Complications, Including Premature Labor

December 14, 2007

Premature Labor Worries OB-GYNs MOST

Of all the concerns an obstetrician must deal with in guiding the two patients, mother and child, toward a healthy delivery, prematurity is the most fearsome. For this is a complication whose repercussions are so staggering that the damage cannot be truly assessed. Seventy or eighty years of a human being's life, severely altered, plus the emotional suffering to parents and siblings, not to mention the shocking economic costs to an entire family's financial security and to the community itself--it is overwhelming. And although many of these children end up just fine, we see the others that have been afflicted by the unfair penalty of premature labor. We may indeed have the appropriate compassion for them, but it is a passing sympathy. To those who live the problem, however, the upheaval in their lives happens every day. This is the powerful thought of an obstetrician when faced with a premature labor.

True, there are many reasons why premature labor must sometimes proceed. Premature separation of the placenta, infection, "overload" from twins or triplets, and toxemia (pre-eclampsia) are major causes that can't be resolved. There are also numerous less likely causes that cannot be helped. When these complications present, the obstetrician must answer two questions:

    1) Is the baby better off inside the mother or outside the mother? and
    2) If outside, is the child best delivered vaginally or by C-section?

Catastrophes that cause premature labor are usually straight-forward, and answering these two questions can be easy. It is the outcome that may prove difficult, so a doctor must answer these questions early. Often, premature labor happens for no apparent reason. An in-depth work-up rules out all of the identifiable causes, and we are left with a labor that seems unprovoked. Fortunately, we have medicines to stop premature labor. Success is mixed, however.

Magnesium sulfate, an IV drug used in toxemia (pre-eclampsia, pregnancy-induced hypertension), Procardia (a heart medication), terbutaline (an asthma drug)--these are the standard regimens used today instead of the alcohol drips used in the seventies and before (an extremely sickening, dangerous, and outdated therapy).

In cases that are difficult to stop, we may only buy a little time. Still others go on to maturity, making the diagnosis of real pre-term labor doubtful:

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      Just having contractions does not mean pre-term labor. Contractions have to be organized enough to cause a net vector force outward, causing thinning and dilation of the cervix (same definition of real labor). Contractions usually begin after 20 weeks in normal pregnancies. It's just that they're so mild they're not even felt, much less damaging.

Some cases are difficult indeed, and even if we seem to be fighting a losing battle, we may at least get in a few more days of gestation while lung- maturing medicine can take effect in the baby. High level nurseries at even medium sized hospitals are now equipped to handle very small babies that years ago needed a trip to a regional center.

Home monitoring with portable devices (Home Uterine Antenatal Monitoring--or, HUAM--see article below) can give early warning of troubling irritabilities in the womb, meaning a doctor can jump on the problem before it becomes unstoppable. Home health nursing is playing a greater role today in keeping a medical plan in action while keeping the patient comfortably at home and costs down. Identifying the risk factors of premature labor is a crucial aspect of prenatal care, and a doctor--personable, outgoing, and warm--hides these worries well from those patients who "just get pregnant" and then "just have a baby" nine months later. But for the rest of women, prenatal care can be the most important part of their unborn child's life.

New tests are being developed all the time. The Fetal Fibrinectin test, the saliva test just now being marketed, and others to come will add to our arsenal of early warning systems. Some of these will fall away when they don't prove to help outcomes, but others will become standard fare for those at risk. Prenatal care is the clearing house--the air-traffic control tower to clear the runway for incoming arrivals--premature or otherwise.

In fact, with so much riding on it, prenatal care and stopping or identifying premature labor is one of the most important developments in the twentieth century. To the top of the page (Contents)


Incompetent Cervix, including Treatment

Mechanical Aspects of Premature Delivery Premature delivery is one of the most expensive complications of human existence.  Besides the devastating emotional costs of physical suffering, there is the astronomical financial burdens put on families and society for the lifespans of babies affected.  There are many causes for premature delivery, but I'd like to ultimately expound on the incompetent cervix--a mechanical weakness of the mouth of the womb (cervix of the uterus) which diminishing its ability to hold in a pregnancy to term.

As a very cursory primer, however, let's get some other causes of premature delivery out of the way.  Infection inside the womb (amnionitis) can cause uterine irritability which can in turn cause contractions, usually a benefit to an unborn baby exposed to such an infection, but with the trade-off of premature delivery .  Trauma like car accidents or falls can do the same, especially if there is injury to the placenta that provokes bleeding.  The placenta itself is a common cause of premature delivery, with premature separation (called "abruptio placentae," or abruption) decreasing the amount of surface area responsible for oxygen exchange from mother to baby.  Besides unknown causes, cigarette smoking or cocaine use can cause abruptions.
 But premature delivery can be a result of disability to actually hold in the baby.  The cervix  is that circular, muscular, and fibrous opening which holds tight until contractions cause enough force to push the baby's head against it as a dilating wedge.  When it finally gives way and opens, this is what is called real labor.  But if there is a weakness in its structural integrity, it can fall open without the usual forces necessary. This is an incompetent cervix.

Actual labor at term is a complex mechanism that just happens to fall into place like so many tumblers in a lock.  We are designed with a clock that ideally lines up the chemical and physiological tumblers only after a baby is mature enough to survive.  But if the cervix is weak,  gravity alone may be enough to allow even a premature baby's weight to cause it to dilate.  The gate is open, so to speak, and the baby can follow uninhibited into the outside world.  The earlier before term this happens, the worse off for the baby of course.

In the 1950's an estrogen called DES was used to try to prevent miscarriage.  Not only did it not work, but it also caused congenital abnormalities in the developing female babies the mothers were carrying.  These abnormalities were alterations in their daughters' reproductive tracts, ranging everywhere to weakening of the cervix all the way to cancer.  Now in the late 90's, most of the children of these mothers have had their windows of risk come and go, so it's a moot point.  But the very problems which haunt a lot of today's handicapped generation are due to the weakening of the cervixes (cervices) of these women who came to childbearing age.  With congenital weakening in these patients premature babies were born, many with the complications of prematurity that are at this time exacting a heavy price in money and heartache.

With the early diagnosis of precancerous lesions of the cervix, more and more young women and adolescents are having their cervices altered by freezing or burning away these lesions.  Although this typically doesn't set one up for a weakened cervix, it can.  Tragically, obstetricians often don't know there's a problem until a pregnancy so troubled forces a patient to undergo surgery to keep the cervix closed with or without continued bed rest.

The surgery is actually a simple matter of inserting a noose-like tape around the perimeter of the cervix to keep it closed until which time it can be snipped to allow delivery.  Called a cerclage, it usually works well, but sometimes the compromise to the cervix is so profound that there's nothing left into which to sink the cerclage, thereby eliminating the benefit of this surgery.  When this happens, prolonged bed rest, even in a hospital, may be necessary for months.

The usual cerclage placement is from a vaginal approach, but when there's nothing left of the cervix to work with, an abdominal approach is necessary to purse string that portion of the cervix that extends internally past the wall that is the back of the vagina.  Called an internal cerclage, it involves an abdominal incision and is best done before conception rather than after, because any surgery done during pregnancy, especially abdominal, is fraught with problem bleeding due to the extra blood vessel development that accompanies pregnancy.

That's the trick: to predict which patients won't do well with a second-trimester vaginal- approach cerclage before they even become pregnant, so that the internal one can be done before the pregnancy.

Internal cerclage has other problems.  Because it's placed via an abdominal operation, this mandates a C-section, because the vaginal birth route is closed off from within the abdomen.  And although the cerclage can be left in for subsequent pregnancies, we're also talking about subsequent C-sections.  Also, few ObGyn doctors have actually done them at all and are therefore uncomfortable with learning to do it on one of their patients.  Even in our practice, where we offer internal cerclage when clearly indicated, we've done less than ten in fifteen years.  It's a simple operation, actually, but it is nevertheless...an operation.

Unlike the permanence of the internal cerclage, the vaginal cerclage is designed to be removed near the end of each pregnancy--a mere office procedure--allowing a vaginal delivery soon thereafter in the hospital.

So it's easy to see the pros and cons for each of these approaches.  A vaginal approach is simpler and safer and can be removed to allow for a natural delivery later, but it is structurally more risky as success rates go.  The internal cerclage is a better cerclage, but you're talking a surgery to put it in and a C-section for each baby thereafter.  The perfect choice between the two does not exist--it's got to be a decision individualized for the patient.

Although it's somewhat barbaric to think of preventing premature delivery by "tying the sack" closed, still a cerclage is a lifesaver and an intuitively obvious solution to the problem of incompetent cervix.

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Drool as a tool to prevent complications of premature delivery: The SalEst test

Obstetrics is an amazing field, because more than any other specialty new developments that change everything happen so frequently that even last year's pregnancy care is outdated. All of the recent examples are too numerous to include here, but just consider a few:

    RhoGam, a blocking antibody to protect Rh Negative women from stillbirth has saved untold thousands of lives.

    The simple non-stress test, a non-invasive evaluation of fetal heart tones, has tipped off obstetricians to babies in otherwise unnoticed jeopardy for life-saving intervention.

    Simple screening for gestational diabetes has picked out an amazing 10% of pregnant women who are unknowingly diabetic while pregnant, decreasing stillbirth rates and c- section rates.

    Tests for lung maturity on unborn babies at risk have allowed safe delivery before complications of pregnancy did them in.

    Steroids to enhance lung maturity on those too premature but needing delivery have swelled the ranks of those babies surviving.

The list goes on and on, and these are just the relatively recent ones. The most dramatic of battles in obstetrics have involved the prevention or management of premature deliveries, because this is one of the most expensive complications in human existence. Not only is the financial cost high (as much as $2-4,000/day in an NICU), but the emotional toll on parents and the physical tragedy for the baby's quality of life for his or her upcoming seven or so decades in unfathomable.

Prematurity is the major risk for handicaps that last a lifetime. Cerebral palsy, blindness, behavioral disorders, retardation, and many other permanent disabilities are the regrettable outcomes for too many innocent babies. There are things prospective mothers can do to avoid prematurity, like quit smoking, not use illegal drugs (cocaine, etc.), report vaginal infections or contraction patterns immediately. But there are still too many women at risk for surprise premature delivery even when doing everything right. These are the tragedies that have stymied obstetricians because of the lack of warning. Warning wold be a valuable thing when dealing with premature delivery, but unfortunately the dependable warning is the one thing in obstetrics that has eluded us.

Mature Baby Lungs: The lungs are the key. Bad lungs make bad complications.

Steroids to mature the unborn baby's lungs, one of the Godsends mentioned above, need about 24 hours to work; having a window of a day or so before delivery can make all of the difference in the world to these immature lungs. If a doctor could even have a warning of a week or so before a premature delivery, one can imagine the extraordinary benefit that would afford the baby, the parents, and our society as a whole.

Medical tests are being developed all of the time to try to lengthen this window of predictability. There are two types of results that can be seen with medical tests to foresee premature labor. There is the ability of a test to pick out which patients will not go into labor and the ability of a test to pick out which ones will go into labor. A test that is better at picking out the ones that won't but poor at predicting which ones will can only reassure us to a certain extent. The test that predicts the ones that will labor but doesn't reliably pick out the ones who won't will only allow us to prepare some of those at risk, not all. Ideally, what we need is a test that will exclude those not at risk, reliably, but include those who are with little error. It may be that a perfect test is impossible.

Fetal fibronectin is the main test used today, with mixed results.

More recently, a test called SalEst was developed.

There is a hormone called estriol that comes from the pregnancy. It is produced from precursors secreted by the fetus's adrenal gland and liver. It has been observed that estriol that has passed from the pregnancy to the mother shoots up to higher levels roughly three weeks before any type of delivery--term or premature. Apparently this estriol allows the uterus (womb) to be more sensitive to chemicals that cause contractions. These natural chemicals, oxytocin and prostaglandin, have been used for years to induce labor in those past their due dates that needed to be delivered. Now we use this knowledge to prepare for those who might be born too early.

SalEst was the test that determined the amount of estriol in the mother's system, with certain levels predictive of impending labor. If there were to be an abnormal rise, this would be an omen that things may happen sooner and preparations--steroids for lung maturity, for instance--could be made in anticipation. Besides indicating which patients may require more agressive management, it was also hoped that this test could be used to avoid complicated medical protocols mistakenly used to stop merely false labors. Less is better when there's really little risk, and it was hoped that this test would help identify those people as well.

In December, Biex, the company that made the test, went out of business.  Physicians for the most part didn't feel the results changed any of their methodologies, and in the days of cost-containment the death knell sounded for SalEst.

Was SalEst given a proper clinical trial? Maybe not.  Was it everything its proponents said it was?  Probably not.

Let's talk academics now. The cost of the test was about $90, so there were those who talked about only screening those at risk. They said that if every pregnant woman were tested, we'd only save so many babies at the needless cost of so many unnecessary tests on those not at risk; to which we obstetricians in the real world will reply that every baby is priceless, well worth the costs of any unnecessary tests if that's the only way to seek out the ones we can save. If air bags are unnecessary for the majority of drivers because they're never used, then why does the federal government mandate them as standard equipment when it raises the cost of every car sold? I submit that thinking differently about tests to predict premature labor is hypocrisy.

SalEst wasn't the answer.  But people are trying.  After talking about how terrible premature labor is, and listing the complications from it, we need to keep trying.  Premature labor and delivery and the complications resulting therefrom demand it.

As the father of a son born 12 weeks too early in 1984, I can't tell you just how enthusiastic I am when something new comes along. If SalEst bombed as a gold standard, we resort to the still-silver standard fetal fibrinectin with its unreliabilities.  Until something better arrives.

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Your Baby Goes On-Line

The information super-highway is being paved by us for the children of tomorrow. But already great strides have been made in making your pregnancy interactive with the best in prenatal care. Home uterine monitoring is a technique wherein a pregnant patient wears a belt around her which contains a pressure-sensitive button which is discriminating enough to record uterine contractions (contractions of the womb). This information is collected by the belt for an hour a day and recorded into a small electronic device. A telephone can then be laid on the recorder, a toll-free number dialed, and with a push of a button all of the information is transmitted within a few moments. Nurses at a central location have computer software which interprets the results and can allow them to call the local doctor if there are any troubling data.

For instance, if a mother-to-be had a risk factor for premature labor--if she had had previous premature labors in the past--she could be placed on this service and monitored nightly. Her part is just an hour a day plus the few minutes it takes for the transmission of the recording. The results may indicate that she is having contractions perhaps too mild for her to notice but yet enough of a pattern to indicate that premature labor is a real danger. The nurse notifies the doctor who can then prescribe or change medication, send her to the hospital, or merely have her re- monitor herself a second time.

On the other hand, irregular harmless contractions (called "Braxton-Hicks contractions") may have a patient very worried, and the home uterine monitoring can serve to reassure her that the activity she is perceiving is safe. It's easy to see that home uterine monitoring can save a lot of false alarms from turning into unnecessary, expensive hospital visits. But it can also alarm a doctor to send a patient to the hospital hours or days before an unstoppable labor were to develop. And since prematurity is an incredibly expensive and heart-breaking complication, home uterine monitoring was once seen as the savior of the preemies, with promises of turning two and three-pound deliveries into five or six-pound babies.

Then studies began reporting that it doesn't seem to make much difference in most of the outcomes. Suddenly insurance companies began not allowing home uterine monitoring as a covered expense. After many years, the reality has emerged to indicate that under the right circumstances home monitoring really can make a difference, but under other conditions it won't lengthen a pregnancy at all. Like any medical procedure, the legitimate indications became accepted, and the disallowed indications were not used to designate patients for this service. In other words, it is a once-new procedure that has come of age--has attained maturity.

Today, home uterine monitoring is considered legitimate and efficacious if there are complaints of contractions and there is a history of pre-term labor with previous pregnancies or there is a change in the cervix as determined by a patient's doctor.  Since this is a non-invasive test that poses no risk, it's hard to argue against using home uterine monitoring in such cases.  Also, conditions in which it may be prudent to monitor patients in this way include fibroids in the uterus, abnormalities of the architecture of the uterus, and the hyperthroidism or arrhythmias which use medicines that might provoke contractions.  All multiple gestation pregnancies are an indication for home uterine monitoring.

I have at any one time at least two or three patients using home monitoring, usually pregnancies involving twins, uterine fibroids, or patients already hospitalized for premature labor. Used scrupulously, it is an aid in buying more time for a pregnancy. It won't get someone all the way to her due date, but in a maturing baby every day counts.

  Matria is a company that provides services for patients, including home uterine monitoring for early warning of preterm labor.  They can be contacted by filling out their form

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Horizontal Pregnancies Take Their Toll On Upstanding Women

If you were to read this one Sunday morning, you probably slept a little late and are finally having that first cup. Certainly Sundays can feel pretty good to sleep late on. Because most people actually crave that extra time in bed, it wouldn't necessarily seem that you could have too much of a good thing. Not many specialties can prescribe bedrest with a straight face, but I happen to practice one of them.

Often an obstetrician must put the prospective mother at rest. When there is suspicious bleeding or premature labor, denying gravity its role in taking the weight of the baby off of the mouth of the womb can be helpful in prolonging pregnancy. Lying the patient on her side improves blood flow by taking the pressure of the womb off of the main blood vessels running along the back. One would think that such a simple method of treatment would be well accepted. Unfortunately, life seems to go on around the person at bedrest. The world continues actively around her, spitefully dramatizing the stark contrast between her forced inactivity and the hustle and bustle just out of her reach. Income falls if the provider is down. There are children that need to be fed and who insist on being held, chores that can't be ignored, and emergencies and mishaps that pop up one or two rooms away in any household. The pregnant woman at bedrest is just one ill-timed lurch away from taking action that begs her involvement.

Bedrest is hard. Many doctors understand perfectly what they are asking their patients to endure when the sentence is handed down. Not all patients have parents or in-laws to help out in a pinch. There are husbands that must travel in their work, leaving the other head of the household on her own to manage the home from a horizontal position. Often, the best intended therapy of bedrest becomes impossible, which is why as medical students we are taught that hospitalization may be best for a patient who may not or can not be compliant with a doctor's directions.

The biggest risk of bedrest in pregnancy is psychiatric.

Hormones can accentuate feelings of helplessness and depression as a woman lies ridiculously impotent in bed--the clock ticking outside of her room for those who are distracted enough not to be watching it. Anger is easy when she sees something handled differently from the way she likes to do it when she is actually doing it. If the bedrest is in a hospital, there are also the never-ending surprises of blood tests and the daily nuisances of monitors and hospital noise.

And then there is the uncertaintly.

Rarely do we as physicians know exactly when the pardon will be handed down, allowing the patient to resume her upright life. If the bedrest is substantially long, physical therapy can be helpful to reinforce range of motion with passive movements and exercises. Being put to bed for a complication of pregnancy is one of the most grueling therapies in medicine.

Will the little darling appreciate it? Of course not. How you sacrificed won't come up when you are asked to lend out your car years later. But is it worth it? Of course it is, for reasons that transcend philosophical differences over car use and make-up and your children's choice of friends. Parenting puts those other trivialities into an obvious perspective--a perspective a mother has gained by lying in bed thinking about what the really important things in life are all about.

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Herpes: Confusion Between Obstetricians and Gynecologists

Lately there's been a lot of confusion between the two sister specialties of obstetrics and gynecology over herpes.

The obstetricians have always feared this virus (herpes simplex), because if a mother had a lesion at the time of the delivery, about half of babies born vaginally caught it, and out of those one half died. Although anti-herpes drugs like acyclovir are now being given to infected newborns and things aren't quite that bad anymore, it's still felt that all one need to do is perform a C-section to provide a delivery route that by-passes the infected vaginal tissue. Problem solved, right?

Not quite. Managed care, buoyed by support from the American College of Obstetricians and Gynecologists, attacked the high C-section rates in the U.S., and along with protocols to reduce the numbers, a herpes rationale was developed as well:

Herpes cultures would be obtained every week in the last month until delivery. If there were no positive cultures and if there were no active lesions, a woman could deliver vaginally with safety. Problem solved, right?

Not quite. The field of gynecology, ignoring any obstetrical implications, saw herpes as a sexually transmitted disease only. Strangely silent about pregnancy, gynecology literature began to demonstrate that a person infected with herpes could shed the virus silently with no evidence of an active lesion. So all herpes patients are now told they can possibly infect their partners anytime, lesion or not. They are all told to use condoms all of the time for the highest safety.

Meanwhile, we obstetricians, who happen to read the same articles the gynecologists read because we are they, become confused, since we now come to understand that a woman can give a baby herpes even without an outbreak. And since the herpes cultures are notoriously inaccurate with a lot of false negatives, we the obstetricians wonder that if we the gynecologists say always use a condom, then shouldn't we also be saying always have a C-section?

We combined OBGYNs speak with forked tongues.

A pregnant woman comes to me and says she has herpes outbreaks about twice a year. I tell her the newest guidelines: if there's no active lesion within two weeks of delivery, then she can deliver vaginally. But then I tell her I'm also in touch with my gynecology side, which implies a C-section if she wanted to do everything she possibly could to avoid infecting the baby. And then I add that nearly a third of babies who get infected do so after C-section, which makes no sense since the baby gets infected by traversing the vagina and outside skin. She asks me what should she do?

I tell her that the right answer is that there is no right answer. That silent shedding of virus, while feared in gynecology, is ignored in obstetrics. And I tell her that screening cultures are not helpful and have been abandoned. I give the patient two choices: either believe the obstetricians and take only a very slight chance that the baby may get herpes, or believe the gynecologists and take no chances by having what will probably be an unnecessary surgery. Now thinking is finally moving toward reconciling these two opposite viewpoints, which is good for me since I'm both an obstetrician AND a gynecologist.

Now I'm beginning to see in the literature giving pregnant women Acyclovir (a medicine for herpes) during the last month of pregnancy to diminish the theoretical silent shedding, and if there are no active lesions, allow vaginal delivery. This is still considered investigational, but at last something makes sense.

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Group "B" Strep--As If Pregnant Patients Didn't Have Enough To Worry About

One of the newest "official" concerns of pregnancy is a flimsy little bacterium called Group B streptococcus. Harmless in the vagina of the prospective mother, it could present a significant risk of infection to a baby coming through the birth canal. It is common to find women who are carriers of it. In the mother it is usually without symptoms; in the newborn, it is quite a different story.

Premature rupture of membranes, resulting in complications of premature birth, has been associated with Group B strep in the mother. Also, meningitis can develop in the baby due to a mother's vaginal strep, causing devastating complications or even death to the newborn. It's no wonder that a few years ago the American Academy of Pediatrics invaded the domain of the American College of Obstetricians and Gynecologists by recommending routine screening of all pregnant mothers with a simple swab culture. Soon, most Ob-Gyns began this simple screening method. A Q-tip-like sampler is used to take a gentle swab that is then sent to a lab for growth. Called a "culture," it is usually done at 35 to 37weeks into the pregnancy, and the result is added to the list of items that are already on a prenatal check list.

If the culture is negative, nothing need be done, of course. If the culture is positive, treatment is still not done at that time. This is because the patient is a carrier, meaning if it were treated then, it would only come back. Actually, the value of the culture is in being forewarned. The strep is ignored until time for delivery, for that is the time to eliminate it. The antibiotics are given during labor (usually a simple penicillin will do--or another antibiotic, if allergic), and the baby allowed to deliver normally.

Sometimes strep can present in sneaky ways. Occasionally a woman may have a negative culture but have had a history of a bladder infection caused by this very same bacterium. In my practice, I lump these patients into the same category as ones whose vaginal cultures were positive. I also treat them right then and there, in addition to during the time of labor, because it's not just a "carrier" status I'm noting--it's an actual urinary tract infection in which treatment is indicated.

When a pregnant patient presents in labor without the benefit of a Group B strep culture--if she has had no prenatal care, for instance--the treatment is so simple and safe that an obstetrician and the baby are best served by giving treatment anyway. Since a certain percentage of all pregnant patients are carriers, I often wonder how many patients exposed their babies to Group B strep in the years before it was sought. Yet the infection rate in those years remained extremely low. This is reassuring, for although the one baby that contracts Group B strep meningitis is in grave danger, the chances of any baby actually developing this complication is actually quite unlikely--even in mothers who are carriers. The screening cultures are only another simple item included in modern obstetrical prenatal care.

But there's controversy now. The American College of Obstetricians and Gynecologists advise that cultures, while a good idea, are not crucial in determining those at risk. Instead, this organization recommends treating any pregnant patient as if she had Group B strep when she presents with certain delineated risk factors, like premature rupture of membranes, a fever, or premature labor. Medicolegally, we follow these guidelines and get the cultures. We like to think we're doing everything we can possibly do to stack the deck in our favor toward a healthy, happy baby.

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Home delivery--beauty and the beast

This article is repeated in OB Overview.   But I list it here, under complications, because there are few things more worriesome than being called to bail out a a situation arriving at the hospital from a failed home delivery.

I've been in private practice doing obstetrics and gynecology for over 15 years now, and I've seen many welcome changes. I've also seen many "fashionable" ideas about childbirth, many of which are lovely and befitting to this special event. Unfortunately, there's one that keeps surfacing from time to time that remains dangerous.

Home delivery still remains a baby's biggest threat. It poses significant risk to the mother as well. This is because obstetrics is a specialty in which a prospective mother can be normal one moment and bleeding to death the next. An unborn baby can be normal one moment and suffering devastating fetal distress the next. Even in the most modern private practices and best-equipped hospitals there are still isolated disastrous outcomes that no one could have averted. But there are also many more miracle stories that just wouldn't have been so if a patient didn't have a whole hospital wrapped around her.

Hemorrhage remains a major life-threatening complication in pregnancy. Unfortunately, it is usually sudden. In placental abruption, the afterbirth (placenta) separates away from the womb before delivery. Since the baby is dependent on the surface area of the placenta adhering to the mother so as to exchange oxygen and nutrients, fetal death can quickly ensue. Emergency cesarean section is life saving for the baby, and sometimes for the mother as well. Emergency release blood can keep a mother from undergoing cardiovascular collapse and shock. Anesthesia is there to make the whole thing painless as well as balance the tricky fluid balances during the melodrama. In a bedroom in her neighborhood, a mother doesn't stand much of a chance.

Seeking the beauty of home delivery possibly means accepting the ugliness of death.

I cannot overemphasize the importance of cesarean delivery as a life saving measure. Maligned as over-utilized, insurance companies and consumer groups have been successful in reducing the number of preventable C-sections. But this in no way takes away it's importance in getting a baby out in the most expeditious way when disaster strikes suddenly. I write this article on an evening when I managed the case of a baby with a prolapsed cord. This is when the umbilical cord--the baby's "lifeline"--falls past some presenting part of the baby and gets crimped, effectively cutting it off. Luckily, there was a wonderful baby born. But he was not only born healthy but also in minutes--all because it happened in a hospital.

Often a baby is born vaginally, every phase of labor and delivery having been completely normal. Yet within a moment the baby may not be breathing. A hospital has resuscitative equipment on hand, but your home does not. The riskiest time in a newborn's life is the first 24 hours, and except when your baby's with you, a hospital has a nurse watching him or her the entire time. Any abnormalities can be immediately assessed and pediatricians notified.

Some people still choose home deliveries and their reasons are many. Many see a certain beauty in the hearth. Others fear and distrust motives of doctors and hospitals. Still others do it to avoid the big hospital bills. As far as the beauty of the home for important events, save that beauty for important events like your baby's following birthdays, not THE birthday. You will want to stack the deck in your favor for taking part in the birthdays to come. As far as fear and distrust of doctors and hospitals, I never get tired of saying that I love what I do and I have nothing to gain in compromising a patient's well-being by unwarranted manipulation. As far as saving money by delivering at home, this is by far the saddest reason. Certainly a baby is more important than our car, so why don't we build our own cars at home? Is it because it can be done better elsewhere?

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The most famous spot in obstetrics

If you were to put a cross on the abdomen, a vertical and a horizontal divider intersecting at the navel, it would designate four quadrants doctors often refer to in locating symptoms. These are the left and right upper quadrants, and the left and right lower quadrants. In obstetrics one of these, the right upper quadrant, has particular significance.

The right upper quadrant is where the liver and gall bladder reside. Also, especially in late pregnancy, the appendix hides there from its usual right lower quadrant location. So it's easily seen that when a pregnant patient complains of right upper quadrant pain, an obstetrician addresses that complaint most seriously.
A disease unique to pregnancy, preeclampsia (formerly called "toxemia," also referred to as), often shows up as liver involvement. No one yet knows the exact reason a woman sometimes rejects a pregnancy with preeclampsia, but it's obvious that there's trouble in paradise, because the cure is delivery. But even without the high blood pressure usually seen in preeclampsia (the so-called "pregnancy induced hypertension"), the liver can be the organ tipping off the obstetrician that something is amiss. In fact, there is a variation of preeclampsia called HELLP syndrome, where the "-EL-" stands for Elevated Liver enzymes. (H-hemolysis; LP-low platelets). Enzymes are chemicals detected in the blood whose levels can indicate liver disease. In HELLP syndrome, the enzymes can go sky-high. Such a patient complains of right upper quadrant pain usually as a result of swelling in the liver against the sensitive liver capsule (you know that pain in your side when you run a long time?). With this type of presentation, it's usually necessary to effect delivery immediately, because it may be life-threatening and it's not going to improve until mother and baby are separate.
(See also Chronic Hypertension and Pregnancy-induced Hypertension.)

Pregnancy, and birth control pills for that matter, can affect the emptying of the gall bladder. Gall bladder symptoms--even stones--may present as right upper quadrant pain, but blood work for enzymes can usually exclude the HELLP syndrome described above. Gall bladder pain often radiates to the right shoulder blade and punishes the wrong diet, these symptoms varying from the more serious liver disease of pregnancy. Ultrasound, famous for showing prospective parents the baby, can also show them the stones. Management is usually conservative and delayed until after the pregnancy.

Plain ol' colic can hit the right upper quadrant, too, because a portion of the large intestines takes a turn at the liver, and small bowel is just about everywhere, this quadrant included. A kidney infection, usually more symptomatic in the mid back to one side, can select as its side the right; it is often difficult for a patient to discriminate between where the right side of the back ends and the right lower quadrant begins. Therefore, ruling out a kidney infection is necessary with this complaint.

And then there's the sneaky appendix.

Late in pregnancy, the enlarged uterus (womb) pushes everything else upwards. The appendix goes along as well. Unfortunately, this weird location can delay the diagnosis, which means that there are a lot more ruptured appendixes in pregnancy than in non-pregnant patients.

Did I mention labor? I was so busy describing the weird things that I didn't mention that irregular contractions can occur on any part of the uterus, the upper right as well. Premature separation of a portion of the placenta (afterbirth) can present in any particular spot as pain. But this is usually exquisitely sensitive on the uterus itself. This means that an obstetrician must run through the check list to tell the difference between false labor and the complications discussed above. Luckily, that's what we do for a living and what we can do best.

I'm reminded of a Gary Larson cartoon in which three cavemen stare in wonder at a Wooly Mammoth laying dead on the ground, felled by only one tiny arrow in it's skin. "We should write that spot down," one says to the other. Doctors in training learned early which spot to write down. The right upper quadrant holds a special place for the obstetrician.

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When a Baby Throws a Shoulder Block

One of the most frightening complications during a delivery is shoulder dystocia. This is when the infant's shoulder girth is too large, causing the baby to be "stuck" in mid-delivery, the head out but the shoulders wedged in. In this position a sort of point of no return has been reached, as the umbilical cord may be compressed by the chest and shoulders of the undelivered baby. And with the chest compressed by the vaginal walls, the baby can't expand the lungs to move air.

Back in the olden days--that is, just a few years ago-- shoulder dystocia frequently resulted in injury to the infant. Nerve paralysis, brain damage, as well as the subtle outcomes of oxygen deprivation could follow a difficult birth that involved this complication. After traction in different directions, complicated cork-screwing maneuvers were next in the sequence of attempts to finish the delivery. The clock would keep ticking. The baby's clavicle, a flimsy bone of the shoulder, would give way either by accident or by design so as to make a collapsible escape for the respective shoulder. The scene was tense for all of the right reasons.

Now we use a technique called the McRoberts maneuver.

In this technique, the woman's thighs are pulled far back onto her abdomen while an assistant applies pressure downward right above the pubic bone. The maneuver of the thighs causes the pelvic ring to increase in size, and the pressure on the baby's shoulder from above the mother's pubic bone forces it out toward the doctor who is pulling with an additional force. Most often these babies are delivered within a moment of recognizing the problem. It's hard to give credit to this maneuver to the extent that it deserves. How many injuries or even deaths have been prevented would be impossible to tabulate. This uncomplicated technique is a powerful reminder that for all of it's intricate biochemical processes and miraculous genetic unfolding birth is still a process of mechanical simplicity.

Shoulder dystocia is a risk factor that every large baby has. The obstetrician knows that the chances of it occurring are increased with a history of previous shoulder dystocia, a history of large babies, or diabetes. Since the head is thought to be the largest part to deliver, with the rest of the baby supposed to follow thereafter, shoulder dystocia often comes as a surprise. But there are subtle signs that can tip off the obstetrician. Slow progress of labor (dilatation of the cervix) or prolonged descent of the baby's head down the birth canal should caution the doctor not to "help" the head out with forceps. This may in fact invite a shoulder dystocia, and no vaginal delivery at all would be preferable. A C-section, although second choice, is better than the victory of a vaginal delivery at the expense of one's child. The McRoberts maneuver works well. There may still be a broken clavicle from time to time, often found incidentally after delivery, but the laws of physics are used to advantage to prevent terrible outcomes in what used to be one of the most feared complications of childbearing.

(Additional note: I have a colleague who is currently being sued for applying the McRoberts maneuver in a VBAC delivery. He saved the baby's life, but the force used opened her previous C-section incision. She eventually needed a C-secion for this, but she's got a great baby. No good deed goes unpunished.)

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The Womb Should Be a Smoke-Free Environment

Forget about lungs and hearts for a moment. I can assure you that smoking causes its share of misery in the specialty of obstetrics as well. An unborn baby is at risk for many complications when the mother-to-be smokes. Everyone wants a perfect baby, but smoking makes all the fuss over birthing methods and drug avoidance trivial.

Growth retardation before birth and decreased intellectual potential after are well-proven. Performance in school can be compromised by the smoking that occurred before the future student was born. While pregnant, the smoking mother puts her child at risk for premature separation of the placenta, called abruption, which is a devastating hemorrhaging event that can result in death of the baby and possibly even to the mother. Additionally, nicotine is a vasoconstrictor, which means it narrows the nutrition- and oxygen-carrying blood vessels to the baby. So each and every drag of a cigarette not only means less oxygen and nutrition to the baby's brain and other organs, but also injures the placenta which is the crucial life-sustaining link between mother and child. There is also evidence that smoking increases the risk that a child may develop leukemia. Each research year it becomes even more frightening.

Pediatric asthma and the repeated upper respiratory infections (croup) are more likely in a smoking home. Spending three hours in an emergency room in the middle of the night, over and over, can get pretty old pretty fast. It's unfair to the child, certainly, and no one from the tobacco industry is there to help out the next morning when you have to go to work anyway after a night like that.

A child gets hit on both sides of his or her birthday, before and after birth. Premature rupture of membranes, premature labor, and premature births are a higher risk with smoking pregnant patients. With neonatal intensive care bills often exceeding $2,000 a day for a single premature baby, the costs to our country become unfathomable. Smoking has been found to be a risk factor in sudden infant death syndrome (crib death). Allergies in children multiply over those of children not exposed to smoke in the home or in the car.

Children just plain lose with smoking.

In spite of all this, 26% of women of reproductive age choose to smoke, and nearly a third of them continue to do so during pregnancy. But it may not be entirely their fault. Smoking is a very tough addiction. When I talk with internists and perinatalogists I hear smoking referred to as being as addictive as heroin and cocaine.

With over 2,000 different chemicals in tobacco smoke, not one of them is nutritious or enriching for you, your baby, your family, your gender, or the generations to come. Just a thought:

take the money spent each day on cigarettes, use common financial methods, and then put your child through college when the time comes.

For more information on pregnancy complications check out our pregnancy videos.

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