y's therapy to the Judge--who had no understanding of neonatal health or survival, nor any awareness of how he was being fooled that day.

In an email submitted to the court, Dr. Art would argue that Y's case was one of the 'most traumatic moments' of her career. This may be because she was a newish doctor and had seen only a few cases of ABO incompatibility in her career. That is hardly our fault, but we can blame Stanford Medical School. Whatever the cause, Dr. Art would submit an email to the court accusing my home birth of endangering the health of our child Y. Further, just days before our trial, Dr. Art would make up to 50 changes in the medical record, all on the same day, many of them about events that had occurred 10 years earlier in 2007 (Y's birth). I will never know if it was guilt, fear, or antipathy against a home birth, but Dr. Art's email to the court was enough to convince the judge to award legal custody to Ashok, despite a report from the DCF (Department of Children and Families) and GAL (Guardian ad Litem) that showed Ashok's ongoing physical abuse of our son K between 2013-2016 (including violent shoving, pushing him off the porch, slamming him into walls, kitchen counters, & stoves). Rather than admit that her views about home birth hampered her ability to care for our children, Dr. Art summarily dismissed all 3 children from her care in 2017 when I wrote, giving her proof of Ashok's physical abuse of K. 

Why does this story matter?  It was as if I had a scarlet letter on my forehead during that trial--H for homebirth.  

If you have a home birth, your Pediatrician might actively work against you for the next decade of your children's care. In fact, she might even support an abusive ex who is physically assaulting your children. 

Dr. Childsy Art seemed to forget that I had stayed home for more than a year after my twins birth, taking them to every medical appointment & developmental check ups (most of which Ashok failed to attend), while also assisting with weekly and daily developmental therapy at our home with physical and occupational therapists.  She knew I studied neonatal and maternal health, and midwifery care.  

Once the Judge and Ashok's attorney knew I had a home birth, I was suspect. It did not matter than I have studied birth for 20 years, have written dozen of essays, and would soon publish an acclaimed volume Sustainable Birth in Disruptive Times (Springer Nature, 2021) with co-editors Robbie Davis-FLoyd and Betty-Anne Daviss, who have advocated for midwifery care and home births across the globe for more than 35 years. 

It is only by telling the truth that we can hope to bend the arc of justice towards women's rights, human rights, newborn rights... 

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.

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.

Two Births, Two Twins, Two Boys.

Two boys, both twins, my son on right, my friend N's son on left.
Two boys: the one on the right is my son and the one of the left is my friend N's son. Both were born vaginally and both were part of pair of twins one of whom was breech. But there the similarity ends.

N delivered her twins at term and at home in rural Zangskar at 12,000 ft. She was attended by her sister, a midwife, and the local pharmacist. My son and daughter were delivered at 26 weeks in a stainless steel operating theatre at Dartmouth hospital, attended by no less than four obstetricians, several obstetric residents, three anesthesiologists, two neonatologist, a few neonatology residents, and a dozen nurses.
N's labor and delivery took all of six hours. I was in early labor for four days and active labor for 27 hours, with an obstetric team that was willing to be as patient as modern obstetrics would allow.

N received a single shot of muscle relaxant called epidocin (valethamate bromide) used to relax the cervix and speed up dilation. When I asked to deliver my preterm twins naturally, the doctors looked at me with pity or morbid fascination. Despite resistance, I received the following drugs: magnesium (accidentally) to slow my labor (abandoned once it emerged an amniotic sac had broken), antibiotics to prevent infection (habitually used for preterm births), IV fluids for rehydration (no evidence of benefit other than the ease of administering further drugs), steriod shots to hasten fetal lung development (good evidence of benefit), pitocin to speed up my labor (painful, mixed evidence of benefits), and an epidural just before I pushed my first twin out (anecdotal evidence, as my OB insisted that she didn't want me crawling up the operating table like a former patient as she reached into my uterus to pull out the second twin, who was breech).

If I had delivered my twins in Zangskar, they would have had little chance of survival. If Nyima had delivered her twins in the US, she would have had trouble finding a midwife willing to do a homebirth for twins and no chance finding a doctor willing to do a vaginal delivery where the first or presenting twin was breech. It was luck that I, not she, had the antenatal hemorrhage. Roughly half of all maternal deaths in Nepal and a third of maternal deaths in India and Tibet are due to hemorrhage, and even in the US, hemorrhage remains a major cause of maternal death. Rather than enumerating statistics, let't turn to N's delivery in the rural Himalaya.

***

Neither N nor her sister Lhaskyid, the midwife, was sure N was having twins nor a breech until the day of her delivery.

When L performed her first internal exam, shortly after N went into labor, she discovered two things in rapid succession. First, N was already ‘two fingers’ (3 cm) dilated after only an hour of labor. But the real surprise lay beyond the cervix. Rather than the comforting roundness of a head, she could feel buttocks. She nearly cried out because this baby was not headfirst.

L had delivered many breech babies in her life, but none of them were twins. She knew the problems a breech could cause---cord entrapment or cord prolapse in which the oxygen to the baby gets cut off, or head and shoulder entrapment in which the baby gets stuck on its way out. Most critically, she knew that in any of these scenarios, there was no option for an emergency cesarean or any of the other life saving measures for baby or mother in Zangskar. The nearest hospital was a 22 hour drive over a high pass that was still blocked by several feet of snow.

L thought of her mother, who had died almost 33 years earlier, after delivering her ninth child, a few years after N's birth. L, only six at the time, recalled the palpable fear in the kitchen as the two most prominent Tibetan doctors in all of Zangskar appeared at their door that night, one after the other. Although the second doctor performed best while inebriated and the first was more familiar with astrology and the texts of Tibetan medicine, neither had been able to do much to prevent her mother from bleeding to death after she expelled a lifeless infant.

L finished her internal exam, smiled, and told her sister that she would soon deliver. Almost in tears, she returned to the kitchen where her stepmother was churning the butter tea. She took the wooden tea churn and sent her stepmother off to call one of Karsha's more skilled birth attendant, a local pharmacist.

The pharmacist arrived perplexed, for he knew that L had delivered many babies in her career. After he performed an internal exam at L's suggestion, he went into the hallway and said "kam log", which mean vomit, the Zangskari equivalent of "oh shit". He and L resolved to labor strategy in Urdu rather than Zangskari so that N never suspected how difficult this delivery might be, nor that she was having twins. While L rubbed her sister's back and made sure that she stayed warm, she also knew to keep her ‘hands off the breech’. It was not long before N pushed out the first twin, a boy who came feetfirst. Although Zangskaris prefer a man to cut the umbilical cord, when L yielded the scissors nobody objected. While L knew to put the baby to N's breast to keep the oxytocin---biology's natural pain medication---flowing, N caught her breath and recovered some strength. A twin girl arrived shortly afterwards, slipping easily past a cervix already widened by her brother. L reached down to catch the second baby, cut the cord, wiped the baby dry and handed him to her mother who cried in relief.

Both of these stories are about “skilled attendance at delivery”, something the WHO measures and counts across the globe. This quantification has brought funding and a measure of attention to the problem of women dying in childbirth. Yet ethnography can provide an equally powerful way of suggesting what ‘skilled delivery’ or ‘humanized birth’ might mean. N and my delivery shared several critical features including the skilled management of twins and breech positioning. Yet they differ in one key regard; I had far choices more choices than N and most of the women in Zangskar. In India this year, roughly 16 million women will deliver at home and roughly 13 million will lack access to skilled attendance at birth. They deserve more, and ethnography may have a critical role to play.

For Dr. Padma

Dr. Padma (back left), Kim Gutschow (back right), and the chowkidar or night watchman at Leh Hospital.


Picture this. The Sonam Norbu Hospital in Leh, Ladakh is one of only two hospitals that serve an area the size of Norway. This area is only home to 250,000 people, making it one of the least populated regions in India, with one of the lowest fertility rates in the nation.

Why so few people? Did I mention the forbidding desert landscape at 12,000 feet above sea level--- some of the lowest precipitation in India? Or the fact that many crops don't or can't grow that high or in such a dry climate? So why all this talk about altitude?

Imagine a hospital where electricity is imminent at times and the back-up generator takes 10 minutes to kick in, depending on how cold it is and whether they guy who is supposed to start it feels like getting out of bed in the middle of the night. Imagine doing a cesarean section by flashlight, as I have heard done in Leh.

Imagine having to beg the anesthesiologist repeatedly to come in just one more night, one more time, for one more emergency obstetric complication, and he is twice your age, and is better friends with your parents than you in a very small town.

Imagine a delivery room where the heating is spotty, the mother lies down on a cold rubber surface that was scrubbed by ice cold water that may or may not have been hauled there in a bucket when the pipes freeze.

And now imagine Dr. Padma, doing her morning rounds, after she has walked the 100 yards from her tiny one bedroom apartment that is in the staff quarters next to the hospital. Always cheerful, always professional, even in the coldest weather, or in the worst mood. She is happy to discuss each patients' progress, give the nurses their instructions one more time, clarify the meds that should and should not be administered, order another ultrasound, and then discuss the latest literature on corticosteroids with me.

She graduated from one of Delhi's most prestigious medical colleges and then left a fellowship at one of New Delhi's finest public hospitals---Safdarjung--- three years ago to return home, to Ladakh, to work at Leh's government hospital. She has never accepted payment under the table for her services as many do in India's public hospitals where the salaries are almost as poor as the infrastructure.

And tomorrow she goes back down to Delhi for another shorter fellowship. Let's hope she returns.

We need more doctors like her in Ladakh. And everywhere in rural India for that matter.

AMA and ACOG fight home births

Have you heard the news?? According to ABC news (7/11/2008), the American Medical Association (AMA) recently agreed to support proposed legislation that could make having a planned home birth difficult if not impossible.

The AMA agreed to back resolution 205, in which it agreed with a recent ACOG (American College of Obstetricians and Gynecologists) position that home births are not as safe as hospital births. Both the AMA resolution and the ACOG statement on home births (2/6/2008) have come in response to the publicity surrounding the new film, the Business of Being Born. The fact that ACOG feels threatened by the film's open advocacy of home births---when home births only account for under 1% of all births nationwide in the US (the official figure, actual figures may be closer to 2%)----suggests how paranoid ACOG has become of midwives and their support of home births.

Like many of ACOG's practice guidelines or seemingly innocuous educational reports, their "statement on home births" is a highly politicized document, which bears little relationship with evidence-based medicine. Their attack on Lake and Epstein's film is hardly disguised when they say, "childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause celebre."

As if women are choosing home births because they are trendy.  It may be because home births are now safer than a hospital birth for the first time, given the current trends towards unecessary interventions, many of which are not evidence-based.  

ACOG might also have noted that childbirth decisions should NOT be influenced by legal issues. Indeed, the epidemic of inductions (up to 60%) and cesareans (30%) within low risk hospital births in the US, may be due to obstetric fears of malpractice than concern for maternal or fetal or neonatal well-being.

ACOG might have noted that childbirth decisions should NOT be influenced by economic issues. They might have noted that hospitals are trying to save money when they use electronic fetal monitoring (EFM, now used in over 90% of all hospital births in America) rather than the intermittent auscultation with a hand-held doppler still used in Europe and the developing world that offers improved neonatal and maternal outcomes over EFM in many low risk births. Click here for the NEJM article on electronic fetal pulse oximetery (which was hoped to be an improvement over EFM but the trial was cancelled when it became clear it was no improvement over a technological method already deemed questionable). Interestingly, Michael Greene's scathing rebuke of EFM in the New England Journal of Medicine (vol 355 Nov 23, 2006) that was picked up by news wires around the country during Thanksgiving week that year, is only available to NEJM subscribers, but you can see the abstract here. 

 

But they ignored the practices prevalent across the US that have contributed to a profound crisis in hospital based obstetrics that the film Business of Being Born so ably unpacks. There are no clear answers to our dilemma, but a fear mongering against the very groups that are trying to improve the birthing outcomes for women is not one.

As for the AMA decision, it is one thing to reject a phenomenon that has been studied, but quite another to reject a phenomenon they have shown almost no interest in. The most recent study of home births in its flagship journal, JAMA, dates to 1980. In other words, for 28 years nobody on the JAMA editorial board has felt the need to address the evidence on home births. Perhaps it is too difficult to study home births or there simply aren't studies out there worth reviewing? Actually there are great studies, but from Canadian or European journals, which DO show an interest in the evidence comparing home and hospital births. One of the more recent and largest studies---from the British Medical Journal (18 June 2005)---found far lower rates of intervention for home births, but comparable intrapartum and neonatal mortality rates (1.7 per 1000) than the average low-risk hospital birth.

Yeshe, small and thin

Appropos the low birthweight study I discussed in my previous post, our third child, Yeshe, who was born on Dec 30th, 2007, was low birthweight. She was born full term, at home, after a calm, smooth labor. So calm in fact that she was born with her sac intact, what is traditionally referred to as in the caul. Midwives have told me this is a sign of wisdom, psychic insight, and even spiritual teachings, while another friend set me a clipping from an early 20th century memoir that talked about how ship captains would take a caul with them to the sea for good luck. I hope this gift serves Yeshe, which means wisdom in Tibetan, well.

Will Yeshe experience any sequelae of her low birthweight? And how did she come to be low birthweight? I ate like a horse during my pregnancy and gained 35 pounds. Her weight---5 lb, 10 oz---is a mystery as is so much in life.

The question I recently debated was---when should I tell Yeshe that she was low birthweight? Or would I pathologize her by showing this concern? Sure, she'd get her birth certificate, but unless mentioning her birthweight was relevant to an ongoing health issue, why burden her? But what about my twins---who were born at 26 weeks and are now 3.5. The same strategy could apply---unless they need to know about their prematurity because of an ongoing health issue, why bring it up?  Now

Six years later, in 2017, when my kids started asking me about the books I am writing---one of which is called Sustainable Birth and teh other a medical memoir about birth in the USA and India---we read the chapter that contains their birth story, and they asked lots of questions that I tried to answer as best as I could.   The key is to remember that my story of their NICU stay is different than their story of that stay and I tried to be helpful to them first and foremost even as I explain how their birth relates to my work, as well as my mission and passion around midwifery care... .

Small and Thin

There was an article in the New Yorker (Nov 19, 2007) that had some disturbing news. For almost 20 years, scientists have been debating the "Barker Hypothesis" which found a strong association between low birthweight and increased risk of adult diseases like coronary heart failure, hypertension, type 2 diabetes, and strokes. Although initially dismissed as heretical, these findings have been repeatedly confirmed in recent epidemiological studies. The causal mechanism behind this finding appears to be a complex dialogue between fetus and mother's body---in which the fetus or even embryo adapts itself to the nutrient levels in the maternal environment. In cases where the nutrient levels are less than ideal, the fetus adapts by slowing its growth and thereby lowering its ultimate birthweight. Ironically, such infants later find the more plentiful nutrition of the postnatal environment a stressor rather than an aid to growth. Most at a disadvantage are those children who are born with low birthweight, but gain rapidly in BMI after two years of age.

This last conclusion has serious implications for parents of low birthweight babies (two thirds of whom are premature in the US). If it is dangerous for premature babies to grow too big, too fast, after age two, shouldn't we be more interested in these kids maintaining their percentile position rather than trying to jump up into higher percentiles. Are pediatricians aware of these studies and advocating against rapid weight gains between 2-5 years of age?

What does your pediatrician say? Please let us know...

The Fracas About Resuscitation

I am going to start by a recent exchange that occurred over at the preeemie experiment. The conversation---rather impassioned but never truly disrespectful---spanned two separate posts (Nov 7 and Nov 6) and garnered more than 100 comments in a 24 hour period! I like to think it began with a comment made that my husband and I made a decision a few months ago that we would not seek resuscitation in this pregnancy prior to 26 weeks. We discussed this with the high risk OB who had delivered our twins at 26 weeks 3 years ago, and duly entered this decision into our medical records.

Thankfully, we were spared the decision, as I am now 32 weeks pregnant.

However, the issue remains a serious moral quandry that I have thought about for quite some time. I had first contemplated a DNR under 26 weeks, hypothetically, years ago, when I began reading more about prematurity. While my twins' 3 month stay in the NICU in 2004 was relatively uncomplicated and they are doing very well now, my decision had less to do with their outcome than with a profound understanding of how dicey outcomes are for all premature infants. Precisely because the decision was NOT made based on my own childrens' outcomes, I don't believe it reflects on how much I value my own children. More importantly, I do not believe that a decision not to resuscitate casts any children's lives as not meaningful. However, this seems a common assumption in the heated exchanges on this topic that I have observed.

I think it is significant that very few people post or comment about DNR orders they have made. Yet a few of us who actually made the decision or acted upon it did comment in this exchange and that to me was a real accomplishment.

I think it is extremely valuable to have these kinds of comments---especially on such a sensitive and unpopular moral issue. The true test of an open and respectful forum is one in which people feel safe commenting on these issues and possibly learning from each other. Sadly, the emotional tenor of the debate led TPE to shut down comments on her blog.

I do hope that this conversation will continue. And I also believe there are many, many equally important issues surrounding prematurity that need further discussion.

Please scroll to the bottom of this website for a set of web pages that include the entire ACOG practice bulletin on resuscitation limits.

Antenatal Steroids: The research

There was a heated discussion earlier this year at Neonatal Doc which turned offensive and resulted in the blog's slow death as well as the deletion of some comments regarding antenatal steroids. Oddly, the topic of antenatal steriods--which remains under research and debate---had not been covered in the neonatology blogosphere that I know of.

Let me try and summarize the gist of the debate on antenatal steriods from a cursory reading of the literature. For at least ten years there has been considerable debate on what type of corticosteroid therapy is most effective and safe in improving neonatal outcomes. The efficacy and safety of a "single repeat dose" of antenatal steroids---generally betamethasone, administered in two, repeat 6 mg shots, 12 hours apart---is unchallenged.

As doctor Roger Newman, past president of the Society of Maternal Fetal Medicine, proudly told me in an interview a few months ago, "a single course of antenatal steriods has saved as many lives as the discover of penecllin in its era." Yet he admitted the jury is still out on several major questions, including the efficacy of antenatal steriods for twin pregnancies as well as the efficacy and safety of administering multiple doses---which have been administered to women who go into preterm labor early but do not deliver.

Because the efficacy of the steroids appears to decline after one week (although question remain), women who remain pregnant have been encouraged to have repeat doses of steriods until their ultimate delivery date. Several studies have shown that three or more courses of antenatal steroids can have significant detrimental effects on fetal growth, fetal weight and length, and most importantly head circumference. As such, debate remains about the best time to initiate steriod therapy and when best to end it, to maximize its benefits but minimize the potential harm to fetal development.

An article in the April 2007 issue of Pediatrics by C Bonnano, K Fuchs, and RJ Wapner offers caution. Effectively it shows that while a single or a "rescue" course of antenatal steroids is efficacious, these effects must be tempered against adverse effects seen for 4 or more courses of steroids (these would be given if, for instance, a woman remained pregant for several more months after first going into labor and receiving a dose of steroids at perhaps 22 weeks). Moreover, further evidence about the 24 month neurological and developmental outcomes for infants treated with repeat doses of antenatal steriods is still lacking.

A recent Cochrane Database article indicates that repeat doses of corticosteriods were associated with reduced risk neonatal lung disease (primarily RDS), as well as reduced birthweight and/or head circumference. They too call for caution and studies analyzing long term outcomes of infants treated with repeat doses of antenatal steriods.

It is good news that researchers are calling for caution. Perhaps they hope to avoid the recent debacle in postnatal steriod therapy for premature infants---where dexamethasone was later shown to have profoundly deleterious effects including higher rates of CP and other neurological damage.

Click here for the Cochrane Database abstract.

Research contradicts the Term Breech Trial (TBT)

A study of 13,000 breech and headfirst births at a Parisian Hospital resulted in a surprisingly high rate of vaginal breech delivery (79%). This is of the highest rates recorded in the literature. The most surprising finding was the absence of significant differences in neonatal morbidity between breech and vertex babies regardless of mode of delivery.

Additionally, there were no significant differences in neonatal morbidity between breech babies delivered vaginally and those delivered by planned cesarean. The use of strict obstetric protocols for breech presentation---including pelvimetry, continuous cervical dilation, very limited use of oxytocin or induction, and specific extraction techniques were held responsible for the excellent neonatal outcomes.

Among both headfirst and breech babies, those delivered by planned cesarean were MORE likely to be intubated than those delivered vaginally. Vertex babies delivered by cesarean were eight times more likely to be intubated and six times more likely to be admitted to the NICU than those born vaginally. See Pubmed Abstract.

These latter findings confirm recent studies showing the link between cesarean delivery and increased risk for respiratory distress syndrome in near term infants.  A 2006 study looking at over 8,000 breech births in France and Belgium concluded that there were no significant differences between planned vaginal and planned cesarean deliveries. The study used similar outcome measures as the TBT, but far stricter criteria for obstetric management. Thus, the outcomes for vaginal deliveries far surpassed those of the TBT and several similar studies. This study showed vaginal breech delivery to be as safe as cesarean delivery, as long as careful selection criteria are followed. The TBT, by contrast, did far less to ensure the safety of the vaginal deliveries it interrogated.

Unlike the TBT, all babies in the vaginal arm were in frank breech position, with no hyper-extension (the star-gazing position). There were no infants with excessively high or low birthweights and all were subjected to continuous electronic fetal heart-rate monitoring. Moreover, pelvimetry was used for over 80% of the candidates in this study, unlike the TBT where only 10% of all women received any pelvic measurement. In this study, roughly 75% of all breech babies were delivered by cesarean. Pubmed Abstract here.

A study of over 600 births in Ireland concluded that vaginal delivery is as safe as cesarean, as long as strict protocol were followed including: appropriate fetal weight (between 2500 -3800 gms), sufficient amniotic fluid, normal fetal morphology, absence of hyperextension of the head, and absence of complete or frank breech presentation. There was no induction nor augmentation of labor other than amniotomy, and women were supposed to dilate 1 cm per hour and limited to no more than one hour of pushing. All women were attended by an experienced obstetrician, using Løvset's maneuver to deliver shoulders and the Mariceau-Smellie-Veit maneuver, if required. The authors state that both obstetric protocols and the avoidance of oxytocin for induction/augmentation are responsible for the favorable outcomes. Pubmed Abstract here.

Recent Studies in Support of the TBT

Several well-designed research trials have confirmed and improved upon the findings of the TBT, using better obstetric protocols and management. They are:

A 2005 study of nearly a million births in Sweden found higher rates of mortality among breech babies versus headfirst babies, as well as higher rates among breech babies delivered vaginally than those delivered by cesarean. Essentially, planned cesareans reduced the risk of mortality by half. Yet the study did admit that one third of all the deaths may have been independent of the mode of delivery, due to high prevalence of malformations. While the results were not strong enough to recommend that all twins be delivered by cesarean, nearly 90% of all singleton term breech babies already are sectioned in Sweden. Here is the Pubmed Abstract.

A 2005 study of term breech babies from the Netherlands confirms a dramatic rise in the cesarean rate and accompanying decline in perinatal mortality and birth trauma. Looking at more than 33,000 breech infants, the study noted a twofold decrease in perinatal death and a fourfold decrease in neonatal trauma in the two years following implementation of the Term Breech Trial. Within two months of the trial's publication, the cesarean rate for term breeches shot up from 50% to 80%, where it has remained since. Here is the Pubmed Abstract.

A retrospective study from California looked at over 100 ,000 term breech babies born over a decade. It concluded that full-term singleton breech babies delivered vaginally had much higher rates of mortality and morbidity than babies those delivered by planned cesarean. However, more than 95% of the breech babies were delivered by cesarean, suggesting a very low threshold of tolerance (or skill?) for vaginal delivery. Here is the full article.

Critiques of the Term Breech Trial (TBT)

Marek Glazerman published a scathing critique of the TBT in ACOG 's flagship journal, American Journal of Obstetrics & Gynecology . Here is the Pubmed Abstract. The argument notes:

• Most cases (8 out of 13 in the vaginal delivery group) of perinatal mortality were unrelated to the mode of delivery.
• Nearly half of all perinatal deaths arose from infants who should not even have been in the study---ie. undiagnosed twins, anenchephaly, & stillbirths.
• There were far more fetuses with birthweights over 4000 gms in the group intended for vaginal delivery than in the planned cesarean group. Again, all of these fetuses should have been excluded from the study.
• The standard of care at two thirds of participating hospitals was so low as to put vaginal deliveries at a definite disadvantage---no facilities for immediate resuscitation, bag/mask, or immediate intubation of newborns.
• Roughly one third of all infants with significant morbidity failed to have an experienced obstetrician in attendance.
• In a two- year followup, study authors themselves found no differences in neurological or developmental outcomes between planned cesarean and planned vaginal deliveries. In fact, infants from the cesarean group had slightly worse outcomes than those from the vaginal delivery group.
• This last point effectively negates the trial's major findings. Rather audaciously, Glazerman suggests that the Trial Recommendations be withdrawn. Yet even if this were to happen, he thinks it is too late to rescue the rapidly dwindling option of vaginal breech delivery. Indeed, the Trial has has been overwhelmingly adopted in most of the developed and developing world.
  

MJ Turner discusses the further flaws of the TBT in the Journal of Obstetrics and Gynaecology (Aug 2006):

• The findings may apply largely to primigravidas or women giving birth the first time. There were twice as many perinatal deaths among primigravidas as among multigravidas.
• The slight differences in immediate perinatal outcomes were not related to delivery, but to labor, especially augmented or induced labor. The adverse effects of synthetic oxytocin and other uterine stimulants on breech deliveries is well known, but was not adressed in the study's conclusions. Even more disconcertingly, the study abandoned a pre-trial consensus to use oxytocin sparingly, if at all.
• Turner concludes that the trial's findings should be reconsidered, although he,too, agrees it is probably too late.

In an early critique published in Birth (March 2002), Marc Keirse claimed hat study guidelines doomed vaginal delivery from the start. Why so?

• A large majority (87%) of births without an obstetrician were in the planned vaginal group.
• The study included 2 stillbirths, two cases of twins, and two with lethal malformations---many of which died, but none of whom should have been included in the trial.
• One third of the babies who died were low birthweight babies---whose death may have had litttle to do with mode of delivery.
• Finally, those countries with higher rate of successful vaginal deliveries had lower rates of overall morbidity and mortality. This implies that a familiarity with vaginal deliveries may be crucial for the ultimate outcomes of those deliveries. As intuitive but often overlooked point that is the focus of Kotaska's brilliant critique.

Andrew Kotaska expresses deep reservations about the TBT and randomized control trials more generally in the British Medical Journal (2004; vol 329):

• The study achieved a remarkable 57% successful vaginal delivery rate only by asking those centers with lower vaginal birth rates to withdraw from the trial or increase their rate.
• As a result, centers may have increased vaginal delivery far beyond their ordinary comfort or skill level, thereby reducing the success of vaginal delivery outcomes.
• More disturbingly, they unwittingly compromised the safety of infants and mothers in the trial.
• The delivery as well as selection of breech babies for a safe vaginal delivery requires considerable skill and finesse---not randomization, which may take the choice out of the physicians hands.
• The questionable results of one randomized trial are now dictating a new standard of care worldwide. This does little justice to the complex variables that influence the safety of a vaginal breech delivery.
  

News flash--- second twins at higher risk

A new study has just been published in the British Medical Journal (BMJ) that claims that second-born term twins are twice as like to die at birth or shortly after birth as first born twins. This finding reflects a relative risk, not an absolute risk which remains very small. It also does not hold for premature twins.

The Atlanta Journal Constitution (3/2/07) reports
" '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."

Yet this is precisely my fear. How many doctors will use this study to push mothers with twins into having cesareans? The author of the BMJ study, Gordon Smith, says that cesareans lower the risk for second twins and the research study concludes: "the findings of this and other studies suggest that planned cesarean section may be beneficial for all twins." However the key word is MAY.

This conclusion runs head into an ongoing debate about the best way to deliver twins. Medical opinion is divided on whether cesareans are protective for all twin deliveries . A rather large debate remains, especially when it comes to premature twins or twins that are not headfirst. Yet that debate rarely makes it into the news. when it does, an expert is usually called up to "interpret" the findings.

Our expert here is Dr. Cole, who is quoted as saying that the study applies more to Britain than the US, because we monitor twins better in the US. I think a few British obstetricians might object to this generalization. Dr. Cole also states that most doctors are happy to deliver twins vaginally in the US. This is hardly the case. Between 50% and 90% of twins are delivered by cesarean, depending on their orientation. I'm not talking about sexual preference here. In the twin literature, orientation refers to the twin's position in the uterus: headfirst ( vertex), breech, or transverse. The latter two are likely candidates for a cesarean according to some studies, while this is debated by others.

It is good that Dr. Cole is questioning automatic cesareans for all mothers with twins. Yet the rate of obligatory cesareans for twins is rising in the US and elsewhere. In the US, roughly 60% of all twin pregnancies will include one twin who is not headfirst. This amounts to more than 79 thousand babies a year in the US. Many women with twins where one is headfirst will have little choice but to opt for the 'planned' cesarean their doctor recommends. They won't find a doctor willing to risk a vaginal delivery.

This is what happened to me. My second twin was transverse. I went to the four best and most vaginal-friendly obstetric providers I could find in a 100 mile radius. Not a single OB even entertained the thought of a vaginal delivery. Not the OBs in the hip, feminist, pro-lesbian town of Northampton, nor the crunchy, earth-mother practice in southern Vermont. Luckily, I delivered accidentally into the hands of one of the few doctors on the East Coast who was comfortable with a vaginal breech delivery at 26 weeks.

Studies disagree about the safest mode of delivery in my case---when only twin B is breech and preterm. A French study shows that vaginal delivery is as safe if not safer for twin deliveries, regardless of presenataion or gestational age. Here is the Pubmed abstract of the 2006 study.

So why are so many doctors afraid to deliver breech twins vaginally? Because of the hostile legal climat they labor under, but also because the newer generation of obstetricians has less and less experience delivering twins or breeches (and god forbid, both combined!) vaginally. The public, too, is to blame for wanting a perfect birth and not understanding the very real risks of breech and twin deliveries.

My brilliant obstetrician gives me some hope. But what happens as the younger generation of OBs take over, few of whom have seen or done a vaginal delivery of a breech or twin birth?

Mothers of twins, esp. breech twins----read those scientific abstracts. It may be that a cesarean is safer in your case. It may be that a vaginal birth is safer. It may be that nobody really knows. But don't take one doctor or one expert as the final word.

PS. My second twin actually did better than my first twin. Yeah, yeah, only anecdote. But guess how many cases were responsible for one of Gordon Smith's earlier conclusions? Nine births!!