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Her Survival Was a “Christmas Miracle,” but the Disaster Was Man-Made

Many of you will have read the story of the woman laboring on Christmas Eve who suddenly went into respiratory and cardiac arrest in front of her horrified husband. She recovered shortly after her son was delivered by emergency cesarean, and the baby, too, was successfully revived. As the MSNBC article tells the tale:

After their miraculous recovery, both mother and the baby, named Coltyn, appear healthy with no signs of problems, Martin [the obstetrician who responded to the Code Blue and performed the emergency cesarean] said. She said she cannot explain the mother’s cardiac arrest or the recovery. “We did a thorough evaluation and can’t find anything that explains why this happened,” she said. Mike Hermanstorfer credits “the hand of God.”

However, an ABC video interview with Tracy and Mike Hermanstorfer and Dr. Martin provides details that call into question the hospital’s failure to find an explanation. I have transcribed the relevant section.

Tracy: [Tracy was being induced for her third child because membranes ruptured.]The pains [with Pitocin] were a lot harder than I remembered. We decided to go ahead and do the epidural for the very first time. . . .

ABC: Mike, you were holding her hand as Tracy got the epidural. . . . When did you start to notice that there was a problem occurring?

Mike: Well, we had her sitting up when they were doing the epidural and afterwards she lay down and said that she was tired and that’s when the whole nightmare started.

ABC: What happened?

Mike: She started going numb and everything in her legs . . . and she laid down to close her eyes and take a little nap . . . and she wasn’t waking up.

ABC: When did you notice that her breathing was shallow or her color was blue?

Mike: Well, I felt her hand—I was holding her hand—and it started getting cold and I looked down at her fingertips and her fingertips were blue and one of the nurses noticed that the color in her face was completely gone. She was as gray as a ghost.

ABC: Code Blue was declared, a scary thing in any hospital. [Dr. Martin arrives in response.]

Dr. Martin: . . . When I ran into the room, the anesthesiologist had already started breathing for Tracy. There were preparations already being made to start a resuscitation should her heart stop. About 35 to 40 seconds after I got in the room, her heart did stop and we started making preparations to do an emergency cesarean delivery right there in the room in the event that we were not successful in bringing Tracy back. Unfortunately, in most of these situations, despite the best efforts of the team, Mom is often not able to be revived, so we anticipated that possibility and when it became clear that Tracy was not responding to all the work that the team was doing on her, we had to make that difficult decision to do the cesarean section, primarily in an effort to give Coltyn the best chance at a normal survival and also hoping that it would allow us to do a more effective resuscitation on Tracy, and fortunately, she cooperated and we got a heartbeat back immediately after delivering Coltyn.

So, according to Dr. Martin, Tracy is an example of how things can go suddenly and horribly wrong for no discernable reason in a healthy woman having a normal labor. All I can say is that Dr. Martin must have slept through the class on epidural complications. Tracy’s story is the classic sequence that follows what anesthesiologists term an “unexpectedly high blockade,” meaning the anesthesiologist injected the epidural anesthetic into the wrong space and it migrated upward, paralyzing breathing muscles and in some cases, stopping the heart. High blockade happens rarely, and even more rarely does it result in full respiratory and cardiac arrest—one database analysis of 11,000 obstetric epidural blocks reported a rate of 1 in 1400 women experiencing a high block and 1 in 5500 requiring intubation, and no woman experienced cardiac arrest. It does happen, though, and I am willing to bet that high blockade and its sequelae happened to Tracy.

The moral of the print version would be: have your baby in a hospital where you can be saved should this happen to you. The video interview, however, reveals a different picture. The real moral of the tale is that the safest and healthiest births will be achieved by avoiding medical intervention whenever possible. Induction of labor is by no means always necessary when membranes rupture and certainly not immediately. If Tracy had been allowed to start labor on her own, which, considering that this was not her first baby, she would likely have done within a few hours, she probably wouldn’t have wanted the epidural any more than she did for her first two children. Tracy almost certainly would have gone home the day after Christmas after another uneventful, unmedicated vaginal birth. Instead, she is recovering from surgery, and she and her husband have the emotional trauma of her and her son’s near miss experience to deal with. Along with the Hermanstorfers, we can thank God for the prompt actions of the hospital team, but the safe money says they were rescuing her from a disaster they themselves had caused.

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  1. January 5th, 2010 at 19:56 | #1

    Unrelated to the topic of our pitocin/oxytocin discussion but very relevant to the topic of how much evidence there is behind ideal practice: when you were a practicing OB, what was your episiotomy rate? Routine prophylactic episiotomy was brought into practice without good supporting evidence. So did you avoid it, using it only for fetal emergencies? In that case, I’d expect your rate to be in the low single digits.

    The move away from routine episiotomy is a great example of how the theories that may not have immediate scientific proof are still worth listening to and, sometimes, following up on, because sometimes (not always!) they are right.

  2. January 5th, 2010 at 20:25 | #2

    “Routine prophylactic episiotomy was brought into practice without good supporting evidence.”

    Liz, have you ever heard of the “fallacy of the lonely fact”? It is a logical fallacy often used as an “argument.”

    Consider:

    Jane: Australians are thieves.
    John: Can you prove that?
    Jane: Are you saying that no Australians have ever stolen anything?

    Jane has committed the fallacy of the lonely fact. Knowing that at least one Australian has stolen something, she has concluded that all Australians are thieves. The example of the Australians shows that it is an absurd “argument” but it is a favorite of “natural” childbirth advocates.

    For example:

    NCB Advocate: Obstetrics is not evidence based.
    Me: Can you prove that?
    NCB Advocate: Are you saying that no principle of obstetrics has ever been proven wrong? Look at what happened with episiotomies.

    The reasoning is based on the assumption that a specific example tells us something about the whole. The fact that episiotomies were used even though scientific evidence later showed them to have no benefit is used to justify the assumption that everything in obstetrics is used even though there is no scientific evidence to support it.

    The fallacy of the lonely fact is a fallacy because it is based on the assumption that a specific example (episiotomies, for instance) can be generalized to the every possible example (all of obstetrics). Just as the fact that one or even more than one Australian stole something doesn’t make all Australians thieves, a single example can never be assumed to apply universally. So if you are invoking episiotomies to discredit obstetrics, you’ve chosen a fallacious argument.

  3. January 5th, 2010 at 22:09 | #3

    Dr. Amy, (sigh, can’t believe I am doing this)

    “Modern” obstetrics has also had routine high forceps deliveries with an episioproctotomy (what an older academic ob/gyn I know said was the norm when he trained…and he still sees it as an ideal), twilight sleep, DES, thalidomide, enemas, shaving, banning family support from the room…need I go on?

    Modern obstetrics is not infallible, and does better when it is examined critically. Dr. Archie Cochrane started what ended up being the Cochrane Database because he thought obstetrics was so poorly based on evidence. It is not infallible. Its history of problems is not a “lonely fact”. Why does examining obstetrics critically scare you so much?

    If you are interested in logical fallacies, you should look up “Straw man arguments”. I have mentioned this habit of yours to you previously, a few times.

    The original post is about a major complication of epidural (intubation is a big deal) whose absolute risk is higher, yet very similar to that catastrophic (leading to fetal death) uterine rupture during VBAC, which you have repeatedly called too risky.

    Who is distorting risks again? Both are absolute risks (of the eligible population) of less than 1 in 1000 (the catastrophic rupture risk is 1 in 2400). Epidurals are a lot more common than VBACs. However, there are other documented medical benefits to trial of labor with VBAC, and other documented risks to repeat cesareans, and other risks to childbirth, period. Is there documented risks to not getting an epidural? Is there documented medical benefit to getting one?

    There are a lot more risks to epidural anesthesia than a high blockade. I am not saying they should be banned. I am arguing for it to be treated like an elective medical procedure with risks. It’s not a radical proposal. Why do you have to pretend it is? It should not be a moral crusade on either side.

    I have personally sat through several cases of so called “informed consent” for an epidural when the entire explanation of risks was “it won’t hurt you or your baby.” I had an anesthesiologist storm off when I asked how common blood pressure drops are, in his experience. I was honestly trying to reassure the couple, who were there on a homebirth transfer and were terrified of the epidural, and were specifically worried about the blood pressure issue. I expected the anesthesiologist to say he does these all the time, and the women were generally fine. I guess he didn’t want to say that to them. I can’t guess his reasons why.

    Look, these are anecdotal studies, but what is your point, Dr. Amy? Obstetrics, doctors, anesthesiologists and midwives are not infallible. Obviously there are different opinions out there on how to improve obstetrics. I know we don’t see eye to eye, but downplaying the very real risks of epidurals is not going to improve obstetrics, especially if it’s only to make it fit in with your point of view to what are acceptable risks (interventions that increase the control balance to the physician) as opposed to unacceptable risks (increasing the autonomy of the patient).

  4. January 5th, 2010 at 22:33 | #4

    @Liz Chalmers

    “#3. I intentionally used the example of pit given before labor has started. In that scenario, there must surely be a period of time when natural OT production in the brain is lower than normal because when the pit starts to flow, normal OT production will be practically zero. I agree that we don’t know when and if it rises to normal levels at some point, but there has to be a lag at least. Using my once-again-anecdotal personal case, when they turned down the pit because my baby was showing signs of distress, my labor stopped and didn’t restart till they turned the pit back on. That would suggest that my brain was still not producing normal oxytocin levels, and this was far into my labor (8cm+)”

    Just to fill in here -

    Receptors for pitocin decrease in number rapidly in the presence of higher and higher levels of blood pitocin. This is why we need to increase pitocin drip rates over time to achieve the same effect. This effect on pitocin receptors has been demonstrated in myometrial cells in culture using fluorescently labeled pitocin receptors in in vivo cultures.

    When you were on pitocin for many hours, the receptors became fewer. Once the pit was taken off, the natural amount of pitocin wasn’t enough to adequately stimulate contractions, and so they stopped. Given enough time, the release of negative inhibition would have led to a repopulation of pitocin receptors and resumption of labor. Restarting exogenous pitocin got the same thing done in less time.

    The idea of ligand/receptor action is common throughout molecular biology and human physiology. We describe the relationship between blood level of a ligand (the pitocin) and the effect as “Km”. As Km rises, it takes more ligand to cause a certain amount of action. Exogenous pitocin, by downregulating pitocin receptor function over time, raises Km over time.

  5. January 5th, 2010 at 22:37 | #5

    @Liz Chalmers
    Or to summarize – your brain was still making oxytocin (Pitocin – same thing Pitocin is a brand name), it just wasn’t enough at that time.

  6. avatar
    Patsy
    January 5th, 2010 at 22:37 | #6

    @MomTFH
    No. “Modern” obstetrics has eliminated high forceps with episioprototomy by doing C-Sections. Which do you think is preferable?

  7. January 5th, 2010 at 23:35 | #7

    MomTFH,

    Since you are a medical student, I will share with you the most important thing I learned in my training:

    Assume nothing, trust no one, check everything.

    You’ve made insupportable assumptions and you’ve checked nothing.

    I know that Henci Goer is convinced that the arrest was caused by a high block from epidural. It is certainly possible, but it would not be the first thing in my differential because the presentation was different than expected. Typically with a high block, the patient complains of difficulty breathing and may have difficulty speaking. Feeling tired and passing out is not a classic presentation.

    Such a presentation suggests that it could have been an amniotic fluid embolus, a pulmonary embolus or a cardiac defect. So we really have no idea what happened.

    “Modern obstetrics is not infallible”

    That would be a relevant point if I had claimed it was infallible, but I haven’t.”

    “Who is distorting risks again? Both are absolute risks (of the eligible population) of less than 1 in 1000 (the catastrophic rupture risk is 1 in 2400).”

    They are not similar risks; they take place in entirely different settings and they have different outcomes. As Goer herself pointed out, in a series of 11,000 cases, only two women needed intubation and none had a cardiac arrest. Moreover, epidurals are placed by anesthesiologists, the exact same people who can immediately treat a high block.

    In contrast, in 11,000 VBACs we would expect something like 50 ruptures and 2 or more neonatal deaths, not to mention blood transfusions and hysterectomies. And unlike the situation with epidural and high block, the appropriate rescue personnel might not be present and certainly would not be present at a homebirth.

    “I am arguing for it to be treated like an elective medical procedure with risks.”

    Do you argue that the treatment of pain from 3rd degree burns is an elective medical procedure with risks? Opiates have very real risks, both short term and long term. Are you planning on standing in front of burn patients and trying to persuade them to “work through” the pain in order to avoid the risks of opiates? You need to be VERY careful to keep your judgmental attitude about the “value” of labor pain to yourself when you counsel women about pain relief and risks.

    As feminist critics of the “natural” childbirth movement have written:

    “… [T]he tendency of ‘birth junkies’ to valorize the experience of natural (i.e. painful) childbirth is not only moralistic, but unrealistic… The idea that women do (or should) savour, enjoy, or feel empowered by the experience of labour and delivery … assumes an emotional and physical reality (or posits an emotional and physical norm) that does not exist for many…”

    And:

    “In short, some feminists perceive the alternative birth movement as rigid and moralistic, insistent that giving birth ‘naturally’ is superior and, indeed, is a measure of a ‘good mother’. The perceived moralism of this stance is quite troubling to some; according to one feminist critic, the ‘natural’ philosophy … is as tyrannical and prescriptive as the medical model, but pretends not to be by emphasizing women’s right to individualized and alternative births.”

    I find your attitude toward pain relief in labor to be inappropriately rigid and moralistic. Don’t confuse your personal opinions with scientific evidence. Patients are entitled to scientific evidence. You should keep your personal opinions to yourself.

    Stop pretending that you are rescuing women from their ignorance. You don’t know enough and it is not your place to “rescue” anyone. It is not your job to judge whether women should or should not have pain relief in labor, just like it is not your job to determine if a woman should or should not have an abortion or whether a woman should or should attempt to get pregnant. If you think it is, you don’t belong in medicine.

  8. avatar
    cinnemonn
    January 6th, 2010 at 00:48 | #8

    I see Amy has still avoided providing her stats on 1 in 13 women would die if it weren’t for “modern obstetrics”. Which means she can’t find it. Which means you can’t believe a word that she says. She throws around a bunch of statistics and cries “show me proof” when one writes something that challenges her views but refuses to show her own proof… instead uses “look it up yourself”. Which really says she can’t even back up her argument. I used to read her site but when people would intelligently provide a challenge to her ideas she would then ban them and delete their posts. Meanwhile she attacks people and is rude even though the others would be respectful to her.

    I appreciated Henci’s article and feel that it is important to get the information out there that interventions are not risk free as what is often told to women in my area by the medical community. As a doula I provide the information and let my clients choose for themselves. I don’t tell not to get an epidural, nor do I tell them to get one. However, I don’t pat their hand and say everything will be alright either.

    As your advice to the medical student, Amy, I also trust no one. Not even my doctor as, unfortunately, some have an agenda and do not really have my best interest at heart. The variety in care from doctor to doctor is great. As a Doula I’ve seen doctors be very open and flexible in the mother’s desires for her birth. In a couple examples one said he’d delivered babies in the shower before, let the mom push in the position she desired whereas another OB,for another client, was adamant that the mother push on her back even though she was doing extremely well on her hands and knees.

    Part of the problem today is all of these large practices where women can’t even choose what OB will be around for their birth. They may find they trust and like on OB but may have the one they hate attending their birth.

  9. January 6th, 2010 at 07:19 | #9

    cinemonn,

    “I see Amy has still avoided providing her stats on 1 in 13 women”

    Hardly. I’m merely ignoring you.

    “I also trust no one.”

    Yes, well without the other two components, that’s merely paranoia. If you remember, the other two components were “assume nothing” and “check everything.” Instead you checked nothing and assumed whatever you felt like.

    Google “lifetime risk maternal death” See the many entries? Read them. Some say that the lifetime risk of maternal death in countries without modern obstetrics is as high as 1 in 8. I chose to use the numbers of the Population Reference Bureau.

  10. January 6th, 2010 at 08:59 | #10

    @Amy Tuteur, MD

    No, not at all either an amniotic or pulmonary embolus…

    The symptoms associated with an amniotic embolus and/or a pulmonary embolus include difficulty breathing/shortness of breath, respiratory distress, chest pain, anxiety, cough, sweating, and passing out.

    The patient we are all discussing here did not have these symptoms.

    The husband reported that his wife said she was tired and wanted to take a nap and that soon after that she went cold, blue, and wasn’t breathing.

    All four major complications of epidural anesthesia: hypotension, high
    block or blockade, anaesthetic toxicity, and total spinal include light-headedness, dizziness, feeling faint, passing out, and etc. in their symptoms.

    In fact, in the case of a high block, “Difficulty in talking (small tidal volumes due to phrenic block) and drowsiness are signs that the block is becoming excessively high and should be managed as an emergency.”

    And, in the case of a total spinal, “The result is profound hypotension, apnoea, unconsciousness…”

    Update in Anaesthesia, Issue 13 (2001), Article 11: Page 4 of 4, Epidural Anaesthesia

    While we can not conclude unequivocally that this was an anesthesia-related emergency, it is highly suspect simply based on the known information and the known complications associated with use of epidural anesthesia.

    This does not mean that laboring women should not have epidurals. I don’t believe that Henci Goer nor any other natural/normal birth advocate believes that.

    What Henci Goer’s point was is that had this mother’s normal laboring process NOT been intervened upon in the first place (pitocin due to ROM), she may have very simply labored on to birth naturally without requesting an epidural (she hadn’t had one for either of her other two previous births) and would likely NOT suffered the tragic events clearly related to an anesthetic complication.

    There is plenty of evidence in obstetrics about the iatrogenic effects related to unnecessary interventions. The fact that Dr. Amy wants to dismiss the use of obstetric interventions as the fault behind the complication only serves to discredit any “authority” she thinks she has on the issue.

    I think the biggest red flag of all is that Dr Amy doesn’t practice obstetrics anymore…

    I think so she should just stop talking. Because no one is listening.

  11. January 6th, 2010 at 09:08 | #11

    “What Henci Goer’s point was is that had this mother’s normal laboring process NOT been intervened upon in the first place (pitocin due to ROM), she may have very simply labored on to birth naturally without requesting an epidural (she hadn’t had one for either of her other two previous births) and would likely NOT suffered the tragic events clearly related to an anesthetic complication.”

    And that is an assumption that is unjustified. That’s my point. Without an accurate timeline, measurements of vital signs, knowledge of what went into the epidural catheter and when, no one really knows.

    “Because no one is listening.”

    Another bit of wishful thinking. I’ve heard that in the first two days I participated in this thread, this blog had more traffic than in the entire previous month.

  12. January 6th, 2010 at 10:33 | #12

    Another bit of wishful thinking. I’ve heard that in the first two days I participated in this thread, this blog had more traffic than in the entire previous month.

    And I’m sure Henci Goer & Amy Romano and any others affiliated with this site are very appreciative as every hit pushes them ever higher in the google rating. But that doesn’t mean they’re listening to *you*.

    It’s true that we need “an accurate timeline” — How long after an epidural is placed is a urinary catheter inserted? Immediately, or an hour afterwards? The consistent testimony is that the mom got the epidural and was getting the catheter (presumably urinary) inserted when she passed out. Also, how long does the anesthesiologist hang around after placing an epidural? I ask that, because he was still there when she coded, and began bagging, which indicates to me at least, that it was likely fairly quickly after getting the initial epidural. Not having had one, however, I don’t know how long an anesthesiologist is usually there post-epidural. While we don’t have access to her medical records with a precise minute-by-minute account, facts such as these can help to create a timeline.

    Also, what *exactly* is under consideration when you use the term “modern obstetrics”? You use that term freely but never define it, leaving it open to interpretation. Some clarification would be appreciated.

    Oh, and to clarify the 1/13 or whatever comment — that refers to a lifetime risk of dying, not saying that 1 out of every 13 women dies in childbirth. You left that unclear, which might have been confusing. The worst MMR is I think Sierra Leone which was 2100/100,000 in 2005, which is 1/48, and most countries have far lower MMRs. Sure, some of that is undoubtedly due to a lack of C-sections and other medications; but maternal mortality includes more than death during childbirth, but any maternal death (defined as the death of a woman while pregnant or up to either 42 days or 1 year after the end of her pregnancy, whether by abortion, miscarriage, stillbirth, or live birth) except those due to accidental (e.g., car wreck) or incidental (e.g., boyfriend killing her for not having an abortion) causes. Unsafe abortion (either legal or illegal) count, as do deaths due to AIDS and malaria, since pregnancy can exacerbate these conditions. Girls having children before their pelvic structure matures and grows to its full potential, girls and women with pelvic malformations due to rickets or other causes, malnutrition, female genital mutilation, and other causes also play into this. While “vaginal bypass surgery” could be performed to save some of these girls and women, that doesn’t address the real causes, nor does it provide a long-term cure. And, as I’m sure you’re well aware, in a country that doesn’t have money for antibiotics or sterile places for surgery, C-sections may be more harmful than beneficial. Oh, well, “let them eat cake,” eh?

  13. January 6th, 2010 at 11:19 | #13

    @Amy Tuteur, MD

    “And that is an assumption that is unjustified. That’s my point. Without an accurate timeline, measurements of vital signs, knowledge of what went into the epidural catheter and when, no one really knows.”

    Oh come on, Dr. Amy… are you THAT ignorant of being able to discern this mother had an anesthesia complication? She CODED within a matter of just a few minutes of receiving an epidural! It doesn’t take a chart review to see the writing on the wall.

    No one is assuming anything. We are simply talking about the KNOWN RISKS of epidural anesthesia and the FACT that this mother, prior to receiving an epidural was FINE. And yet, during the procedure while the anesthesiologist was still with her, she stopped breathing and he had to begin CPR (rescue breathing) for her. The doctor responding to the emergency stated that within less than a minute after his arrival in the room, the mother was in cardiac arrest. We don’t need to know what drug the anesthesiologist put in the catheter to discern that the mother’s REACTION to receiving that drug (or the dose, or the placement of it) it was abnormal! No, we don’t have all of THOSE facts, but we don’t need them to have an intelligent decision about risk.

    No one blames the anesthesiologist for the complication. But we must acknowledge that such an event must NOT be merely swept under the rug with statements like Dr. Martin’s (the surgeon in the article),
    ““We did a thorough evaluation and can’t find anything that explains why this happened,”

    What does “thorough evaluation” mean? It means that no one from the hospital will take responsibility for the FACT that this mother had an anesthesia complication. It is likely that a thorough INVESTIGATION will bring out facts that support this hypothesis.

    See: http://www.nda.ox.ac.uk/wfsa/html/u13/u1311_04.htm

    Kim Mosny, CPM, LM
    Home Birth Midwifery Service
    http://www.RichmondMidwife.com

  14. January 6th, 2010 at 11:21 | #14

    “Another bit of wishful thinking. I’ve heard that in the first two days I participated in this thread, this blog had more traffic than in the entire previous month.”

    Amy… don’t you get it??

    No one is listening to YOUR ramblings.

    The huge amount of traffic on this thread are heavily weighted on the side of supporting Henci Goer’s article. The interest in this article is NOT because anyone here is standing up to defend or support your antiquated opinions. You stand quite alone in your rhetoric about obstetric interventions being the REASON birth is safer for today’s mother. HOGWASH.

    Kim Mosny, CPM, LM

  15. January 6th, 2010 at 11:21 | #15

    “And I’m sure Henci Goer & Amy Romano and any others affiliated with this site are very appreciative as every hit pushes them ever higher in the google rating. But that doesn’t mean they’re listening to *you*.”

    Oh, the irony! Didn’t you write a post only a week ago entitled “Open Letter to Dr. Amy” attempting to drive traffic to your site?

    “It’s true that we need “an accurate timeline”

    You and other lay people need far more than that. You need an understanding of the differential diagnosis of loss of consciousness during labor. You have no idea what the other possible causes are and no way to judge what is most likely.

    Do you remember the story of Carri, the mother of 8 who mistakenly thought she was pregnant with twins, and collapsed during her homebirth. Her husband’s description of what happened is very similar to the husband’s description in this case.

    Do you remember the diagnosis? It was a presumed amniotic fluid embolus.

    Do you remember how homebirth advocates responded? They rushed to exclaim that AFE is rare, that is can happen in a hospital, that no one can predict it.

    The outcome was different, though, wasn’t it? By the time Carri’s was transported to the hospital, the baby was dead, and Carri spent time in the ICU near death.

    So how do you know that this woman didn’t also experience an amniotic fluid embolus? You don’t.

  16. January 6th, 2010 at 11:24 | #16

    “No one is listening to YOUR ramblings.”

    The people who comment are only a small fraction the thousands who have read the post and comments.

    As I said before, I have no hope of reaching those who make decisions based on their personal beliefs. I write for those who understand science and statistics, which, of course would involve far more education than the pathetically inadequate CPM certification.

  17. January 6th, 2010 at 12:26 | #17

    Amy Tuteur, MD :
    “No one is listening to YOUR ramblings.”
    The people who comment are only a small fraction the thousands who have read the post and comments.
    As I said before, I have no hope of reaching those who make decisions based on their personal beliefs. I write for those who understand science and statistics, which, of course would involve far more education than the pathetically inadequate CPM certification.

    Well, well, well… Amy, how rude and unprofessional you are!
    But we already know that about you, Amy, don’t we!

    I don’t think I will refer to you as “Dr” anymore, as you certainly don’t merit the title just because you have MD after your name. Referring to one as “Doctor So-and-So” connotes a level of respect for the INDIVIDUAL who has attained the title, and the observance of one’s professional credential as being held in high esteem.

    Bwah ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha!!!!
    YOU, Amy, are pathetically inadequate. You certainly don’t earn
    anyone’s respect with such an unprofessional attitude.

    And here you go again, bashing the CPM credential, is if any one of us wants to hear your biased, unscientific, statistically-proven WRONG opinion about it to begin with!

    So… my credential is painfully inadequate, huh? Says you!

    Tell us, WHY aren’t YOU practicing obstetrics anymore?
    Yes, Amy, please, tell us why?

    After 16+ years as a home birth midwife, the latter 10 with the CPM credential, I am STILL catching babies at home.
    I am a LEGAL practitioner, licensed in my state of Virginia.
    Having just recently moved to VA, I have a VERY busy practice, my client load is TWICE as busy as my former town in TN.
    I have physician collaboration for ALL my mothers and babies.
    My transport rate is about 10%; my C-section rate is under 5%;
    I have lost ONE baby in my 16 years of practice.
    I actively participate in research and data gathering projects.
    I complete Continuing Education credits every year in the area of maternal and infant health.
    And I am pursuing a MASTERS degree in Midwifery at this time.

    You know NOTHING about me. I certainly understand science & statistics. You USE them to support your biased position without citation, notation or evidence of the statistics that you throw around.

    I present notations and citations with any research or statistic that I make reference to, including the url for those interested to read further. You don’t.

    I challenge you to do so from this point forward. My guess is you won’t, because your antiquated obstetrical point-of-view is being proven WRONG on a regular basis by evidence-based research all over the world.

    Your “MD” isn’t worth a whole lot to those of us who stand in opposition to your anti-Hippocratic attitude, Amy.
    “First Do No Harm” really does mean something to the CPM.

    And so I’ll ask my question AGAIN…
    Why are YOU not delivering babies anymore? huh…

    YOU are pathetically inadequate.

    Kim Mosny, CPM, LM
    Home Birth Midwifery Service
    http://www.RichmondMidwife.com

  18. January 6th, 2010 at 12:28 | #18

    Oh, the irony! Didn’t you write a post only a week ago entitled “Open Letter to Dr. Amy” attempting to drive traffic to your site?

    What ironic about what I said? I like to bait you sometimes, and freely admit that I have in the past — it can be great fun in a way — but, no, that wasn’t why I posted. It was because I know you read my blog, or at least have a Google Alert for your name, and I knew you’d read it. I thought it was an important question, based on the convos that went on at The Unnecesarean blog. While you said I misunderstood you, you never did answer my question, though you know I never delete your comments: “do you think that natural childbirth makes any difference in a woman’s birth experience; and if so, in what way?”

    I figured out a long time ago that if you linked to me, that got me hits, and if you didn’t then I didn’t have to deal with your cr@p. It was a win-win situation for me either way. The same I think about this current comment thread. I chose to post at all because of my bright idea to post something every day for 2009, and that was as good a thing to post as any. Besides I did want to know your opinion — you’re an odd mixture — sometimes very human, sometimes almost cyborg, hard to figure out sometimes. Oh, on convos like this, you’re pretty cut-and-paste, but occasionally you say things that surprise people. Your comments piqued my curiosity, and I didn’t want them lost in the shuffle of the multitude of comments posted on the various threads (or ignored). I chose the particular day (rather than earlier) to post my open letter because it was my father’s birthday, and that’s another thing you and I have in common – we’ve both lost our fathers, although the circumstances were widely different. At one point, I thought about bringing it up in the post, but decided not to.

    If I wanted to just drive traffic to my site (which, yeah, I like having high blog hits — who doesn’t?), I could post on this and every other blog post and comment section possible; but I choose to write comments when I have something to say.

    As far as the story of Carri — no, I hadn’t heard it. Got a link to share?

  19. January 6th, 2010 at 12:35 | #19

    Amy Tuteur, MD :
    “Oh come on! The risks of dying in a car accident are 1 in 84, the risks of dying in childbirth is 1 in 7,700.”
    You’re proving my points for me.
    The risk of dying in childbirth is 1 in 7,700 ONLY with the interventions of modern obstetrics. Without modern obstetrics, the lifetime risk of dying in childbirth is 1 in 13!
    “Natural” childbirth advocates don’t understand that the only thing that makes childbirth safe is the interventions of modern obstetrics.

    Interventions are CAUSING an INCREASE in U.S. Maternal Mortality…

    http://www.msnbc.msn.com/id/20427256/

  20. January 6th, 2010 at 12:50 | #20

    “nterventions are CAUSING an INCREASE in U.S. Maternal Mortality…”

    This is precisely what I mean about the fact that only some people understand science and statistics. MSNBC is not a scientific journal and if you are relying on it for scientific information, you are making a very big mistake.

  21. January 6th, 2010 at 13:24 | #21

    Amy Tuteur, MD :
    “nterventions are CAUSING an INCREASE in U.S. Maternal Mortality…”
    This is precisely what I mean about the fact that only some people understand science and statistics. MSNBC is not a scientific journal and if you are relying on it for scientific information, you are making a very big mistake.

    Amy, I did NOT suggest that this article is a scientific journal whatsoever! For you to say that I did is a misrepresentation!

    I posted the article because it cites the National Center for Health Statistics research on the INCREASE in maternal mortality. The article also quotes a health statistician and several doctors regarding the causal factors underlying the increase.

    I am making no mistake. I am sharing information with research and citations included.

  22. avatar
    FangedFaerie
    January 6th, 2010 at 14:01 | #22

    According to the Population Reference Bureau, in this press release about family planning, a woman’s lifetime risk of dying in childbirth in developing countries is 1 in 75, and in developed countries is 1 in 7300. I still don’t know where Dr. Amy got the 1 in 13 number, but it’s a start.

    As for the original point of this article, it was speculation to begin with, and has resulted in a spinoff conversation about home birth, which is Dr. Amy’s pet project. I, for one, would like to chime in by saying that studies regarding relative safety of hospital vs. birth center vs. home birth are not going to be completely reliable, ever, because there are too many confounding variables: training and competence level of care provider, rules and standard practices for given locations and providers, and mindset and reasons for choice of location, or the need for emergency relocation, are just a few.

    As for the issue of pain relief, it’s highly individualized. Studies have shown that some people find pain relief, in general, from listening to certain types of sounds and music. Some people who exercise believe in “no pain, no gain.” Dismissing the psychological aspect of pain reception, for example due to fear, is disingenuous at best.

  23. January 6th, 2010 at 14:18 | #23

    Amy Tuteur, MD :
    “Oh come on! The risks of dying in a car accident are 1 in 84, the risks of dying in childbirth is 1 in 7,700.”
    You’re proving my points for me.
    The risk of dying in childbirth is 1 in 7,700 ONLY with the interventions of modern obstetrics. Without modern obstetrics, the lifetime risk of dying in childbirth is 1 in 13!
    “Natural” childbirth advocates don’t understand that the only thing that makes childbirth safe is the interventions of modern obstetrics.

    Let’s look at other countries, shall we, while we all debate how “Well” the U.S. (and modern obstetrics) is doing…

    WHO/UNICEF/UNFPA/The World Bank Estimates of Maternal Mortality 2005
    http://www.childinfo.org/maternal_mortality_countrydata.php

    Here’s the list the top countries for the lowest maternal mortality…

    #1 – Ireland – 1 in 100,000

    #2 – Bosnia and Herzegovina \
    Denmark \
    Greece > 3 in 100,000
    Italy /
    Sweden /

    #3 – Australia \
    Austria \
    Czech Republic \
    Germany \
    Iceland > 4 in 100,000
    Israel /
    Kuwait /
    Spain /

    #4 – Switzerland – 5 in 100,000

    #5 – Hungary \
    Japan \
    Netherlands > 6 in 100,000
    Solvakia /
    Solvenia /

    #6 – Canada \
    Croatia \
    Finland > 7 in 100,000
    Norway /

    #7 – Belgium \
    France \
    Malta > 8 in 100,000
    Poland /
    United Kingdom /

    #8 – New Zealand – 9 in 100,000

    #9 – Cyprus \
    Latvia > 10 in 100,000
    Macedonia /

    10# – Bulgaria \
    Lithuania \
    Portugal > 11 in 100,000
    USA /

    33 countries have fewer maternal deaths/100,000 than the USA.
    Interesting to note that midwifery is the PRIMARY model of maternity care in the majority of those 33 countries.

  24. January 6th, 2010 at 16:33 | #24

    “33 countries have fewer maternal deaths/100,000 than the USA.
    Interesting to note that midwifery is the PRIMARY model of maternity care in the majority of those 33 countries.”

    Sigh … faulty “reasoning” yet again.

    1. Every single one of those countries utilizes modern obstetrics with all its interventions, right? There is not a single country in the world with low maternal mortality that doesn’t use modern obstetrics and widespread intervetions, right?

    2. What difference does it make if the country uses midwives. Midwives don’t take care of high risk patients, do they? And it’s the high risk patients who die, right?

    3. Both maternal and perinatal mortality rates are affected by race. Women of black African descent have higher rates of maternal mortality. The countries that have better rates of maternal mortality than the US are generally whiter, often far whiter.

    4. What about perinatal mortality rates, or do babies not count?

    5. Can you correlate maternal mortality rates with intervention rates? That wouldn’t prove causation of course, but if you can’t even correlate the two, there is no reason to assume that one causes the other.

    You seem to think these statistics “prove” something. They prove nothing.

  25. January 6th, 2010 at 16:35 | #25

    “I posted the article because it cites the National Center for Health Statistics research on the INCREASE in maternal mortality.”

    Unless you read the paper, you have no idea what the paper shows or what it means. Reading MSNBC is not a substitute.

  26. January 6th, 2010 at 16:38 | #26

    “Dismissing the psychological aspect of pain reception, for example due to fear, is disingenuous at best.”

    Why do you think the way other women manage their pain is your business? Are “natural” childbirth advocates really that desperate for validation of their own choices that they cannot help themselves from criticizing other women for their choices, and “educating” them to make the NCB choices? And why do the people who are truly educated about childbirth, women physicians, particularly obstetricians, think NCB is a bunch of baloney?

  27. avatar
    Meredith
    January 7th, 2010 at 00:19 | #27

    Dear “Amy Tuteur, MD”

    I have read your arguments against every one of these people posting on page 4. I gave birth to my son 21.5″ long and 10.3 pounds (first baby) at home. I was in labor 9 hours and pushed for 53 minutes. I don’t think that it is “radical” of me to say that I am certainly proud of my natural childbirth. I don’t claim painless childbirth, but I certainly feel more empowered. I don’t think that is wrong. Have you had children? I don’t see why it’s so important to you to prove that natural childbirth is a bunch of baloney. It is personal. As birth is personal. It is not a 3rd degree burn, it is bringing your child into the world. I think that most here would agree that it is a personal choice whether to have an epidural or go to the hospital. But I think if you are chosing whatever you chose, it doesn’t take Medical School to educate yourself in the facts and information that are out there. So instead of trying to persuade everyone here that NCB is baloney, how about encouraging people to research and come to an educated decision? Henci Goer is the reason why I came to this article. I think you could take some pointers from Henci Goer in having people hear you. People respond to kindness and passion. Not angry close minded people. I hope in the future that you are able to find a way to express your opinions in a more palatable and kind way.

  28. January 7th, 2010 at 07:20 | #28

    “how about encouraging people to research and come to an educated decision?”

    I do. I repeatedly emphasize that if you want to be “educated” you MUST read the scientific papers. When you read the books, articles and websites of lay people, you only learn their personal opinions, not what the scientific evidence really shows.

    The women who are truly educated about childbirth decisions are doctors, particularly obstetricians. They’ve read the scientific papers and, in addition, they have tremendous clinical experience. They know that the scientific literature does NOT support “natural” childbirth, does not support rejecting pain relief in labor, does not support claims that pain relief interferes with bonding, and most certainly does not support the notion that a vaginal birth without pain medication is an “achievement.”

  29. January 7th, 2010 at 08:04 | #29

    Amy Tuteur, MD :
    “how about encouraging people to research and come to an educated decision?”
    I do. I repeatedly emphasize that if you want to be “educated” you MUST read the scientific papers. When you read the books, articles and websites of lay people, you only learn their personal opinions, not what the scientific evidence really shows.
    The women who are truly educated about childbirth decisions are doctors, particularly obstetricians. They’ve read the scientific papers and, in addition, they have tremendous clinical experience. They know that the scientific literature does NOT support “natural” childbirth, does not support rejecting pain relief in labor, does not support claims that pain relief interferes with bonding, and most certainly does not support the notion that a vaginal birth without pain medication is an “achievement.”

    :-)

  30. avatar
    chris
    January 7th, 2010 at 11:59 | #30

    “And why do the people who are truly educated about childbirth, women physicians, particularly obstetricians, think (Natural Child Birth) is a bunch of baloney?”

    Dr. Amy, We plan on having a natural child birth, not at home, but in a very good hospital, with a very reputable OB, Dr, Christine Brass-Jones. There are several OBs in this area that support natural child birth. We understand the need for intervention if complications arise, as does our supportive doctor. We are choosing to be in the hospital setting in case anything does go wrong (Ill let you know in two months how it went). In this case, why is it better to give my wife (and tiny child) doses of narcotics? She is not doing this for an “achievement”, and not everyone interested in natural childbirth is a feminist. Unlike you, I have a tendency to look at both sides of an arguement before making an informed decision.

    For being a medical professional, you are very critical of other people’s views and very opinionated. It saddens me that you hold the “DOCTOR KNOWS ALL” viewpoint, claiming that doctors have read the “scientific papers” so this proves NCB is baloney.

    How many births have you been the OB for? what % of those were given an epidural/pitocin? what % of those were C- sections? These numbers should be readily available to you… and based on fact, not opinion.

    what are your views on Cord clamping and the third stage of labor?

    For being such an advocate of the epidural, you list several other possibilities as to what happened in this “miracle” birth. Do you seriously think it wasn’t a complication of the epidural? she passed out within A MINUTE of receiving it. Now, thinking scientifically, how long would it take before the medicine reaches the brain? the heart? You are contradicting yourself by not acknowledging the validity of this article.

    Ill anxiously wait for a response.

  31. January 7th, 2010 at 18:57 | #31

    “how about encouraging people to research and come to an educated decision?”
    I do. I repeatedly emphasize that if you want to be “educated” you MUST read the scientific papers.

    Your style of “encouragement” is rather like Rambo’s style of “encouraging” the cops trying to catch or kill him to become better marksmen.

    Have you ever heard the saying, “You’ll catch more flies with honey than with vinegar”? If you want to catch the interest and minds of people with whom you disagree, bludgeoning them over the head as you do (metaphorically speaking) is not the way to do it.

  32. January 7th, 2010 at 22:02 | #32

    I would like to let you know, that after reading a number of accounts of what happened in this case, I do not believe for one instant that this patient experienced cardiac arrest due to a complication of an epidural. Henci Goer’s use of this event as an attack on the dangers of epidural is totally out of line. The physiology and natural history of a high spinal looks nothing like this. Based on the report, this patient likely had a amniotic fluid embolism, air embolism, or some kind of cardiac event. This is the description of woman who had a central cardiopulmonary arrest, not of a woman who had too much neurological blockade. Goer’s comments demonstrate a basic lack of understanding of physiology, and how a high spinal effects the body.

    Nicholas Fogelson, MD

  33. January 7th, 2010 at 22:11 | #33

    Ms Goer’s claim that a high spinal would lead to primary cardiac arrest is completely untrue. Note that no cardiac arrests were noted in her series. She seemed sure that it could happen, but actually, it couldn’t. The heart doesn’t beat because of signals from the spinal cord. It beats from its own pacemaker. That’s why patients with high spinal cord injuries still have beating hearts. The description of turning gray throughout the body very quickly is a classic description of sudden cardiac arrest. The skin turned gray because the heart stopped beating. The woman felt tired because she wasn’t getting blood to her brain. This was not a epidural issue, and indeed the doctors involved (miraculously) saved the life of her and her baby.

  34. January 7th, 2010 at 22:17 | #34

    An yes, if that had happened outside of the hospital, she and the infant would have died.

  35. January 7th, 2010 at 22:45 | #35

    Dr. Tuteur is not saying that having a baby without pain medication, epidurals or other “interventions” is wrong. She is explaining a paper which shows doing all of things at home without a trained medical professional has been dmeonstrated to increase infant mortality. I did not take this post as being against patients in a hospital having natural labor.

  36. January 8th, 2010 at 01:33 | #36

    There are only so many explanations for the laboring woman’s collapse.

    What is really curious is that the doctors were interviewed by multiple news organizations and claimed not to understand her immediate and complete recovery AND that the mom was shown on video the day after delivery walking and talking and apparently just fine.

    Here are the possibilities:

    a) amniotic fluid embolism – would result in DIC and at least a 2 day stay in ICU – instead she was awake and giving interviews the day after birth

    b) sudden cardiac arrest, perhaps due to cardiomyopathy of pregnancy – would likely result in ICU stay and the doctors involved said they thoroughly checked her and found no cause. If she had cardiac problem, either her echo or ekg would have shown changes and she would not have been sent home 2 days after birth, nor would she be giving interviews the day after birth.

    c) pulmonary embolism – again, the mom would have spent some time in ICU and the doctors would not be invoking the “divine” as an explanation for her rapid recovery.

    d) “high spinal” – I actually have to (reluctantly) agree with the MDs who doubt this explanation, because a high spinal results in respiratory arrest – not cardiac arrest. According to husband’s report and doctor’s report, she went into cardiac arrest, not respiratory arrest followed by cardiac arrest.

    e) the one culprit not yet mentioned – accidental Intravenous Lidocaine (or similar) injection. It is well-known that IV lidocaine (and derivatives) injected directly IV can cause complete (and temporary) heart block. This is one of the most serious possible consequences of epidural ansthesia and the one anesthesiologists are most careful to prevent/avoid. Lidocaine (and it’s cousins/derivatives) is cardio-toxic; even a small amount that reaches the mother’s blood supply can stop her heart.
    This is one of the main reasons why once an epidural is placed, the anesthesiologist infuses a “test dose” – a very small dose of their mixture of (commonly) lidocaine (or simliar for numbing effect) plus fentanyl (or similar for narcotic effect) – they inject a very small dose and monitor both pain response and vital signs in mom because it is very easy to accidentally hit a vein and inadvertently inject lidocaine (or similar) into mom’s blood stream, causing cardiac arrest.

    The likeliest explanation for the mom’s sudden collapse and quick recovery still lies with the epidural – not that anyone did anything wrong – not that epidurals are inherently dangerous – but, like any medical intervention, epidurals have risks.

    I also agree that if pitocin was not used (and it is questionable whether it was warranted), the mom would have likely not requested an epidural and in HER PARTICULAR CASE, this incredibly rare complication of epidural would have not happened, but it still serves as an education that obstetrical interventions do not come without risks (even very rare ones).

    And that is truly the point that so many of you have tried to put across; not that augmentation is never indicated, not that epidurals are necessarily dangerous; but that we should intervene in the natural process with an awareness of the potential risks and weigh the benefits for mom and baby. This was a third time mom with no risk factors for infection or chorio – why speed up the process? Why not let her labor take it’s course? Why was pitocin augmentation indicated?

    Henci Goer asked a very good question.

    IF mom was low-risk for infection/chorio – why was pitocin ordered?

    Mom had last 2 babes without pain meds.

    Had the pitocin not been ordered (and there seems to be no medical justification for pitocin augmentation), would the mom have requested an epidural (considering that she reportedly had the prior 2 babies with no pain meds)?

    IF the mom had not had the epidural placed, would she and baby have not had sudden cardiac arrest requiring emergent cesarean delivery and full resuscitation of mom and baby?

    I think these are valid and important questions to ask.

    Not to say that augmentation of labor is not a wise choice for some women.

    Not to say that epidural anesthesia is not a wise and prudent choice for some women.

    However, I would ask the MDs who so vehemently defend augmentation and epidural in THIS CASE to explain why they agree with the management (as we know it). Not to reflexively defend augmentation or epidural – but why this case doesn’t send shivers down your spine – because it does mine.

    I am very aware of the consequences of interventions in childbirth; but I do use them when indicated. But, I am very cautious to use them judiciously.

    I think you misunderstand the many moms who truly want the best for themselves and their children. There are so many OBs out there who rail-road their clients into induction/augmentation without solid medical justification – I am totally on the side of women getting educated and knowing their rights.

    Samantha McCormick, CNM, ARNP

  37. January 8th, 2010 at 05:16 | #37

    Dr Fogelson, I would like to know what reports you have read that lead you to that conclusion.

    People with high spinal cord injuries have beating hearts because their hearts are oxygenated. The injury may be at a level that enables them to breath or they may have ventilatory assistance. If a heart is not oxygenated, it stops.

    I have worked in an overseas hospital where a woman, following an epidural, had a cardiac arrest because the block was high and she was not breathing. The staff were busy and hadn’t noticed. This situation sounds very similar to what happened in the place I worked in.

    Jeff Livingston, the literature does not support the good dr Tuteur’s position at all. In fact, the opposite is true.

    And you know what helps birthing women to be safest? When women feel important and respected (they have less circulating glucocorticoids – stress hormones – yes Dr Amy, I have the reference if you really want it); where there is interprofessional respect, willingness to work together, cooperative teamwork, great communication, no professional silos, primary health care midwifery practice with obstetricians who see their role as one, like all doctors in every modality, that leave folk alone when they are well and their physiology is normal and intervenes when intervention is required. And for those times when childbearing women are unwell or have medical conditions, women, doctors and midwives work together to help the woman have the best and safest experience. Those are the contextual aspects that help women and birth be safer.

    At John Hunter Hospital (a publically funded, tertiary referral unit) in Newcastle, NSW Australia, is a team called the 3M team (mothers, medicos and midwives). Each woman has a doctor and midwife involved in her care and the three of them develop a plan and work together. A fabulous system that women emerge out of feeling good about themselves, however the baby was born.

    For normal, healthy women having healthy pregnancies, midwives provide the care and consult with doctors as required. If no consultation is required, midwives and women work together. Women can choose to give birth at home, in a stand alone unit, in a birth centre within the labour ward, or in the labour ward itself of the tertiary referral unit. The woman chooses to birth where she feels safest.

    Wonderful maternity care with great collaborative, respectful relationships between clinicians and disciplines.

  38. January 8th, 2010 at 07:28 | #38

    “When women feel important and respected (they have less circulating glucocorticoids – stress hormones – yes Dr Amy, I have the reference if you really want it)”

    As a matter of fact I do. And are you sure you mean glucocorticoids? Most of the papers about labor and stress hormones measure catecholamines.

    Funny thing about stress hormones and labor. The most effective way to decrease stress hormones is to eliminate pain by using an epidural. In fact, labor increases circulating levels of catecholamines by by 200-600%. Epidural anesthesia dramatically lowers catecholamine levels.

    So if you are truly concerned about the deleterious effect of elevated catecholamine levels, you would recommend epidurals.

  39. January 8th, 2010 at 07:53 | #39

    @Carolyn Hastie
    People with high spinal cord injuries have beating hearts because their hearts are oxygenated. The injury may be at a level that enables them to breath or they may have ventilatory assistance. If a heart is not oxygenated, it stops.

    This is correct of course, but its so clearly not what happened I didn’t even mentioned it.

    Stop for a moment and hold your breath for thirty seconds. Thank you. Did your heart stop? Thank you.

    Respiratory collapse will of course lead to cardiac arrest eventually, but it takes _a long time_. Why do I know this? Because of years of experience studying human physiology, which Henci Goer clearly does not have.

    Based only on the same CNBC article that Ms Goer is quoting (and I have no other information), this woman suddenly turned gray, felt tired and quickly fell asleep. This is not the picture of a woman with progressive respiratory arrest. A high spinal would be a woman saying “I can’t breathe!” for many minutes prior to having respiratory arrest, and way, way, way before having cardiac arrest. For whatever reason, and I don’t know exactly why, this woman experienced sudden cardiac death.

    —-

    To respond to a few folks

    What sources about this? The sources about the case are just the CNBC article, which is enough to know that a high spinal is not what happened. As for sources about my medical knowledge, I’m not going down that game. I have studied science, biology, human physiology, and medicine my entire adult life, leading to a degree in medicine and a board certification in ob/gyn. Ultimately one either respects this education as adequate to understand basic human physiology or not. I’m not going to start quoting basic science textbooks, nor am I going to try to prove to anyone that I know what I’m talking about.

    The reason this post really frosts me is that Henci Goer went completely attack dog on the obstetrical word based on a completely incorrect premise, and that the community that reads her, actually believing every word she says apparently, fell for it. The discussion of intervention in labor is something else. But to say that the fact that this woman suffered a sudden cardiac death implicates epidurals or obstetrics in general is just ridiculous, and completely discredits Ms Goer as anybody I would want to read in the future. I am happy to hear opposing or semi-opposing views, but when you make an attack that big based on a completely ignorant view…. Ms Goer there is something on your face, and it is egg.

    As for a discussion on intervention/vbac/induction – I’m not interested in that discussion right now. It is a total side note to the basic premise of the post. We cannot connect any of that to the fact that this woman experienced sudden death.

    Dr Chukwuma Onjeije and I are working on a detailed post on what we can infer from the descriptions of this woman’s death, and how physicians figure out these kinds of mysteries. I invite you all to take a look at it when it is posted in the next few days.

  40. avatar
    FangedFaerie
    January 8th, 2010 at 11:14 | #40

    “Why do you think the way other women manage their pain is your business?”

    Why do you think it’s yours? I posted a very neutral comment, emphasizing that births are very individual, and so is pain management. I support epidurals for women who want them, but I also support women who choose NOT to.

    I am curious, though. You said you had at least one “natural” delivery of your own. If you weren’t convinced it was the best thing for you and your baby, then why didn’t you get an epidural?

  41. January 8th, 2010 at 11:31 | #41

    @Samantha McCormick
    I wanted to respond to Samantha’s McCormick list of possibilities. I will respond in more detail in a blog post, but –

    The list you propose is thoughtful, and I think your reasoning is good too.

    AFE is less likely because of lack of sequelae, but a very small one could maybe do this. We have no information about what happened to her later, she very well may have had clotting abnormalities we do not know about. We are speculating.

    Your idea of intravascular lidocaine injection is a good one, and could present this way. This is generally prevented by the use of a test dose, which as you have said, is done to prevent this complication.

    A primary arrythmia is very possible. Cardiomyopathy of pregnant does not generally result in sudden cardiac arrest. It presents as slowly or rapidly progressive cardiac pump failure, characterized by sharp decrements in ejection fraction, not electrical failure.

  42. January 8th, 2010 at 12:32 | #42

    Thank you Mr (Dr?) Fogelson.

    Trying to inject a note of science into this debate.

    AFE is less likely because of lack of sequelae, but a very small one could maybe do this. We have no information about what happened to her later, she very well may have had clotting abnormalities we do not know about. We are speculating.

    We are not completely speculating. I have watched numerous interviews given to the media by the doctors involved in her care and they claim to have thoroughly tested her and found no explanation. The head of MFM at the hospital gave an interview where she said she found no cause (not quoting directly). It is a reasonable assumption that MFM would have ruled out a clotting disorder.

    I still think that it is valid to examine rare complications of routine procedures. Not to bash them, but to

    a) educate people that just because a procedure is routine and generally uneventful, all medical procedures have risks. You might think “Duh!, of course people know that”, but in reality, many doctors and especially anesthesiologists (in my experience) choose to gloss over the risks of induction/augmentation and epidural anesthesia.

    b) quality assurance. I certainly hope that the OB and Anesthesia department are privately reviewing this case to determine if there were any errors made.

    Very few of my clients in my current practice choose epidurals. I do 90% of my births in a free-standing birth center. I do have hospital privileges and do perform inductions/augmentations for obstetrical/medical indications. About half of those clients choose epidural. I am generally present in the room during epidural placement.

    6 months ago, a client being induced for post-dates had an epidural placed by the head of anesthesia, a very skilled doctor. Just the test dose (which apparently went inadvertently IV) was enough to create tachycardia in the mom to the 170′s. Very uncommon, but scared the bejeesus out of the mom and dad. We calmed her down, waited for the tachycardia to resolved, replaced the epidural and all was fine.

    In 5 years of practice as an RN at a major metropolitan teaching hospital, I witnessed just one “high spinal” (this was also just before they changed the needle size), so I agree that these sorts of complications are rare and not a defacto reason to avoid epidural anesthesia.
    But that particular case was especially traumatic (mom and baby were healthy after emergency c-section), because the husband had begged and pleaded with his wife not to get the epidural. English was not their primary language (some kind of Asian, if I remember correctly), so I am not clear why the husband was so adamant about her not getting the epidural (I was the labor nurse). But it was heart-wrenching to run down the hall to the OR with the husband panicking and sobbing and crying out “why? why? why?”. I can tell you that that couples’ faith in medicine was shaken to the core by their experience. I can imagine (speculating here) that the husband felt lied to by the anesthesiologist who assured him before he placed the epidural that it was perfectly safe.

    And that is really my purpose in posting to this discussion. I believe it is disingenuous for the head of MFM at that hospital to give media interviews claiming there is no possible explanation for what happened. And for one of the doctors (I believe it was the woman’s OB) to invoke the “divine”. Crap – we are scientists, not faith healers, for goodness sake.

    I believe the doctors involved were caring and competent and I do not believe that anyone made a mistake. But I also believe that they were covering their butts by giving media interviews that were misleading.

  43. avatar
    FangedFaerie
    January 8th, 2010 at 14:30 | #43

    “Both maternal and perinatal mortality rates are affected by race. Women of black African descent have higher rates of maternal mortality. The countries that have better rates of maternal mortality than the US are generally whiter, often far whiter.”

    This one really disturbs me. How much of this is a function of biology, and how much is a function of socioeconomic problems?

  44. January 8th, 2010 at 17:30 | #44

    @FangedFaerie
    The latter

  45. January 8th, 2010 at 17:33 | #45

    @Samantha McCormick
    I didn’t get to see any of those interviews. Did they really say there was no possible reason why it happened? That would certainly be untrue and incorrect. Certainly they might not know what happened, but there are some possible reasons.

  46. avatar
    IndianaFran
    January 8th, 2010 at 21:40 | #46

    Here are the links to the interviews. In the second ABC clip, Dr Martin states quite clearly that the mom’s breathing stopped at least “a minute or two” before she lost her heartbeat.

    http://abcnews.go.com/GMA/christmas-miracle-mom-baby-dead-labor-revived/story?id=9442043

    http://abcnews.go.com/video/playerIndex?id=9447356

    http://www.cnn.com/2010/HEALTH/01/05/mother.baby.revived/index.html

    I think we can all agree that the journalism on this matter frankly sucks. There are reported discrepancies in the degree of prematurity (most likely 2 weeks not seven), whether Tracy thought this labor felt different than her others, how long after the epidural placement the drowsiness and respiratory failure occurred. Good luck on trying to piece together a meaningful timeline.

  47. January 8th, 2010 at 23:56 | #47

    @IndianaFran
    After looking at all these sources, its not clear to me that the epidural catheter had even been placed when she went down. One section says the doctor was about to thread a catheter when it happened. No report even mentions the epidural as a possibility, certainly suggesting that it hadn’t been done yet. I really doubt they would completely ignore that issue when they were talking about possible causes, if she had had the epidural placed.

  48. January 9th, 2010 at 00:08 | #48

    @Nicholas Fogelson
    I watched the long video in your second quote – she had gotten the epidural, and it contradicted the other source that suggested that she suddenly turned grey. Based on this, high spinal is more of a possibility. And based on that, I may have jumped the gun a bit saying it wasn’t, and I apologize for that.

  49. January 9th, 2010 at 12:38 | #49

    “it contradicted the other source that suggested that she suddenly turned grey.”

    The bottom line is that we cannot trust media accounts to make medical diagnoses. The accounts from different outlets differ about very important details. Did this woman have a complication of a high spinal? It’s possible, but no one really knows. And that is what makes Goer’s claim irresponsible.

  50. January 9th, 2010 at 13:06 | #50

    @Amy Tuteur, MD
    I’m also not sure where Henci got the idea that she was on pitocin. That’s nowhere in there. The woman presented in labor, and was not induced. Perhaps she was more painful because she was abrupting, leading to an AFE. That would actually make some kind of sense.

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