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

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.

Making a difference in maternal mortality

It isn't that childbirth is more inherently dangerous in countries where many women die in childbirth than in those where relatively few die. The women who survive, statistically speaking, are getting appropriate help from trained attendants.

"...The main complications that lead to death during pregnancy or childbirth are fairly common among all women, regardless of where they live," write the authors of an article titled "Are We Making Progress in Maternal Mortality?" in the May 26 issue of the New England Journal of Medicine.Pregnant Graffiti

Hemorrhage, which most often occurs right after birth, is the leading cause of pregnancy-related deaths globally, accounting for 35 percent of all deaths in childbirth, according to the World Health Organization. And in fact, hemorrhage was the second most common complication seen in pregnancies in the United States in 2000.

However, most U.S. women who suffered hemorrhage were treated quickly, and survived, say the article's authors, Anne Paxton and Tessa Wardlaw.

WHO identified the second most common cause of maternal death as hypertensive disorders — pre-eclampsia/eclampsia, for example. Again, these disorders are a common problem all over the world, but women with access to good medical care have a good chance of surviving them.

The countries that are most dangerous for pregnant women are those suffering through wars, or burdened with a large population with HIV/AIDS, the authors write.

In general, poor women die in childbirth more often than affluent ones, rural women more often than urban ones. These populations are more vulnerable because they often deliver their babies without the benefit of skilled birth attendants, and lack access to obstetrical services like surgery by Cesarean section.

Sub-Saharan Africa, with widespread political unrest and HIV/AIDS infection, "has the greatest burden of maternal mortality," even though most countries there are seeing "small but promising" decreases in pregnancy-related deaths.

Worldwide, there is considerable cause for hope, Paxton and Wardlaw write. Maternal mortality has decreased globally by more than one-third since 1990, according to United Nations estimates.

"Dramatic improvements in China and other Asian countries...are associated with economic improvement, decreasing fertility rates and strengthening of health systems...," the authors write.

"The overall rate of decline in global maternal mortality, 2.3 percent, is lower than the 5.5 percent MDG target but is heartening nonetheless," they write.

Image: "Pregnant Graffiti" by Petteri Sulonen


Leapfrog: Early elective births are common

The Leapfrog Group, a 10-year-old hospital monitoring group, has found that doctors and hospitals are commonly scheduling women for elective deliveries before 39 weeks of gestation, even though studies have established a bright arrow that shows that babies are at risk of death or serious health problems if they are born before then.

A survey of 773 hospitals released this week shows that these institutions performed more than 57,000 inductions and Cesarean sections before 39 weeks just in the last year. The hospitals displayed a wide range of rates for early elective deliveries, from less than 5% to more than 40%.

"Leapfrog’s release of 2010 data is the first real evidence that the practice of scheduling newborn deliveries before 39 weeks without a medical reason is common and varied among hospitals even in the same state or community," the report stated.

The brain and lungs aren't fully developed until the very last weeks of pregnancy, said Alan R. Fleischman MD, senior vice president and medical director of the March of Dimes, a group that works to prevent birth defects, and is working with Leapfrog to cut the numbers of early births.

“Women need to protect themselves by refusing to schedule their deliveries before 39 weeks without a sound medical reason, and by knowing the facts about the hospitals they plan to deliver in,” said Leapfrog CEO Leah Binder.

Some hospitals, notably Hospital Corporation of America, have programs in place to encourage doctors to refrain from scheduling Cesarean sections and elective inductions for nonmedical reason, Leapfrog officials said.

ACOG: Still down on home births

The American College of Obstetricians and Gynecologists came out once again this week cautioning against home births.

Hospitals and birthing centers are the safest place for labor and delivery, the speciality organization of obstetricians stated in a committee opinion on Thursday.

A prior Cesarean delivery "is an absolute contraindication to planning a home birth due to the risks, including uterine rupture," the statement said. Twins, breech babies and pregnancies that have gone beond 42 weeks are not good candidates either — too risky for the babies, ACOG said.

"Home births don't always go well, and the risk is higher if they are attended by inadequately trained attendants or in poorly selected patients with serious high-risk medical conditions such as hypertension, breech presentation, or prior Cesarean deliveries," said Richard N. Waldman MD, ACOG's president.

This is the latest in a long line of statements the group has made cautioning against the less than 1 percent of  American births that take place at home.

Even so, ACOG does want women to know that if they decide to deliver their babies at home, they should get the "standard components of prenatal care, including Group B strep screening and treatment, genetic screening, and HIV screening."

And, they should work with a birth attendant who is part of "an integrated and regulated health system, have ready access to consultation, and have a plan for safe and quick transportation to a nearby hospital in the event of an emergency," the statement said.