Tag Archives: Reply turned post

Reply turned post, I reject your reality! style

OK for Mythbusters, not for health advocacy

I have been participating in the Facebook group VBAC Facts Community for a little while now, ever since meeting the wonderful community founder Jen Kamel at the VBAC Summit last year. It is a supportive group, and Jen runs the site well with the help of moderators and a good foundation of evidence.

This group, at times, can be a good example at how distorted internet microcosms can make uncommon opinions seem much more accepted. In this community, using midwives and having a home birth comes up in almost every thread, it seems. I have seen using a midwife treated like a hipster fashion choice recently on Jezebel and other sites. However, midwife attended births still make up less than 10% of births in the United States. Hardly a huge trend. Midwives are underutilized here compared to many other countries with better maternity and neonatal outcomes than we have. But, depending on your source, midwife attended and/or out of hospital births may seem to be common or even a glorified standard. However, in the circles I travel in my daily grind as a physician, choosing out of hospital birth is fringe, reckless behavior.

So, it’s like entering a portal in another world when I participate on a thread in the VBAC group, and the commenters have a heated argument about epidurals, and many participants did not get one. On our labor and delivery floor, it is a rare to never occurrence that someone wouldn’t get one. Because out of hospital birth, choosing not to have an epidural even if you deliver in a hospital, and VBAC are such rarely available, rarely supported choices, I am usually on the side of defending people who advocate for such choices as underdogs, not the holier than thou bullies that many paint them to be.

It’s also a really strange place for me to be in when I gently try to correct medical inaccuracies, and I sometimes get painted as a brainwashed surgico-technocrat physician. I correct fellow physicians when they say all VBAC is dangerous. For real, even my attending physicians. I also have corrected fellow physicians who state episiotomies are preferable to tearing. But, I also correct women in the VBAC group who state things that are medically inaccurate, like that worsening hypertension in pregnancy is not serious and does not warrant an induction or cesarean unless the fetus is in distress, or that leaving the hospital midlabor is a reasonable course of action if one is faced with unwanted interventions (in one particular thread in which I was painted as a typical brainwashed South Florida cesarean happy physician, the intervention that warranted attempting to leave midlabor was continuous external monitoring).

These are not the majority opinions even in this microcosm. But, they are often aggressively defended positions. One that has come up repeatedly, recently, is an insistence that tubal ligation is linked to “post tubal ligation syndrome”, which leads, according to some posters, to the majority of women needing hormonal interventions to control heavy menstrual bleeding, and / or hysterectomy to control intractable post procedure pain.

I think these communities are incredibly valuable, not just because of the sharing of strictly evidence based facts. I think a lot, even the majority of the benefit is the support and stories from other women who have experienced similar choices and situations, or share similar priorities and stories. I think in the VBAC community, and in pregnancy and mothering as a whole, there is so much value to support, empathy and stories. However, there is a big difference between asnwering an original poster who says “what was your experience with tubal ligation?” and someone answering “geez, I had pain and menstrual irregularity after” and an original poster saying “I am planning on a tubal ligation” and a slew of commenters saying “NO! This is PROVEN to cause a, b and c horrible side effects to the majority of women who get it!” and usually a touch of “Have you considered Natural Family Planning?”

Sigh.

I have reluctantly been the heavy in many of these conversations, but it is triggering a bunch of pet peeves of mine. 1. Medical inaccuracies masquerading as facts. 2. Ignoring the expressed informed choice and priorities of the woman posting and substituting the commenters’ own priorities and (often faulty or anecdotal at best) information

So, this coalesced into a recent thread, and here is the reply I posted:

“This is the best article I have found on post tubal ligation syndrome:

http://www.nejm.org/doi/full/10.1056/nejm200012073432303#t=articleResults

It is a good article because it compares women who have had tubals with women whose partners have had vasectomies. It is also a good study because it has an N number of over 9,000 subjects who had the tubal ligation. It is also authored by a group from the Centers of Disease Control (the CDC). There is no economic conflict, and the New England Journal of Medicine is about as high quality a publication as it gets. Here are the results:

“The original concern about sterilization involved the risk of heavy bleeding and intermenstrual bleeding, but we found no evidence of either problem. Furthermore, we found that women who underwent sterilization were likely to have decreases in the amount of bleeding, the number of days of bleeding, and the amount of menstrual pain and an increase in cycle irregularity. We know of no biologic explanation for these changes, most of which were beneficial, in women after tubal ligation.”

I don’t think there’s any evidence of widespread issues post tubal. In fact, this high quality study seems to indicate the opposite. I am not saying a tubal ligation is right for everybody, but I do think it is inappropriate for every thread on here in which tubal ligation is mentioned to devolve into a pronouncement that tubals are PROVEN to cause these problems, often with alarming figures like half of all women who get tubals end up with hysterectomies, etc.

As I have also said, it is inappropriate at best and borderline bullying at worst for women on here to disregard a woman’s stated informed choice and substitute their own priorities, especially if they are coming from a place of anecdote and questionable information. It is also inappropriate to ignore a woman’s expressed desire for a highly effective form of birth control (like a tubal or IUD) and to tell them to try NFP* instead, when it has a typical failure rate much higher. I hold a woman’s right to make informed decisions about her reproduction to include highly effective birth control if desired as well as safe options for trial of labor after cesarean.

I am not a surgery lovin’ medicoindustrial defending brainwashed doctor. I trained as a midwife, had both of my kids unmedicated** with midwives, and have never used hormonal birth control myself due to my own priorities and reasons. I support low intervention birth and VBAC for two main reasons which may seem contradictory, but are wonderfully not. 1. It’s a woman-centered approach and 2. It is an evidence based approach. Bullying women into avoiding their choice of safe contraception is neither.”

*I love this site for comparison of contraceptive methods: http://www.birth-control-comparison.info/
**The first labor was augmented with pitocin without my informed consent, but was otherwise unmedicated

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Reply turned post, single mother in medicine style

I am a contributor at the wonderful site Mothers in Medicine, and this week a guest poster wrote in to ask Do Single Mothers Go to Medical School? Please go read her original post and the other comments. Here is my very long-winded reply:

Hi! I am a single mother who just finished medical school. I would be happy to chat with you through email, if you’re interested. Please feel free to let KC know, and she knows how to get ahold of me. Also, you can read the posts I have written on here (click on the MomTFH link in the labels to the right–>) or read my blog at http://momstinfoilhat.wordpress.com. Not all of my posts are about being a single mom, obviously, but it is my constant reality as I write. As I hope you have discovered, it is easier and harder to be a single mom than you may have expected, and it does not dominate all of my thoughts, conversations and interactions.

OK, on to your questions. Let’s start with the simpler one. I took the MCAT after being out of the basic science classes for several years, too. I used a single review book and did OK. I happen to be a good test taker. If I had a time machine (Oh, geez! the things I could fix!) I would have taken a review course and probably scored higher. I think taking a targeted MCAT review would be higher yield for you than retaking all of your premed. That will also take quite a while. But, if you think having domestic good grades will improve your chances of admission, it’s definitely an option.

As for RN vs. NP vs. being a physician, that is really up to you, and I don’t think there is an easy answer to that. There are many days in which I wish I had the time machine and could go back and be an NP, but I may be a unique case. I am older than you, I want to go into obstetrics, and I didn’t match into residency last year. If I was a nurse practitioner / midwife, I could be working already, no residency required, and be doing everything I want to do as a doctor (I am not super gung ho about being a lead surgeon and am more interested in low risk obstetrics, obviously, but there are plenty of NPs that assist in the OR, just don’t lead surgeries).

Obviously, yes, single mothers do go to medical school. I was pleasantly surprised at the diversity in my class. I sat next to a grandmother all of 2nd year, and I was not the only single mom in my class. Also, single mothers do a lot of things that take them away from their kid(s). Many single moms work outside the home for long hours and have to rely on different forms of help and childcare. And, most of these single moms are not pursuing a life long dream, one that will most likely provide financial security and a fulfilling career. Moms have guilt, single moms have guilt. I don’t let that keep me from pursuing my career in medicine.

Medical school is not a bad situation to be in as a single mom. Especially the first two years. There are many schools that even stream most of the classes online, and do not have an attendance policy for many of the classes (mine did). Your clinical years may be more difficult. Your schedule can change from month to month, and I have had to ask a caregiver to show up at my house at 4:30 am some months so I can get to my rotation on time. Even more difficult, my schedule would change in a month. My kids were in school and had after school care from a trusted family member, so my main issue was the early mornings.

As for being able to handle it, I was the president of more than one extracurricular club. I won a research fellowship and full tuition scholarship. I was recommended and inducted into the humanism honors society by one of my attendings / professors. I qualified for the regular honors society, but I won’t go into the political BS that kept me from that group. I aced my boards and never failed a class. I am not just tooting my horn here; I am telling you that, if you work hard and have the aptitude and right attitude, you will do well.

I have written on my blog about my sometimes frustration with some of my former classmates. These are things my single, childless classmates have told me: I gave up using any washable dishes or glasses during medical school because I don’t have time to do any dishes. I gave up my dog to my parents during board review because I can’t take care of it. I don’t have time to do _____ activity or ______ club. I didn’t have time to take the required scrub class before rotations started because I wanted to go on a vacation. I need to take off a month because I am planning a wedding. I can’t make the meeting at that time because that’s when I nap. (Yes, for real) I would see some of these same students go to yoga 3 times a week, or party frequently, or get their mani/pedi once a week, or watch every episode of the Jersey Shore, or make what ever bargains or compromises they chose. So do I. (Make compromises. I don’t do any of those things on the list. I have a dog and two cats, I cook and use real dishes and plates, and I don’t get to work out often if at all, watch much TV, or take care of my fingernails, hairdo or other beauty routines often. I also schedule my naps, rare as they are, around my obligations, not the other way around). So will you, compromise, that is, regardless of your path.

As for divorce, moving, family support – that stuff is not easy. If you email me and are up for it, I can regale you with the soap opera that was my divorce and coparenting (they don’t call it custody anymore) agreement, and the sacrifices I had to make to be able to move if I matched out of the area. Single parents relocate all the time for many reasons. It is not fair to expect every single parent to remain, forever, in a 50 mile radius of where they divorced. There are a lot of moving parts to this, and I could write more words than this entire post already (seriously not kidding) about it. A lot of this depends on your ex. This battle was infinitely harder than medical school for me.

Anyway, I hope this wasn’t too much, and was helpful in some way. Good luck, and please keep us up to date.

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Reply turned post, not ranting about pap frequency

I want to be Dr. P at The Blog That Ate Manhattan when I grow up. If you like my blog, you should love hers. She has been especially on fire, both with her cooking posts and her women’s health posts. Her blog has been in my sidebar forever. But, I can’t resist linking to her now and then, even when huge women’s health and politics related stories pile one on top of each other and don’t budge me to post.

She wrote about the new American Cancer Society cervical cancer screening recommendations on her blog here. She does an excellent job of breaking them down, and discussing their implications to both patients with different clinical histories and providers. Go read her post, and then I had a reply. Usually my reply – turned – posts are ranty, but this one is just guidelines wonk-y:

Your blog posts are always wonderful, and they have been especially informative and well researched recently. Thanks!

The ACOG / USPSTF recommendations currently say not to do HPV testing under age 30, as far as I know, even if the cytology is abnormal: http://www.acog.org/About_ACOG/Announcements/New_Cervical_Cancer_Screening_Recommendations

Am I correct that the ACS recommendation are slightly different? (Which is not unheard of, they are different when it comes to mammography initiation and frequency, for example.)

If these ACS recommendations accept a higher rate of cervical cancer in the 20 – 29 group, I wonder what the effect of reflexive HPV testing will have on cancer detection in that age group.

What do you think of scheduling annual appointments for bimanual exams and counseling? I think bimanuals are still recommended yearly. How would that work, practically?

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Reply turned post, from abortion to homebirth style

Hello! Hey, I’m a doctor!

Please go read this excellent article at RH Reality Check: Why Birthing Rights Matter to the Pro-Choice Movement.

Here is a great quote from the author Laura Guy, who is a doula (yay!) and a certified lactation consultant (IBCLC) (double yay!):

But let’s be clear about something. Reproductive justice means that everyone has complete control over if, when, where, how, and with whom they bring a child into the world. It means that people have accurate, unbiased access to information regarding all facets of their reproductive lives, from contraception to pregnancy options, from practices surrounding birth to parental rights. It means that our choices are not constrained by politics, financial barriers, or social pressure. In other words, how can the right to give birth at home – safely and legally – not be on a reproductive justice advocate’s radar?

As I commented on the article, I was thrilled when, during the keynote address at my first Medical Students for Choice meeting, the speaker mentioned out of hospital birth. Reproductive rights are full spectrum. They start before sexual activity begins – bodily autonomy begins with birth, stretches through childhood with protection from oversexualization, extends through accurate sexual education, includes contraception and freedom to choose when and how to become sexually active, and definitely doesn’t end once one decides to carry a pregnancy to term. The ability (or lack thereof) of women to choose the site and mode of their delivery, among other important issues of autonomy during pregnancy, are key ways that women’s rights are challenged daily in this country. Pregnant women are not human incubators.

So, seems like a bunch of mutual appreciation society activity here. Where is the angst that usually prompts the reply-turned-post? Well, on the RH Reality Check link of Facebook, one commenter says: “This is great and it’s also important for women to have the right to medical interventions (like elective C-sections) they feel are right for them.”

Here is my reply:

‎@Kathleen – within reason. Feeling something is right is one thing, but unnecessary medical intervention is not a “right” per se.

It’s a very nuanced issue that may not fit well in the comments section on Facebook. For example, evidence and expert position statements warn against early induction. Feeling like an induction is right is not enough of a reason to get one. Take it from someone who has been in the paper gown, sick of being pregnant, and in the white coat – many women feel like an induction before the end of pregnancy.

Also, someone who is a really poor candidate for vaginal delivery (placenta previa, for example), may feel like they want a vaginal delivery, but it is not medically advisable. Same goes for women who are poor candidates for homebirth. I think homebirth is an excellent option for good candidates. Not all. There is a role for practitioners to play here, too.

As a physician and most likely a future ob/gyn, I will be one of many practitioners who need to constantly work that balance between respecting a patient’s autonomy, providing good informed consent, and practicing good medicine with a good conscience. Medicine is more than ordering off a menu.

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Reply turned post, midwives are hacks style

When I signed onto Facebook this morning, a link showed up on my feed from a page that I don’t remember “liking”, but, as it is called “Nurtured Moms”, I can see it being a possibility.

The link was to an article by OB Management examining collaboration between ob/gyns, nurse midwives, and CPMs / lay midwives. The original article is actually not that bad, and does encourage collaboration with midwives (mostly with CNMs) and higher standards and licensing for CPMs, which I support. It didn’t accurately give the background on the Flexner Report, the purpose of which was to weed out inferior MEDICAL SCHOOLS, not midwives. But, I didn’t bring that up because I thought it wasn’t fully relevant to the discussion.

The posting on the Facebook page included the caption:

Exactly. In fact, it is even worse than the article suggests.

It states, “The North American Registry of Midwives’ Portfolio Evaluation Process requires midwives to be the primary care provider during 50 home births and to have 3 years’ experience. The average ObGyn resident gets this much experience in 1 month.”

However, this is not the requirement one needs to meet to become a CPM; this is the requirement to be a PRECEPTOR of CPMs — to pass your “knowledge” on to others!! In fact, to become a CPM, you only have to attend 20 births as a primary care provider. Also, just this year, they added the requirement for a high school diploma. For the last 15 years, you didn’t even need one to become a CPM. The most recent requirements are here: http://narm.org/req-updates/

The first commenter said this:

People need to understand that high standards do not limit choice for mothers. It boggles my mind when I hear lay midwifery apologists insist that making CNM the standard would “limit mothers’ choices.” Limit *what* choice, exactly? Oh right, clearly they want women to be able to “choose” substandard care (CPM) even though the very best (CNM and OBGYN) is readily available to everyone. It’s disgraceful that in America we allow uneducated hacks to practice medicine on the most vulnerable citizens. The ACOG is right not to “collaborate” with lay midwives.

I posted this:

The requirements for direct entry midwives are higher than that in Florida. Also, ob/gyn residents are already licensed doctors by the time they get that experience. There is no requirement for any specific clinical experiences first, although most medical students do at least observe a certain number of births.

Also, ob/gyn residents are not on labor & delivery every month. It depends on the training program, but most involve less than 100 vaginal deliveries a year.

Don’t get me wrong. I am a supporter of adequate training for CPMs/DEMs/LMs. I am also a supporter of accuracy.

Commenter #1 replied:

Accuracy? Lay midwives’ “education” pales in comparison to that of legitimate medical professionals. That’s accurate. Split all the hairs about med school that you like– lay midwives are still substandard, full stop.

I replied:

I am not splitting hairs. I am giving accurate information. A first year ob/gyn resident on her first labor and delivery rotation may have never caught a baby herself. She is a “legitimate” licensed medical professional.

Again, I am all for adequate training and licensing for CPMs. I do not think it is fair to call them all “hacks” or “substandard”. I also don’t think it is safe for ob/gyns or ACOG to not cooperate with lay midwives, nor is it accurate. ACOG does acknowledge that birth center births have been proven to be as safe as in hospital birth, and they support birth centers as a safe site of birth in their position statement, and most birth centers are run by CPMs or other types of lay midwives.

The best way to make homebirth and other out of hospital birth safe, other than adequate training of midwives, is to ensure seamless cooperation with other “legitimate” medical professionals when necessary. Anything less is unethical and unsafe for mothers.

Full stop.

I am not sure I am going to go back to comment on the thread, but if you follow the link to the new qualifications, 10 + 20 + 20 + 5 = 55 births required, not 20.

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Reply turned post, blame the mom or the system? style

My buddy Jill of The Unnecesarean has launched an awesomely Rad Pitt (inside joke, you’d get it if you were from San Diego or South Beach) new project called CesareanRates.com. She shared a top ten list from my lovely state of Florida on Facebook, which got, as expected, an avalanche of disgusted responses.

It is hard not to see rates of 50, 60% + without choking on your third cup of coffee. OK, maybe I’m the only one on my third cup of coffee. And I didn’t really choke, since I was well aware that some hospitals down here have had rates higher than that, as you can see by Jill and my silly little guerrilla action here, which was when we first became partners in crime.

Well, in the flurry of comments on her Facebook page, many people followed the familiar line of – blame the moms. Blame the women for not educating themselves. Blame them for choosing a hospital birth over a homebirth. Blame them for being all Hispanic (Mexicans and Brazilians in particular were blamed for our cesarean woes) and wanting a cesarean. Blame them and the OBs for creating an atmosphere of fearing birth, and forget about changing that system, because it’s a lost cause. There are plenty of good replies to this, but I am sharing mine here:

OK, diving in. First of all, the Mexican and Brazilian population in Miami and Broward County is pretty low. Cubans are by far the majority of the Hispanic population. Also, research shows that maternal request and ethnicity as factors influencing primary cesarean are both way overblown.(1) In fact, some research indicates that being Hispanic decreases your chance of having a primary cesarean in the United States.(2)(3)

Training as an OB in residency and insurance are not the primary reasons why OBs in South Florida don’t want to do VBACs. My assertion is based on as yet unpublished research from my fellowship project. Residency sites are probably the most consistent place you can get a VBAC in Florida – note that someone on this thread is going to do a VBAC at Jackson, which is the only OB residency in South Florida. Most OBs cite malpractice concerns as their reason for not doing VBACs, and that was very consistent with responses in my research. And, no tort reform is not the answer, because Florida has had some of the most extensive tort reform for OBs in the whole US – OBs here can and often do “go bare”, which means they don’t even have to carry malpractice insurance, and can limit their liability totals in various ways. Jackson has immunity as a public hospital, also.

I have to say, I am not fond of blaming moms, either for their site choice or their cultural backgrounds. I also don’t think it is effective to turn our back on changing the system. As Jill said, almost all women choose to birth in hospitals. Even with out of hospital birth rates increasing, we are still talking rates around 5%. Of course, I have to believe on changing from within, or else my life’s path is a waste of time.

(1)http://www.childbirthconnection.org/article.asp?ck=10372
(2)http://www.ncbi.nlm.nih.gov/pubmed/19788975
(3)http://mchb.hrsa.gov/research/documents/finalreports/declercq_r40_mc_08720_final_report.pdf

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Reply turned post, Trisomy 18 and mental masturbation style

I can get really frustrated by people who enter into philosophical arguments about serious medical ethics questions online. Many of these people have a definite agenda, often controlling access to abortion, but try to couch it as some sort of intellectual exercise. Many of these commenters are men who toss around large words like “autonomy” and “qualitative determination.” This happens all over the interwebs, and I know better than to spend my time hunting down every blowhard that litters a comment section with his ideas on viability and fetal rights.

However, I clicked through a link on my Washington Post headline newsletter on Trisomy 18, since it is a topic that genuinely interests me. Presidential candidate and notorious crusader against contraception and abortion Rick Santorum has a daughter with Trisomy 18, one who is questionably lucky to have survived the few years she has, and has been hospitalized yet again. I was generally pleased with the accuracy and tone of the article. I hesitantly stumbled into the comments section, and then happened upon a perfect example of what I like to refer to as mental masturbation, from a commenter named “johnbmadwis”, which he wrote in response to a comment drawing the logical connection between the suffering and medical expense of Santorum’s daughter, and his position on the ability of other families to choose this road for themselves:

But haven’t you just made Santorum’s point and fueled the fire of the pro-life proponents? That is, the pro life advocate’s long held belief that abortion rights advocates are not really talking about rape and incest, but rather personal evaluations of the quality of life of the fetus or externalities such as heartache and expense. Regardless of the condition of the fetus, pro life advocates would say society has a moral interest, they’d say imperative, in preserving the life of such a fetus from individuals such as yourself, who may want to terminate that life due to such condition. At what point, if any, does that societal interest give way to individual autonomy? Would you truly advocate for the ability to terminate that life after birth? in the last weeks of pregnancy? 3rd trimester? viability? Whatever the point, what is the guiding principle? Individual autonomy? Quality of life? (determined, assuredly, by one other than the one whose life is at stake – so, whose individual autonomy?) at what point does one achieve individual autonomy? Does a fetus have individual autonomy At some point the life of the fetus does, presumably, outweigh the individual’s autonomy, right? When? Is individual autonomy equally valid if it were exercised for clearly base purposes such as mere inconvenience or desire, say, to have a boy instead of a girl? Who should make that qualitative determination? Society? The individual carrying the fetus. The affected fetus? The personal choice of a couple does affect the life of another human being in your scenario, so, it is reasonable to ask you when, if ever, do you believe that personal choice must give way to other principles or interests?

My reply, which was thankfully limited by a character limit, is here (I added a few hyperlinks to this version, but otherwise it is unchanged):

@johnbmadwis, these questions have been answered by courts and medical ethicists. There is an obvious glaring difference in autonomy between a child who is already born and a fetus, whose existence depends entirely on the mother, whose life is intimately affected and at risk by carrying a pregnancy. Late term abortions (post viability) are extremely rare, and most states have strict limits on the conditions under which such procedures can be performed.

If you are worried about a slippery slope, it is pretty obvious the slope has been tilting towards restrictive legislation limiting all abortion, not just the dramatic but rare cases you bring up. More than 400 bills have been proposed recently in state legislatures seeking to place barriers on access to abortion, from extended waiting periods for all terminations, overreaching excessive requirements for providers and facilities that don’t extend to other, riskier outpatient surgeries, to personhood bills for fertilized eggs.

Trisomy 18 is a serious condition that is considered mostly “incompatible with life.” Not only is the fetus likely to die in utero, but if it survives, it is likely to die as newborn. The article (mostly) covered this really well. (We do know the “cause” of most trisomy 18 – nondisjunction during meiosis II – which is much more common the longer the egg has been in a suspended state of meisosis, i.e. in older mothers).

Santorum’s daughter is lucky in some ways to be a 1% in more ways than one, but this is more than just some sort of ethical masturbation in a comment section of a blog. This issue involves the emotional and physical challenges to the mother. Have you ever carried a fetus, commenter with a male sounding handle? Have you ever had a stranger put their hand on your belly and ask when you were due, when you knew the fetus would most likely die before birth, or soon after? Then there’s the suffering of the baby if it survives, and the emotional toll such care takes on caregivers – do you have any idea what it is like to work in a NICU on suffering, terminal infants? With major cutbacks in personnel in public hospitals, too.

Not to mention the health care dollars arguably misproportioned here. I got to tell pregnant mothers with no insurance yesterday that they had to pay full price, cash up front for necessary basic lab tests. These are mothers who don’t have husbands flying around the country campaigning for president. These are mothers who may and do skip important labs, or prenatal visits, because they have to choose between knowing if they have hepatitis B or food for their existing children. We got to tell a mother who was having her fourth baby and desired a tubal ligation that there was no funding anymore for it. She could pay $1400 up front to the clinic then pay more in hospital fees. Maybe she could google birth control – oh, wait, she probably doesn’t have a computer.

Enjoy wringing your hands about the autonomy of a trisomy 18 fetus. It’s a luxury.

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Us vs. them (or a blog retrospective)

I cut down on my blogging a lot this past year. It was due to a combination of a different factors. It is harder to tell stories about clinical experiences without discussing my patients or attending physicians in a possibly sensitive way than it was to tell stories about studying or research. Also, I became a single mother, and blogging time is more negotiable than cooking dinner. Or cleaning muddy footprints up from the entire. fricking. house last night. After shower muddy trampolining and wooden sword fighting? Great idea!

But, another reason I stopped blogging has to do with the polarization and vilification that is so common in internet discussions of topics I find dear. Give me a nuanced discussion about breastfeeding, birth, contraception or abortion, please? Please?

I keep ending up writing posts like this one about the rhetoric surrounding “natural” birth, the how to present risks surrounding birth without freaking out post, the one about a death threat I got over a post about vaccination, abortion, fetal monitoring for chrissakes or posts one, two, three, four, five, six (OK that’s enough!) posts about polarizing breastfeeding if-you-can-call-it-conversation. I’m not going to start searching for my posts on race.

Let’s not forget Mommy Wars Bingo.

After one and two disappointing posts and comment sections on Skepchick about breastfeeding, I was tempted to post another plea on here. I want to like Skepchick because of posts like this about female genitalia self image, and a post about female body hair shaving that seems to have disappeared. I was going to beg, again, to please, please let a discussion of breastfeeding science go by without the “GUILT!!” hammer coming down, but I am starting to feel like I will be rating level five on the Professor Internet dick meter if I keep covering the same territory. Even though I’d rather fancy myself more like Jon Stewart preachin’ it on Crossfire.

Hell, I know I have “rant” as a tag on my blog, and I think I coined the term reply-turned-post, even though I hardly invented it. I replied on both Skepchick posts, but I didn’t even bother reposting it here. I am just tired of it. And, I have a sandwich, or a rank list, to get to.

By the way, this is apparently post #665. My next post will be from hell.

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Reply turned post, “reasonable” commenters style

Jill has had a great series of posts on The Unnecesarean about a large malpractice payment based on jury findings of a lack of appropriate informed consent prior to a shoulder dystocia that resulted in a permanently affected child, and a follow up post on how to properly counsel a patient with a baby with a large estimated fetal weight.

As you may have expected, both of these posts had lively comments sections. I only got involved in the second post. Yes, I haven’t just been MIA here, I have been MIA in the interwebs in general. However, I tend to jump in when I actually get a chance to read something, and then see someone creating straw men arguments or grossly misinflating aspects of the conversation in order to make a point, which happened a few times in the second comment thread.

My first comment was in regards to informed consent. A few commenters acted as if there is an exact formula for informed consent, and it includes presenting every worst case scenario, even if the risks of that scenario are diminishingly rare. Also, some commenters were treating the one verdict and award in this very specific case as the totality of case law on informed consent.

ACOG has a Committee Opinion on Informed Consent which discusses the complicated and amorphous subject of malpractice case law and informed consent. This opinion, which I recommend that you read, like I recommend you read all of the links I am including (yeah, I know, you haven’t got all day, but still), states that first of all, informed consent is more of an ethical issue than merely a legal issue. Secondly, the adequacy of disclosure, which is the issue that the huge malpractice payout in the original Unnecesarean post hinged on, has been judged by different criteria in different cases. In recent history, “common practice of the profession” was the most common trend for judgments. That could be troublesome, because standard of care in different areas can be quite variable, and not necessarily evidence based or best for the patient. Now, the trend seems to be moving towards the “reasonable person” criterion, which can also be troublesome. Especially if the all the commenters on these threads are “reasonable people.” Ahem.

Physicians are notoriously poor at presenting risk (pdf) in a way a reasonable person can understand. Many practitioners will very selectively and erratically present risk, sometimes exaggerating, downplaying or completely omitting risks or benefits in order to lead the patient in a certain direction. Ignoring that, statistics are still highly complicated even with the best of intentions. This article recommends using “natural frequencies”, such as saying three to five people out of ten taking Prozac will report some sexual dysfunction, as opposed to saying there is a 30 to 50% probability of sexual dysfunction. Many people will assume the latter will mean that every time they have a sexual encounter, there will be a 30 to 50% chance of there being a problem. Percentages or other comparative methods (__ times more likely) can be tricky.

For example, in Liu et al’s Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term, one of the outcomes measured was any hysterectomy. I picked this specific outcome because it is a good example of how to discuss the numbers, but also because one of the commenters grossly misrepresented this particular risk, stating it was ONLY a risk of vaginal birth, and not at all associated with cesarean section.

In this retrospective study, there were 27 hysterectomies in 46,766 cesarean deliveries, and 376 hysterectomies in 2,292,420 vaginal deliveries. That is the same as 0.6 per thousand cesareans, and 0.2 per thousand vaginal deliveries. The adjusted odds ratio of any hysterectomy is 3.2 higher odds for cesarean than vaginal delivery. So, three times higher, or 320% higher. Sounds huge, right? But, the absolute risk difference is 0.4 per 1,000. Or, four hysterectomies per 10,000 cesareans. Does increased risk of hysterectomy need to be part of the informed consent for cesarean section? Does it need to be part of the informed consent for vaginal delivery? How frequent does an adverse event need to be for it to deserve a mention? Does an adverse outcome such as nerve injury resulting in foot drop, usually due to epidural or spinal anesthesia, which only appears in isolated case reports, not even in large studies such as this, need to be mentioned?

I still haven’t touched on the topic of how to counsel a patient who is near term and has high estimated fetal weight. This is a complicated topic, and I don’t think I am going to cover it in this post. Based on the evidence, including the ACOG position statements on the topic and UpToDate’s review of the literature, shoulder dystocia is unpredictable and unpreventable. Prophylactic cesarean section does not prevent nerve injuries or neonatal death. Induction of labor (which is disappointingly common in these cases) actually increases neonatal poor outcomes. Instrumental vaginal delivery (use of vacuum extraction or forceps) increases the risk of shoulder dystocia. Estimated fetal weight is a tool with poor accuracy, given a rating of I for insufficient evidence to support its use by the United States Preventative Services Task Force. This list does not even take into account the maternal history and characteristics.

I think informed consent for any pregnant person should include the chance of a shoulder dystocia. I think as the risk factors increase (estimated fetal weight greater than 4500 g, gestational diabetes, prior macrosomic baby, prior shoulder dystocia, male fetal gender, small maternal pelvic size), that increased risk should be presented. If a practitioner is acting out of fear of a lawsuit in the extremely rare case that there is a very poor outcome, the practitioner should mention this fear.

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Reply turned post, yes, I’m worried

I haven’t done a reply turned post in a while. I used to do them quite often, but my blog reader is currently burgeoning at over 1000 unread posts, and I don’t have time to read, much less post, on other sites, as evidenced by my lack of writing on my own blog. But, sometimes I get moved.

Juliaink wrote a wonderful post on Mothers in Medicine called “Anybody Worried?”, in which she says:

Choice about childbearing comes in many forms. In my own case, it was because I came through training at a time when professional women had trouble finding men who valued us–or maybe it was my evil temper. In any case, I married quite late and had my last child at age 39. This is not necessarily the path I recommend, but I do think that if we support women’s professional aspirations, we should be committed to the proposition that all women should have access to reproductive health services. If Congress prevails, many women who might otherwise make up the next generations of mothers in medicine are going to be instead mothers who lack education, income and the privilege of being able to care for others as well as their own children, in the ways we all do.

I was upset but not surprised by the comments that referred to termination of pregnancy as choosing to “end the life of a child”, and said “A child is a blessing and a privilege from the moment of conception. If you had a problem keeping your legs closed or your birth control method actually failed, it is not the child’s fault or problem – it is yours.”

Sigh.

Here are my two replies:

Reply #1, in response to “Kelley”, a mother and an aspiring physician, who kept an unplanned pregnancy and thinks an abortion is choosing to “end the life of a child” for convenience:

I object to calling terminating a pregnancy ending the life of a child. Neither my first trimester abortion nor my miscarriage was killing a living child, and I am not a murderer. 1/3 of women in this country have an abortion at some point in their reproductive years, and we really should watch the tone of our rhetoric. Calling 30% of women murderers is pretty harsh, and out of step with most of America’s attitudes toward abortion and miscarriage.

One of the leading causes of maternal death in the world is complications following illegal abortion. Most of these women were already mothers, and leave behind real living, breathing orphans who are four times more likely to die once their moms are dead. In these countries, where making abortion goes hand in hand with reducing access to contraception, just like it does here, abortion rates actually increase.

I am not sure what these other options are other than Planned Parenthood, especially with the same politicians trying to cut Title X funding for contraception in general, and wanting to cut social programs to pay for these children once they’re really alive. If we are talking about Crisis Pregnancy Centers, most do not provide any health care and are not run with any licensed health care workers. Only 2% of Planned Parenthood’s services involve termination of pregnancy, and they serve poor communities where unplanned pregnancies and STDs are more prevalent.

It’s all fine and dandy to sit in a privileged seat and call yourself pro-life, but there’s rhetoric and then there’s reality. Cutting funding to Planned Parenthood will increase unplanned pregnancy and abortion, and possibly maternal and child death in the long run.

Reply #2, in response to Ernest, who earnestly believes us sluts just have “a problem keeping our legs closed”, and it’s not the child’s fault, it’s ours. How surprising that Ernest, who is presumably male if I can make assumption based on his moniker, makes no mention of the man who pried those legs open as sharing in the blame responsibility. He thinks a “child” is a “blessing and a privilege” from the moment of conception, but doesn’t think any of these comments actually count as getting into a heated debate. Oh, and anyone who gets an abortion is a murderer. Period. But, he’s not getting into the debate or anything.

Saying a child is a blessing and a privilege from the moment of conception ignores the reality of the 50% of pregnancies in this country that are unplanned, the 30% of women who choose termination at some point, and the 50% or more of pregnancies (some say up to 80%) that spontaneously abort in the first trimester.

Villfying women who choose abortion as not being able to keep their legs together and only choosing abortion as a convenience is speaking from a very privileged viewpoint. The man who date raped me in high school did not give me the option of using birth control as I cried and said no to him. I have been in an abusive relationship, and it was hard enough to leave with the one child we had together that I decided to keep when I got pregnant, unplanned, while using contraception. If I got pregnant again, I might be still living with him with a new “blessing”, if I was forced to keep the baby. And before any lovely judgmental people say I shouldn’t have had sex with an abuser in the first place, most abusers don’t start abusing until their partner gets pregnant, and that is what happened with me. He seemed like a fine, upstanding member of society before that point.

Thank goodness I found a midwife who was willing to put in an IUD after the baby, after I was denied one by a physician because I was divorced when I first started the relationship with the abuser. (No I’m not kidding. This is why we need Planned Parenthood, and we need to step back from judging women for not having effective birth contol). Being judgmental has NO PLACE in medicine, especially not in reproductive issues.

Anyone who mistakenly thinks an embryo is a living child can personally choose to keep any unplanned pregnancy. But your rights end where mine begin. The only alternative is forced pregnancy. I believe children are far too sacred, important blessings to be forced on a woman because her rights were taken away by someone who will never, ever have to raise them and will probably vote for politicians who will defund health care and social services for them.

As others have said, I think bombing civilians is murder. I think capital punishment is murder. No one can argue that the victims of these acts are not living, breathing human beings instead of one inch long bundles of cells completely dependent on another human being who has to risk her life for them for the better part of a year. Save the philosophical conversations for church and around the dinner table. Otherwise, you be the physician in Nicaragua who has to stand there while a woman dies with a ruptured ectopic pregnancy, and tell her surviving orphaned children that well, technically, that embryo’s “life” was worth more than the convenience of them having a mother, and she should have just kept her legs together if she didn’t want to take that risk.

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