Monthly Archives: May 2009

Ugh, what horrible news

After many attempts over decades, Dr. Tiller was murdered today in the lobby of his church. Dr. Tiller performed abortions as part of providing comprehensive reproductive care in Wichita. He was known for being one of the few providers who would perform second trimester abortions in his area.

What a shame. What a cowardly, hypocritical crime against humanity. Anyone who passionately wanted to reduce abortion in Knasas could have promoted comprehensive sex education and access to affordable birth control.

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So, uh, wow

My Mommy Wars Bingo card is supposed to be published in the next issue of hip Mama, the zine.

I am pretty frickin stoked. I didn’t have a lot of peers with children when I had my older son, and I didn’t have a lot in common with the other parents on the playground or at the daycare birthday parties. Ariel Gore, with her hip Mama survival guide, zine, and website, provided me with a sense of community with other mothers from the fringe.

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Studying for boards with crazy mnemonics

I am studying for my step 1 board exams. Not a happy camper, relearning the TCA cycle here.

Anyway, I am not a memorizer. I can stare at a chart for hours and not retain it, but if I come up with some sort of crazy story, I will remember it.

For example, the formula for glycolysis is

Glucose + 2ADP + 2Pi + 2NAD+ —————> 2 pyruvate + 2ATP + 2NADH + H+ + 2 H20

So, how I am remembering this is that glycolysis is like the stereotypical view of getting married. (Hey, I am trying to remember stuff, not create a feminist worldview here).

So, like is all sugar, pie, ‘nads and low energy from partying so much, and then he/she gets married, and then it’s stored energy, drinking water instead of partying, and practical building blocks stuff (pyruvate and NADH) and blowing off air.

That’s pretty straightforward for one of my memory tricks. Hopefully I’ll remember it.

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Reply turned post, VBAC study style

I am generally a really big fan of RH Reality Check, including the quality of their reporting on health topics, which can be tricky for non medical types. They are also pretty good at posting on research, which can be an issue for non research types. Well, I am happy they covered the recent favorable VBAC (vaginal birth after cesarean) study I talked about in the last post. But, I was a little surprised that the weekly news magazine reporting on the study, US News & World Report, was mentioned several times by name, but it was never mentioned that the primary study was published in the ACOG journal Obstetrics & Gynecology. A minor point, but it is always a good idea to try to read the original research when writing about a study, and it adds strength to the good representation of the study already done in the blog entry if you mention it was published in the leading ob/gyn journal in the country, published by the organization that writes the position statements on standards of care in obstetrics in the United States, don’t ya think?

Anyway, after much ado, here is the post and here is my reply:

Not only was this study reviewed in US News & World Report, but it was published in this month’s issue of Obstetrics and Gynecology, which is the journal of the American College of Obstetrics and Gynecology (ACOG).

This is not the first article with significant evidence supporting VBAC that they have printed recently.

What is a shame is that hospitals, doctors, and as noted above, insurance companies are refusing this option, even though all the evidence points that it is a safer and better health decision and the intervention of cesarean is more dangerous. This happened to a friend recently, and she showed up in labor the day before her scheduled repeat section. And they still forced her to have a cesarean, even though that flies in the face of the evidence even more.

What is ironic is that it is ACOG’s own position statement on VBAC, recommending that a team be available for immediate cesarean, is part of the justification for refusing VBACs.

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Congrats, and a shame

I just heard a cousin Susan of mine went into labor yesterday. She had a cesarean. She was scheduled to have a cesarean today, a repeat cesarean because she had a primary cesarean about five years ago after a failed induction indicated by worsening preeclampsia. No similar problems this time around.

When our mutual friend called to tell me last week to tell me about our cousin Susan’s impending scheduled repeat cesarean, I had literally just downloaded Neonatal Outcomes After Elective Cesarean delivery from this month’s issue of Obstetrics and Gyneocology. This article compares elective repeat cesareans to VBACs, and includes analysis of “failed VBACs”. VBACs had the best neonatal outcomes, significantly better than elective repeat cesarean, and failed VBACS were the worst.

Our mutual friend said “Isn’t it great that her doctor gave her a referral to another doctor if she wanted to try for a vaginal delivery?” I am amazed at what a different outlook I have than other people. I guess it depends on where you get your info.

Huh? You mean he didn’t tell her she needed therapy, or ask her to bring in her husband so they could both talk sense into her? (Both stories I have heard from mothers). I try not to rant at my family, but she brought it up. I answered something to the effect of, no, I thought it was a shame that his own organization’s journal put out an article just this month that a vaginal delivery is better for the baby (we already know it is better for the mom) and he refuses to even consider “allowing” it if she remained in his practice. And, because of his refusal of care, and the implied negativity associated with the attempted trial of labor, she did not decide to try for the vaginal delivery.

Of course he should refer. Is he going to forbid her from seeking another practitioner? At least he went through the trouble of offering a specific name.

But, it gets worse. She did go into spontaneous labor. Studies, including this one, indicate that a cesarean after labor starts in a VBAC situation may be worse than a cesarean without labor initiation (of course there are a ton of confounders there). Did they let her labor? Of course not. It was the day before her scheduled cesarean. So they sectioned her. Even thought this study (and others) indicate the best outcome would have been from a successful vaginal delivery.

The most expensive outcome was for the path her doctor chose. Is that an influence? I should hope not. I am more prone to believe that people are more afraid of standing by than taking action, they are trained to do sections, the ACOG statement that they need to be there for the whole VBAC labor is a liability, etc etc. But, I would hope that that the higher health care costs associated with the repeat cesarean (especially once labor has started) combined with poorer outcomes would lead to pressures, either from the government, advocate groups, or the “free market” or private insurance, to curb this.

Sigh.

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Pull and pray – taking withdrawal seriously

A new Guttmacher Institute report, published in Contraception, treats the withdrawal method (aka “pulling out” or coitus interruptus) like a serious method of birth control. This is creating a few ripples in the women’s issues blogosphere.

I was not surprised at all when this article was written, since other sources have long included withdrawal in the discussion. I have always included withdrawal when comparing methods of birth control with poor success rates. The sponge and the cervical cap, especially in parous women (women who have already had a child), spring to mind. Neither offer much STI protection, and the sponge may have side effects such as local irritation. I was surprised, years ago, when I saw a comparison of success rates, and the much derided non pharmaceutical methods such as withdrawal and the fertility awareness (aka symptothermal method, natural family planning, rhythm method) had moderate success rates and fit firmly in the sorta crappy second tier of birth control.

This is the tier my two sons come from. My older, condom son and my younger, vaginal contraceptive film son. I would have never considered withdrawal or fertility awareness. I was in long term monogamous relationships both times and knew that STIs were not a problem. Both would have been good options for me. I cannot use hormonal methods, since I get migraines. Many women don’t want to use hormones or get significant side effects from hormonal methods. I am not saying they don’t work remarkably well for many women, and may even have some therapeutic applications. Different women with different health issues have different needs.

I have known women who have used the withdrawal method intentionally. No, not drunken teenagers, but a woman with a master’s degree in a long term relationship and a midwife(!) who knew the odds and decided it worked for her and her partner. At least one of the sites I linked to above says it shouldn’t be ignored but it shouldn’t be encouraged (and one questioned the ability of teenagers to use the information wisely, which I think is the problem with abstinence only education).

I don’t think any method of birth control should be encouraged. I think every method should be presented without bias, either bias from the sex-is-bad-don’t-encourage-it camp or the must-be-a-pill-or-a-medical-device-or-it-doesn’t-count camp. I thank the medical science gods (ha!) every day for my copper IUD. If it wasn’t refused to me (with bias and non-scientific information from an ob/gyn) I wouldn’t have a contraceptive film child. If I didn’t succumb to “I don’t care what the failure rates say, if it’s a pharmaceutical method, it must be better than our other options” bias in my own head, I wouldn’t have a contraceptive film child. Don’t get me wrong, I love Z and without being refused my IUD the first time and having him, I wouldn’t be the MomTFH I am today, since I ended up training as a midwife at the birth center.

But, I love my IUD now. It is the ideal option for me. It doesn’t protect against STIs. It has a fantastic pregnancy prevention rate. It’s ideal use rate is almost identical to its real use rate, which is what I need. Less room for human error. When I talk about my IUD, I try to present it as honestly as possible. Mutual masturbation is a very viable option that is enjoyed by teenagers extensively. That may not have been ideal for my marriage in my twenties, but at 16 it was a fine option. I know women who are passionately dedicated and successful (to different degrees) with the symptothermal method. I know women who love their pill, hate their pill, and swear they have gotten pregnant on the pill. Hell, IUDs are the top of the top tier of pregnancy prevention, and at the recent ACM some medical students were joking about how their reproductive endocrinologist professor got his wife, their maternal fetal medicine professor, pregnant with twins even while she had an IUD in!

Let’s talk about it all. My ideal teen sex education program would talk about withdrawal and mention how it is dependent on the male being able to control himself, be trustworthy, be sober, and will not prevent STIs. Then I would present the failure rate. I would also talk about sex toys, masturbation, homosexuality, abstinence, anal sex, oral sex, abortion and other topics.

My (almost) ideal sex ed program may be coming to teenagers soon, actually. But it’s not going to be in schools. Rumor has it the Midwest Teen Sex Show is coming to Comedy Central. I hope it does to abstinence only education what the Daily Show has done to cable news.

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Speaking of autism offensively…

Michael Savage just thinks it’s just brats putting on an act. Oh, ha ha, just kidding!

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