When I read this post of hers, complaining about an illegible note in a chart, I giggled and felt a little illicit.  I fight the urge to ever use my camera phone in my training at all.  I know people who have taken pictures of sutures, fibroids, etc.  I was told to take a picture of an abdomen with scabies excoriations on it (that I did an exam on without gloves…ugh), and I didn’t.  I may have an overdeveloped sense of patient rights, but taking pictures like those just creeps me out. 

But, I totally get taking the photo of the illegible note now.  First of all, it doesn’t involve any patient body parts.  Second of all, there is no identifiable information.  Third, if you can’t read a friggin’ word of it, there is absolutely no value to it at all, except to mock it. 

So, here are two consecutive notes in the chart of a patient I was following last week. 

Any guesses as to what sort of progress this patient made?  How about the specialty of the physician writing the note?  I’ll give you a hint, there was a surgery involved.  Sorry it’s a little blurry, but trust me, it wasn’t any easier to read in person. 

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Our jack o’ lantern was inspired by my 6 year old.  First, he loves to color in my anatomy coloring book, and was coloring in it last night while I was trying to come up with an inspiration for our pumpkin.  Secondly, for a while, his favorite punchline for his made up jokes was “eyeball.” 

This was one time when having hospital scrubs to wear came in handy. 

Happy Halloween, everybody! 

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I am a huge fan of RH Reality Check.  However, I was recently a little troubled by a post about choosing elective cesarean over attempted VBAC (vaginal delivery after cesarean).  I am a little, OK way behind on my blog reader.  The original article, I’ve Made My Birthing Choice, and It May Surprise You was published in September, but I just got around to reading it tonight.  I had a gut reaction similar to the reaction I have to many blog entries I have read defending a common, mainstream choice that is disguised as an underdog, against the system, authority challenging choice.  But, I was more troubled by the many medical inaccuracies in the piece. 

So, I wrote a reply.  One I am upset to see has a bunch of html fail in it.  I guess RH Reality Check doesn’t support hyperlinks.  So, here is the prettier version:

I want to support you and your decision to have a repeat elective cesarean instead of a VBAC attempt, and your choice is indeed valid. 

I have to join in the chorus challenging some of your points, however.  On the one hand, I am hesitant, since I cringe at the thought of how judgmental people are towards pregnant women and their choices.  However, there are a few reasons why I am choosing to do so.  First of all, I think you have some statements in your article that are medically inaccurate.  And, this isn’t a personal blog.  This is presented as journalism / advocacy.  Journalism on medical topics needs to be held to a higher standard. 

Secondly, you are defending a choice, elective repeat cesarean, that is really not in need of defense – it is presented as the most reasonable choice, and in many cases only choice, for the vast majority of women in the U.S. The power balance is dramatically tilted against women being able to choose VBAC.  How is it surprising that it was your choice?  Of course it’s valid – it’s almost guaranteed! 

Let’s start with some of the inaccuracies. 

I am in medical school and just completed a research fellowship on labor interventions.  I think the exercise you did in your childbirthing class was atrocious.  We do not need to choose between a healthy baby and evidence based, women centered medicine.  Avoiding non-evidence based interventions that have worse outcomes for the mother and baby makes it more likely that we can have healthy babies.  They should not be presented as competing priorities. 

For example, we can have a healthy baby AND not have an episiotomy.  Episiotomies should be avoided at all costs, according to substantial research.  They do not make babies more healthy.  There is not one situation in which they save a baby’s life.  It is even recommended that they be avoided for operative vaginal delivery (when an intervention such as vacuum extraction is needed) – they lead to more maternal and neonatal morbidity.  I consider episiotomy use to be a litmus test for an obstetrical health care practitioner. 

As other people have pointed out, non medically indicated inductions, especially those in a first time mother, carry more than double the risk of cesarean.  In fact, some hospitals are now banning elective inductions on first time moms as a quality assurance measure.  Rixa has a good synopsis of links on this topic at Stand and Deliver.  The Bishop’s score is an important indicator of whether an induction is likely to be successful, as opposed to a several day long ordeal that ends with a cascade of interventions, leading to an emergency / iatrogenic cesarean.  If there is a compelling medical indication that one would get a cesarean for anyway, that is one thing.  But, in our society, many women are told to get induced before their baby gets to big, or because the baby is looking a little small, or because the obstetrician is going on vacation, or the calendar year is changing, or because they have a certain amount of time off from work and they really want to plan their maternity leave.  These psychosocial factors for induction are all indeed valid, and birth is not the only medical decision in which psychosocial factors are weighed, but they do sometimes increase the risk of not having as healthy a baby or as healthy a mom.  More than an episiotomy would. 

Or an epidural.  Epidurals are associated with maternal fever, especially longer lasting epidurals, such as those associated with inductions.  If a mom’s membranes break, or more likely, are artificially ruptured during active management of labor or an induction, and she subsequently develops a fever, many practitioners will consider that to be an indication for cesarean section. 

Group B Strep is present in up to 40% of healthy women – a cesarean is not the recommended intervention for prevention of transmission of group B strep to a baby.  The current standard of care is to administer antibiotics during labor. 

As for the VBAC vs. elective repeat cesarean issue – it is obviously a highly personal choice, and one I am happy you were able to make without apparent pressure from your hospital system or your chosen practitioner.  Please don’t present VBAC as higher risk, however.  The larger risks of an emergency situation are very, very uncommon in a VBAC.  In fact, they are identical to the risk of perinatal mortality in a primary vaginal delivery.  There is a definite imbalance of risks to the mother (increased risk of hemorrhage, need for transfusion, and infection, as illustrated by your anecdotal experience) with a cesarean, and increased risk of neonatal trauma or morbidity with a VBAC.  But, these risks are vanishingly small.  One set of risks is not large and uncontrolled and scary, compared to one set being small and manageable and acceptable. 

Anyway, I wish you a safe and uneventful birth, regardless of your chosen method of delivery.  I am always happy when this site steps out of the zone of reproductive choice just being about preventing birth.  And, you were very brave to put your personal decision our there.  Just, please remember that when you are writing for a site such as RH Reality Check, a little reality checking may be in order. 

Forgiveness is not the misguided act of condoning irresponsible, hurtful behavior.  Nor is it a superficial turning of the other cheek that leaves us feeling victimized and martyred.  Rather it is the finishing of old business that allows us to experience the present, free of contamination from the past. 

-Joan Borysenko

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Sorry about the blogging hiatus.  I have started my internal medicine rotation.  It has been really great.  I like my attending physician, the resident, the intern, and the other medical student.  I even like the nurses.  I love working in the wards with the patients.  I has been a great experience so far.  But, I have been really busy, and working longer hours than any of the other rotations I have completed.  So, not much time for blogging. 

There are a few books that medical students and residents tote around in their white coat pockets as references.  One of them, the one I decided to purchase for this year, is Ferri’s Practical Guide to the Care of the Medical Patient.  It does more than make my jacket heavy; it has entries on how to interpret labs, and the presentation, pathology and treatment of common conditions.  But, I think the most valuable thing in the book is the quote in the preface:

Pearls of Wisdom in Medicine:

1.  Common things occur commonly
2.  When you hear hoofbeats, think of horses, not zebras. 
3.  Place your bets on uncommon manifestations of common conditions, rather than common manifestations of uncommon conditions
4.  If what you are doing is working, keep on doing it. 
5.  If what you are doing is not working, stop doing it. 
6.  If you don’t know what to do, don’t do anything. 
7.  Above all, never let a surgeon get your patient.