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).

Fathers changed birth story — and parenting

Fathers who pushed to be included in their children's births beginning in the 1950s have brought real change to the modern birth, according to historian Judith Walzer Leavitt's 2009 book Make Room for Daddy.

Buoyed by changing perceptions of how men should function in society, fathers have created "unprecedented new roles for themselves in a traditionally women's event"  and have "helped to make hospitals more flexible in how they handled birth," Leavitt writes.

Dads' participation in birth has helped to break down the "mystique of modern medicine and further opened the world of obstetrics to lay participation and interpretation," she writes.

Fathers often report that witnessing a child's birth is one of the best experiences of their lives.

"It was better than any game I've played or any big hit I've had," said Ian Desmond, the Washington Nationals' shortstop who recently took advantage of Major League Baseball's new paternity leave to attend the birth of his son, Grayson.

However, the journey has not always been easy for men, who in their public lives often are far more in control than they feel attending the birth of one of their own children.

Leavitt quotes the writer Stephen Harrigan, who wrote in Reader's Digest in March, 1979, about attending the birth of his son. Before the birth, Harrigan worried that he would be no more than a spectator metaphorically holding out Gatorade to his wife, the "athlete who would finish the race."

Harrigan found the experience to be more profound and involving than he expected, but some other fathers feel "at sea, abandoned and out-of-control" at birth, Leavitt writes.

Some fathers cringe at the idea of watching their wives in pain or perhaps fear the experience will damage the desire they feel for their wives. Fathers attending birth are now so ubiquitous that a reluctant dad may well feel pressured to go.

Nevertheless, men's foray into the birth process, which may begin with their attending prenatal classes, has led to their increased participation in their families' lives and experiences, compared with those 1950s dads who began the process, Leavitt writes.

Dads who don't attend their children's birth lose a crucial opportunity, according to researcher Jessica Weiss, who goes so far as to say they risk having "missed the boat of shared parenting."

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


Birth Story’s first year: My favorite posts

And so we bid adieu to 2010, Birth Story's first year of life.Happy baby

My Birth Story blog began on Jan. 3 of this year, and this is my 151st post, so I came very close to my goal of posting three times a week.

I have learned a lot. People like compelling stories, posts about history, about medical pioneers, and about advances in the field of obstetrics, “the art and science of managing pregnancy, labor and puerperium (the time after delivery).” They also like stories about celebrities — what a surprise!

Having written about the posts readers liked best, now I would like to showcase some posts from 2010 I especially like. I am really proud of the work I have done on Birth Story, and I like many of the readers' favorites too, but these additional posts are also worth an extra look.

What were your favorite Birth Story posts? I would love to hear from you. Here are a baker's dozen of mine:

1/22 The basics of birth safety

1/27 A Cesarean section in Philadelphia

2/5 A health consumer's BFF

2/22 Pregnant women and drug trials

4/23 To the Lighthouse

5/7 The mothers of Johns Hopkins Medicine

5/14 Riddle me this

6/18 The other Flexner

6/21 Being there

8/18 We dream for our children

8/26 Breast-feeding story: Maeve

11/17 Practical magic

12/22 Your birth plan, courtesy of The Bloggess