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

A closer look at a new study on cesareans

The full text of the article "Contemporary cesarean delivery practice in the United States" published on-line in the American Journal of Obstetrics and Gynecology reveals some interesting insights into the particulars of the study. Birth Story published an earlier post this week based on the abstract.

"The national rate of cesarean delivery in the United States has increased more than 50 percent since 1996, to 31.8 percent in 2007," the report states. "This upward trajectory appears likely to continue in the near future."

The study was performed as part of the Consortium on Safe Labor, an initiative of the National Institute of Child Health and Human Development. It used electronic medical records of 228,668 births at 19 American hospitals between 2002 and 2008.

Here are some highlights:

  • A total of 93 percent of babies who presented "nonvertex" — with any body part other than the head in the lead— came into the world via C-section.
  • Almost 66 percent of multiples — twins or more — were delivered by cesearean section. Most of these moms did not attempt a trial of labor.
  • The C-section rate doubled from 21 percent at age 20 to 42 percent after age 35, "mainly due to repeat pre-labor cesarean deliveries."
  • Half of cesareans performed once labor had begun were because of "failure to progress" or  the belief that the baby's head was too large for the mother's pelvis. More than a quarter were performed because of "fetal distress."
  • Among women who had had previous deliveries, most C-sections occurred before labor began, and that was true no matter when they delivered.
  • More than 60 percent of deliveries at 28 weeks gestation were C-sections. That rate went down as pregnancies progressed.
  • The trial of labor in women with a uterine scar was 48 percent in 1999, 31 percent in 2002, and 29 percent by 2007.
  • The success rate of vaginal births after cesarean (VBAC) in the study was 57 percent (of the 28 percent of women who attempted a VBAC), "markedly lower" than in "previous large studies," which had ranged as high as 87 percent.
  • Overall, 84 percent of women with a uterine scar delivered by C-section.
  • Pre-labor repeat C-sections "have a profound impact on the overall cesarean rate."
  • "Truly elective" cesareans accounted for 9.6 percent of C-sections before labor commenced, and 2.1 percent undertaken during labor.
  • The hospitals in the study represented a wide range in rates of C-sections, from 20 to 44 percent.
  • Nearly 10 percent of the women who participated in the study added more than one delivery to the database; only the first delivery for each was included in the analysis.
  • Two of the hospitals in the study were non-teaching community hospitals. Nine were teaching community hospitals and eight were university-affiliated teaching hospitals.
  • Too many first-time moms get C-sections

    The most telling finding of a new study on cesarean sections in hospitals in the United States is that 31.2 percent of first-time mothers had C-sections.

    "Reducing primary cesarean delivery is the key" to bringing down the overall C-section rate, the researchers concluded. In 2007, the last year studied, America's C-section rate stood at 32 percent, a new high.

    The study, an analysis of nearly 229,000 births at 19 hospitals between 2002 and 2008 published on-line ahead of a print article in the American Journal of Obstetrics and Gynecology, was conducted under the aegis of the National Institute of Child Health and Human Development.

    The study found that 44 percent of women attempting a vaginal delivery were induced. Half of the women who had C-sections for dystocia — slow or difficult labor — were cervically dilated to less than 6 cm, far short of the 10 cm dilation that signals that birth is imminent, when the decision was made to operate.

    Of the 29 percent of women in the study who had previous C-sections, and were allowed a trial of labor, 57 percent delivered vaginally.

    The overall cesarean rate was 30.5 percent.

    The abstract of the study concludes, "To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate (sic) is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor."

    Many of the births included in the study took place at teaching hospitals, where more complicated birth often land, the study's authors noted.

    Pushing back against home-birth critics

    British and Australian midwives are pushing back against a recent editorial in The Lancet, a British medical journal, which builds on a study released last month that appears to show that home births are less safe than those that occur in a hospital.

    "Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk," stated the unsigned editorial from July 31.Pregnant Graffiti

    In an interview today with the Guardian, a British newsaper, Cathy Warwick, the general secretary of the Royal College of Midwives, said that midwives believe home birth is "being unfairly pilloried by some sectors of the global medical maternity establishment."

    Hannah Dahlen, the president of the Australian College of Midwives, weighed in as well. "Intense medical lobbying and strategically released journal articles" had put midwifery in her country "in the hands of the medical profession," she said.

    Warwick said, "What shocked us about The Lancet editorial was its language and tone and how it pumped the hype about the dangers of home birth, and made sweeping and misogynistic statements."

    "The Lancet said it stood by its editorial," wrote Randeep Ramesh in the Guardian article.

    The impetus for the piece in The Lancet was a meta-analysis scheduled for release next month in the American Journal of Obstetrics and Gynecology, a peer-reviewed journal published jointly by a number of organizations that includes the Society for Maternal-Fetal Medicine. The meta-analysis was presented at the SMFM meeting in Chicago in February.

    The article, published on-line last month, "provides the strongest evidence so far that home birth can, after all, be harmful to newborn babies," according to The Lancet editorial.

    Home births account for about 3 percent of births in the United Kingdom, according to the article in The Lancet; in the United States, the figure is about 1 percent.

    American midwifery groups and out-of-hospital birth advocates like The Big Push for Midwives have already questioned the findings of the AJOG article.

    The Coalition for Improving Maternity Services called the report a "poorly designed and methodologically unsound study," expressed itself "outraged" that AJOG accepted it for publication, and suggested the report was rushed on-line as a ploy to stop legislation then pending (since signed into law) in New York that will make the practice of midwifery easier in that state.

    "Pregnant Graffiti" by Petteri Sulonen