Birth in an MRI

Babies are born in all kinds of settings, but a 24-year-old woman in Berlin chose to have her third child in December of 2010 inside a magnetic resonance imaging device at the Charite University Hospital in the German capital.

Researchers at the hospital last month released a brief segment of the seven sequences of real-time images they made of the birth inside a specially constructed open MRI, shown in the photo below. The video accompanied the publication of their article about the event in the American Journal of Obstetrics and Gynecology.

A midwife, an obstetrician, a neonatologist and an anesthetist were in the magnet room while the MRI was on. The hospital's delivery unit was a short distance away on the same floor. Mom and baby left the hospital two days after participating in this historic birth.

The view of the baby's journey into the world from inside the birth canal will provide researchers with valuable insight into the mechanics of this amazing passage, the authors said.

Birth in an MRI

The mother was just shy of 38 weeks gestation, fully dilated and experiencing regular contractions. She received an epidural before entering the MRI, where she remained for less than an hour, according to the article.

One additional "study" was taken of the mother's body after birth, "to evaluate the third stage of labor with regard to placental separation and uterus involution," the authors wrote.

The researchers, all affiliated with Charite, were concerned about subjecting a brand-new baby to the loud noise of the machine without the "maternal soft tissue" padding, so they turned the MRI off just at birth.

Images Christian Bamberg / American Journal of Obstetrics and Gynecology

Predicting problems in labor

How great would it be to be able to tell in advance whether a particular birth would go smoothly or need intervention!

A French team of physicians reported this week at the annual meeting of the Radiological Society of North America that it has developed a new computer model that uses magnetic resonance imaging to predict whether a birth will go smoothly or have problems.Pregnant Graffiti

Olivier Ami MD told a session of the RSNA meeting in Chicago that his team applied the new software, called Predibirth, to 24 MR images of pregnant women, and created a three-dimensional model of the woman's pelvis and the fetus. Using these images, Predibirth calculated the likelihood that the babies could find their way out of their mothers' bodies without assistance.

Of the 24 women studied, 13 delivered normally. Predibirth had predicted normal births for all of these women. Predibirth had tagged three women who opted for elective Cesarean sections as being at risk for dystocia.

Of five women who had emergency C-sections, Predibirth had predicted three might have problems — all three involved instructed labor. However, Predibirth had given thumbs up to two of the mothers, whose problems involved heart arrhythmia.

Predibirth had declared "mildly favorable" three additional moms who wound up resorting to vacuum extraction during birth.

Not perfect, but not bad.

"With this virtual childbirth software, the majority of C-sections could be planned rather than emergency, and difficult instrumental extractions might disappear in the near future," Dr. Ami told his audience in Chicago.

Dr. Ami M.D. is an obstetrician in the radiology department at Antoine Béclère Hospital, Université Paris Sud, France.

Image by Petteri Sulonen

A closer look at birth malpractice cases

Everybody knows that obstetricians are one of the most-sued medical specialties, but nailing down the details on that truism can be difficult.

CRICO Strategies, an international firm that provides risk-management software to hospitals and insurances companies, last month released a "benchmarking report" on malpractice risks in obstetrics that helps fill out that sketchy picture.

The report looked at 800 obstetrics-related medical-liability suits filed between 2005 and 2009.

Families dealing with the death of a mother or child, a severely damaged infant, or some other effect of a childbirth gone awry most commonly charged "communication failures, judgment lapses, and faulty technique as the reasons behind their injuries and their malpractice cases," the report states.

Sixty-five percent of cases involved "high-severity injuries."

Across the board, about one in 1,000 births involves a "preventable adverse outcome," the report noted.

While those can occur throughout pregnancy and birth, most suits in the study concerned allegations that birth assistants had mismanaged labor and delivery, particularly the second stage of labor — the actual birth.

"Substandard clinical judgment" was the top complaint in the suits, accounting for 77 percent of claims. Most of the suits named an attending physician.

The most common reason for suing was "birth asphyxia," a potentially injurious lack of oxygen, which accounted for 27 percent of the suits, and the most common allegation was that of a "delay in treatment of fetal distress" (25 percent of claims involving small hospitals, 19 percent involving large ones).

Answers to why C-sections are on the rise

Why is the Cesarean rate so precipitously on the rise, from 21 percent of all American births in 1996 to 33.2 percent in 2007? The journal Obstetrics and Gynecology has the results of a new study that examines that question.

The Yale University Schools of Medicine and Public Health in New Haven, Conn., reacted to a spike in C-sections during births at Yale-New Haven Hospital between 2000 and 2002 by setting to work gathering comprehensive data on the 32,443 births that occurred there between 2003 and 2009, even while the hospital's C-section rate ballooned from 26 percent to 36.5 percent.

Not surprisingly, the study found that actual birth complications remained steady, while subjective judgments about the births changed.

The new study, presented at the February meeting of the Society for Maternal-Fetal Medicine, looks at the decision-making on the part of individual doctors that drove that increase.

"In this study, we examined physician-documented indications for Cesarean delivery at a major urban academic medical center in Connecticut, a state with one of the largest rate increases in the nation, to determine which specific indications contributed to the increase in our Cesarean delivery rate over a seven-year period," the researchers wrote.

First-time mothers accounted for half of C-sections during the study.

Indications for Cesarean delivery included "nonreassuring fetal heart tracing," an interruption in dilation, more than one fetus, pre-eclampsia, an especially large baby (which begins to be a concern just shy of nine pounds), and the mother's expressed desire for a Cesarean, the study's authors reported.

Complications like breech presentations, an interruption in the baby's progress into the birth canal and cord prolapse  did not increase significantly over time, the study found.

Slow dilation and those unsatisfactory fetal heart rate reports displayed only slight increases over time but contributed to an outsize degree to the increase in C-sections, the study showed. Concern for the baby's well-being, based on fetal-heart monitoring, was the top indicator for a Cesarean section at Yale-New Haven Hospital during the period studied.

Maternal request, suspected macrosomia (a large baby), more than one fetus and pre-eclampsia also showed big annual increases as indications for Cesareans.

Interestingly, the C-section rate among patients of physicians in private practice was 33.2 percent. For "university patients," who received care from the hospital service's residents and faculty midwives, supervised by attending physicians, the rate was 25.6 percent. The rate for "high-risk" patients (whose care was provided by some of the same maternal-fetal specialists who supervised in the "university" cases) was 44.6 percent.

Some doctors refuse to care for obese women

Fourteen of 105 obstetrics-gynecology practices surveyed by the South Florida Sun-Sentinel last month said they will not take on obese women as patients.

Representatives of six of the practices cited higher rates of complications in women who are obese, but other respondents said heavier women tax their exam tables and other equipment.

"People don't realize the risk we're taking by taking care of these patients," the paper quoted Dr. Albert Triana as saying. Dr. Triana is one of two physicians in a South Miami practice that turns away obese patients, according to the article. "There's more risk of something going wrong and more risk of getting sued."

Seventy-two million Americans — about one in three — meet the criteria for obesity, according to the Centers for Disease Control and Prevention in Atlanta, Ga.

"If I had that policy, I wouldn't have a practice. I'd lose half my patients," Dr. Maureen Whelihan, a West Palm Beach ob-gyn, told the Sun-Sentinel's Bob LaMendiola. "We never turn down anyone."

In a followup article in American Medical News, reporter Christine S. Moyer asked doctors to comment on the practice of turning patients away because of their weight.

"This is [primary care physicians'] patient population, and [they're] here to serve the patients," said one of them, Dr. David Bryman, a Phoenix family physician specializing in bariatric medicine, which deals with the causes, treatment and prevention of obesity. Dr. Bryman is president-elect of the American Society of Bariatric Physicians. "If that requires getting a little extra equipment to accommodate them, it's just part of the practice of medicine."