Birth Story

Who doesn't love them? Aren't curiosity and a desire to improve the human condition two of the most interesting traits a person can display?

Paul de Kruif's 1926 book, Microbe Hunters, is an  early, influential collection of some great medical detective stories, 12 important successes in the field of microbiology, which were achieved by extraordinary medical detective work.

Microbe Hunters dramatizes the journeys, among others, of  Anton van Leeuwenhoek, the first microbiologist; Sir David Bruce, who traced African sleeping sickness to the tsetse; and Walter Reed, who led the team that discovered that yellow fever is caused by mosquitoes.

Medical historian William Summers was one of many dazzled as a teen-ager by the book, which he says "inspired a generation or more of budding young microbiologists."

Microbe Hunters has sold millions of copies and is still in print, but from a modern perspective, the book is flawed -- De Kruif presents detailed conversations between historical figures, for example.

Even when it was written, the book had its detractors, Summers writes. Ronald Ross, a researcher who won the Nobel Prize in 1902 for identifying the parasite that causes malaria, describing its life cycle and explaining how it comes to infect human beings, successfully sued to prevent publication in the United Kingdom of the chapter about his work.

But De Kruif was one of the most successful medical science writers of his time, and when readers take up a book like Richard Preston's The Hot Zone, about the Ebola virus, they are reading an account profoundly influenced by Microbe Hunters.

The conquest of infectious disease is important to obstetrics.  Infection was the leading cause of maternal mortality until well into the 20th century -- and it still is in many parts of the world.

Dr. Howard A. Kelly

In 1888, nine years after Robert Felkin brought back his amazing story from Uganda, Dr. Howard A. Kelly of Philadelphia, a brilliant young obstetrician who would go on to help found the medical school at Johns Hopkins University in Baltimore, announced at a convention of the fledgling American Gynecological Society that he had performed the first successful Caesarean section in Philadelphia in 51 years—that is, the mother had survived the operation.

Very few members of the audience he was addressing that day had ever attempted even one Caesarean section because, at the time, the procedure virtually always ended in the mother's death.

What do women need when birth becomes difficult? The Averting Maternal Death and Disability program has identified a handful of intervention capabilities that should be in place for emergencies wherever babies are born.

These "signal functions" include having personnel on hand who are trained to administer drugs by injection -- antibiotics, anticonvulsants and "oxytocics," which can start or speed labor -- manually remove the placenta and other "products of conception" not leaving the body spontaneously, and perform assisted vaginal delivery -- with forceps, for example.

AMDD, a major initiative of the Mailman School of Public Health at Columbia University in New York City,  has worked with UNICEF and other partners for 20 years to bring down maternal-mortality rates in the developing world.

Its directive, issued in 1997, cites two additional interventions that might be necessary to save lives -- Caesarean section and blood tranfusion. These two go beyond the basics of a birth center -- in some parts of the world they are strictly wish-list items -- but they can often make the difference between life and death, as they did in our case.

AMDD doesn't include anesthesiology in its signal functions, although surgery is difficult without it.

We in the United States might view these interventions as humdrum, or even as irksome or worse if they become part of our own birth story, but behind the development of each one of them are amazing tales.

Amniotic fluid embolism was first identified in 1926, but it still isn't fully understood today.

AFE is rare, unpredictable and unpreventable, accounting for between 5 and 10 percent of maternal mortality in the United States, and is likely triggered when amniotic fluid enters the bloodstream. However, by no means every woman who gets amniotic fluid in her bloodstream suffers an AFE.

Some estimates have AFE occurring anywhere from 1 birth in 8,000 to 1 in 30,000, with mortality running as high as 80 percent. Many women who survive AFE suffer life-altering brain damage.

A study published in the American Journal of Obstetrics & Gynecology in 2008 found AFE occuring in about 7.7 of every 100,000 births -- that's about 1 in 13,000 births, which makes it a rare event -- and still killing more than one in five mothers it strikes.

The authors of the AJOG article found associations between AFE and mothers older than 35, Caesarean births and "placental pathologies" like placenta previa, in which the placenta attaches low in the uterus, where it can cause hemorrhaging and other complications during a pregnancy.

However, the study did not find an association with artificial induction -- the use of drugs like Pitocin to start or hurry up labor.

AFE displays a cascade of symptoms that can include cardiac arrest and disseminated intravascular coagulation, or DIC for short. During a DIC, a person's clotting factor is deployed all at once, after which hemorrhage can ensue. A mother can die from these events and so can a baby who is still in the womb -- the saddest birth story of all.

See the figure below on the right? It’s called a tangent bundle, which means something to mathematicians. To me, it’s a circle with many tangents, or lines that go off in different directions.

That is how I envision my new blog, Birth Story — a purposeful exploration bristling with side trips. When Birth Story, the book, comes out (sooner rather than later, I hope), I don’t want you, dear reader, to say, “Hey, I already read all this on her blog!” I want you to say, “This is so interesting! I didn’t know any of this!”

So the blog Birth Story will present stories, factoids, hypotheses and other musings that have come out of the research for my book but probably won’t appear in it. They will be interesting (I hope), relevant (more or less) and guaranteed to make us all smarter about the progress medical science has made in making it possible for women to survive difficult births.

The central topic here at Birth Story is obstetrics, defined as “the art and science of managing pregnancy, labor and puerperium (the time after delivery).” For the most part, I will be investigating the approach Western mainstream medicine takes to birth.

In addition to sharing stories I have come across doing research for my book, I am also looking forward to commenting on current events, reviewing the odd book and responding to readers.

Let the blog begin!

Image by permission  http://creativecommons.org