Newborn Photo Gallery

This is a really cool website, with pictures of babies with various conditions (and some who are completely normal, for comparison). Divided into various categories like ears, eyes, nose, mouth, etc., it covers lots of different problems, benign conditions, and “variations of normal” which are not problems at all. Some of the pictures were difficult for me to look at (particularly the pictures of the eyes, because I can practically start crying just by looking at someone else’s infected eye — my eyes don’t have to hurt at all and I’ll start sympathetically tearing up; or the pictures of the babies crying, which made me want to comfort them), but for the most part, they have been just interesting clinical pictures.

I discovered a new term — ear pits. I’d never heard that term before, but both my children have one, in exactly the same place on the back edge of the ear. It basically looks like a pock mark — a tiny depression like where a deep scab or a chicken pock had been.

And there were reminders of how awful and awesome genetics is. For instance, in the picture of the baby with the very low-set ears, it was discovered that he had Trisomy 18. Most babies with low-set ears do have some sort of genetic problem, such as Trisomy 18 or Down Syndrome.  There were another condition in which it was noted that although the baby had X characteristic, tests ruled out any renal problem. I forget what it was — something about his ears, I think — signified a higher risk of a problem with the kidneys. One might think that the ears would have nothing to do with the kidneys, but I would suspect (knowing what [little] I know of genetics) that the genes that control the development of the kidneys are in close proximity to the genes that control the development of the ears. There were a few other statements like that (and I’m only up to the “neck/clavicles” pictures), in which a physical finding was related to a higher risk of some internal problem. Which is interesting, to say the least.

h/t Diana at Birth at Home in Arizona

Update — one of my readers pointed out that there is a section on circumcision on this website, which includes pictures of babies for whom circumcision is contraindicated and when there is no medical contraindication. It points out,

Though widely practiced in various parts of the world, circumcision remains a controversial issue, with passionate feelings on both sides.  The AAP has a policy of “neutrality” on the issue, and many physicians agree that both the medical risks and benefits of the procedure are small, so usually the decision is made by the family for reasons that are culturally, religiously, or emotionally based.

So, in other words, it’s a medical procedure done for non-medical reasons, and may actually cause many medical problems, including losing the tip of the penis and even rarely death. There are videos of babies undergoing circumcision using three different methods, but I cannot watch any of them.

Breastfeeding, Dr. Seuss Style

Just go read it — hilarious!

And since I’m on the subject of breastfeeding, “What does breastmilk taste like?

….and this humorous commercial:

…and this picture of breastfeeding in public 🙂

Contaminants in Breastmilk

I haven’t read this whole article, but thought it looked interesting. It begins with a laundry-list of benefits of breastmilk for the infant, then asks aloud whether these benefits are worth the risks of the possible contaminants and pollutants that may exist in breastmilk; the remainder is an attempt at answering that question. With sections on the history of anti-breastfeeding, “Human Milk: Its own Immune System,” and other sections specifically looking at particular types of contaminants, it presents a detailed look at what is known on the various subjects. The conclusion is “Net Gain”:

After having considered the problem of environmental contaminants in human milk, the WHO, the U.S. Surgeon General, and the American Academy of Pediatrics continue to recommend breastfeeding. “After three decades of study, there is now fairly good evidence that little if any morbidity is occurring from the more common and well-studied chemical agents found in human milk,” says Walter Rogan, a clinical investigator in the NIEHS Epidemiology Branch. “There are very few instances in which morbidity has been described in a nursling that was due to a chemical pollutant in milk.”

Labbok agrees. “To date, no environmental contaminant, except in situations of acute poisoning, has been found to cause more harm to infants than does lack of breast-feeding,” she says. “I have seen no data that would argue against breastfeeding, even in the presence of today’s levels of environmental toxicants.”

Still, Rogan cautions, human milk contains no proven antidote to contaminant exposure. “To the degree that the overall benefits from breastfeeding overlap with the deleterious effects of the chemicals, those benefits might appear to cancel out the harm, but this is hard to study epidemiologically,” he says.

Because of human milk’s nutritional, immunologic, anticancer, and detoxifying effects, Wang, Rogan, and other environmental scientists encourage women to continue the practice of breastfeeding even in the context of widespread pollution. “At the same time,” says Pronczuk, “breastfeeding mothers should be helped and advised on how to avoid alcohol and drugs and remove themselves from polluted environments, while also creating healthier, safer, and cleaner environments for themselves and their children.”

Misdiagnosis

This has nothing to do with birth, but you need to read this powerful story of a woman who was diagnosed with a rare, aggressive, and lethal form of cancer, “confirmed” by two independent labs — and it was wrong.

h/t Science and Sensibility

Doctor knows best?

This isn’t really birth-related, although I’m sure it has applications in that field; it’s more just a general medical discussion.

Recently, I was in conversation with an older woman who as a child was diagnosed with celiac disease but eventually grew out of it and was able to tolerate foods containing gluten for most of her adult life. Then a few years ago, she started having symptoms of celiac disease again. She went to her doctor, told him of her history and that she was pretty sure the problems she was experiencing (including rapid weight loss) was due to celiac disease, and asked him to perform the test to make sure.

Instead of doing that, though, the doctor mentioned all the possible diseases based on the symptoms, and said he wanted to rule them out, starting with the worst possible one — namely, cancer — and working his way down. I have no problems with him wanting to rule out cancer; it’s a common enough disease and potentially fatal, so if it is a reasonable possibility, it should be known for sure. In fact, someone I know just recently died of cancer that was undiagnosed because the doctor was treating his aches and pains as arthritis; it wasn’t until he became extremely sick and short of breath that he was diagnosed with cancer, and died a mere two weeks later.

What I do have a problem with, though, is the doctor apparently ignoring the most obvious diagnosis, particularly with the patient’s history. The woman said that it took a year of testing before the doctor finally diagnosed her with celiac, because he “started at the top” with ruling out the worst diagnosis, and gradually worked his way down, with celiac disease at the bottom of the list. Sure, rule out cancer, but in the meantime, draw a vial of blood to test for celiac disease — it doesn’t seem that difficult! The woman said that she was glad to know she didn’t have cancer (as would I, if cancer were given as a possible diagnosis), but that she didn’t like that it took so long to get the diagnosis.

And here is where I have a problem with her. I could be wrong, because I didn’t clarify this point, but it sounded like this woman was waiting for her doctor’s diagnosis (or rather, his confirmation of her self-diagnosis) before changing her diet to get rid of the symptoms of celiac disease. After all, the only thing that you can do is to avoid gluten — it doesn’t take a prescription or anything that “only doctors can provide” to start feeling normal again. But she waited a year!!! Inconceivable to me that anyone would do that — to know that you feel like garbage, and to know why you feel so bad is because you’re gluten intolerant, but continue to eat gluten-containing foods until “the authority” tells you to stop. I can see that if you can’t figure out what’s wrong, or don’t know how to fix it, that you would just suffer until the doctor figured out the medical mystery; but she said she knew what it was… and she said that she had researched online so even if she didn’t know at the outset, she must have known with just the tiniest bit of online research — she knew!… and did nothing?

But I will bring birth into this — sometimes women know that something is going wrong, but the doctors and/or nurses won’t listen to them, and then what? Obviously, it depends on the situation — if you’re in labor and strapped to monitors and the nurses won’t listen to you that you think your uterus has ruptured, there’s not much you can do — you can’t exactly go to another hospital or track down another doctor to give you a second opinion! I have heard of people calling 9-1-1 from inside a hospital, but I’m not necessarily recommending it. [Fortunately, uterine rupture is rare, and stories like this are even rarer, but I’ve read more than one study of women telling their nurses that something was really wrong and the nurses responded with answers like, “Well, this is labor, honey, it’s supposed to hurt!” And the blog “My OB said WHAT??” has similar stories with some regularity — of women being ignored when told their care providers of symptoms; or of the reverse situation — nothing was wrong, but the doctor, midwife or nurse insisted that something must be, and it ended up being a faulty machine or just a scare tactic to bully the woman into accepting hospital policy.]

And sometimes, people just order tests for reasons that have little to do with medical necessity, but more to do with the doctor practicing defensive medicine, or just getting money. I’m not accusing this particular doctor of delaying a true diagnosis so he could make more money by having half a dozen office visits plus a percentage of the costs associated with the various tests… but it is a possibility. My sister’s OB performed an ultrasound every prenatal visit because her insurance paid for it, so why not? It obviously was not medically necessary — she was low-risk before, during and after the pregnancy, with no fetal indication for an ultrasound during pregnancy either. Whether the doctor made extra money or not, it is certain that it cost money to do the tests to rule out cancer and anything else that might have caused the symptoms of celiac disease, and to do an ultrasound every prenatal visit.

One of my facebook friends made a comment (in the context of health-care reform… or not) about the United States having some of the best technologies but with worse results than other countries with socialized medicine. I don’t agree with the bills that are in Congress right now [my former CPM wrote this post recently, and I generally agree with her take on it], but think we do need to reform our thinking about health care. Starting with patients just accepting any test or intervention offered, regardless of the benefit. Like my sisters’ multiple unnecessary ultrasounds; or this woman’s multiple unnecessary tests over the course of a year prior to a simple blood test to identify her problem. And many, many other tests which are unnecessary, but cost a lot of money, and add great costs to the nation’s total cost of health care. My sister didn’t pay one dime out of pocket for her ultrasounds, but that doesn’t mean it was free. Assuming that each ultrasound cost her insurance company $200, and she had 10 of them during the course of her pregnancy, that’s $2000. Multiply that times two million (there are roughly 4 million births every year, but many women do not get an ultrasound with every visit, having only one or two per pregnancy, but other women do, and also have more frequent visits and/or ultrasounds, so I bet it would average out pretty close) — that’s $4 billion just in ultrasounds. Sure, some of those are bound to be necessary, but certainly not all.

The problem is, that when a doctor suggests something, it’s a reasonable thing for a patient to do to follow that suggestion — after all, he went to medical school and has all this training and knowledge, and you’ve hired him for his advice and suggestions, so why not take it? So, it’s hard to say “no,” and you don’t want to doubt your doctor’s ability — you want to be able to trust his opinion, since you’re trusting him with your life and health… but sometimes you ought to. I don’t know why that woman I mentioned submitted to a year’s worth of testing rather than insisting on the one test she was certain she needed; and I don’t know why my sister had an ultrasound every visit, except that it didn’t cost her anything.

One thing that would help to control the costs is to know the costs — and many people do not know the costs before the service is rendered, or their insurance covers it, so they don’t look at what it cost or they don’t care. But it all adds up.

No Justification for NPO

The Cochrane Collaboration recently issued its finding on the topic of NPO or “nothing by mouth” [non per os], saying that restricting a woman in labor from eating if she’s hungry and drinking if she’s thirsty is not evidence-based. It also coincides with the recommendations made by the World Health Organization’s guidelines for Safe Motherhood, which I wrote about in this post almost a year ago:

The World Health Organization (see pp. 13-14 for the specific discussion on this) says that while a few women who are at high risk for the potential of general anesthesia may need to restrict food and drink in anticipation of such surgery, that restriction should not be extended to all women, since labor “requires enormous amounts of energy. As the length of labour and delivery cannot be predicted, the sources of energy need to be replenished in order to ensure fetal and maternal well-being.” They conclude the section by saying, “The correct approach seems to be not to interfere with the women’s wish for food and drink during labour and delivery, because in normal childbirth there should be a valid reason to interfere with the natural process. However, there are so many die-hard fears and routines all over the world that each needs to be dealt with in a different way.”

Glad to see that obstetrics is finally catching up to what midwives have known all along. 🙂 Once this becomes ingrained, and routine starvation of women in labor is a distant memory, I’m sure Dr. Amy will point to that along with other hallmarks of “modern obstetrics” as being “midwives only doing what doctors are doing, so they shouldn’t claim any credit for the idea.” 😉

The sad thing to me, though, is that the current and modern practice of NPO is based on a study from 1940, as if nothing had changed in obstetrics or medicine since that time, which would render NPO obsolete, along with routine pubic shaves, enemas, etc., etc. Sheridan at EnjoyBirth wrote a post along these lines several months ago, titled, “Death by Cheeseburger?” which breaks it down this way:

So, while aspiration is a very, very, very small risk***

for Jane Doe, it could happen

If she needs an emergency cesarean

with general anesthesia

and if her anesthesiologist doesn’t intubate well

and she vomits

she may aspirate some vomit

which could cause complications

one of them potentially being death.

…So about 10 in 100,000 moms die due to childbirth in the US.  (I found stats ranging from 9.3 to 11, but to make the math easier, I chose 10.)  Which is the same as 100 in 1 million moms.  So the only statistic I found that could be aspiration related said 6%.  SO –

6 in 1 million moms, who die due to birth related causes, could be due to aspiration.

Which equals 0.000006% chance of dying from aspiration.  Which numerically speaking is a very, very, very small risk.

The post was written because an obstetrician told a patient that aspiration was “the #1 cause of death during birth” is aspiration. Not hardly.

[Update: a 2006 study reported that little is known about eating and drinking in labor, saying, “Only one study evaluated the probable risk of maternal aspiration mortality, which is approximately 7 in 10 million births.”]

Some doctors will almost certainly still try to use this study to justify NPO, I suppose based on the lack of a recommendation to require eating, or that the measured results (which did not include maternal satisfaction, btw) were no different whether the women were assigned to eating or starving, so, “since it doesn’t make any difference,” why not continue restricting food and beverages? Um, sorry, BZZZZ wrong answer! It is the intervention which requires justification, not what is otherwise natural (eating when hungry, drinking when thirsty). You first have to prove that intervention is better than not intervening — that there is overriding benefit from the intervention. And if anyone disagrees with these results, then what they need to help fund a large, well-designed study that is somehow better than the studies already done, to prove a benefit to NPO, not just “a lack of harm.” Until there is proof that NPO is beneficial, or that eating and drinking as desired is harmful, then doctors have no evidence to restrict food or beverages from laboring women.

Patient Autonomy

Click here to read an interesting story of patient autonomy. The mother was a Hmong woman who believed in reincarnation (so if her child died, it would come back as another child), and also that if she were cut open during a C-section that good spirits would leave while evil spirits would enter her body; so C-section was not an option for her, even if her child’s life was in danger… or her own. She had a partial placenta previa, and her doctor was preparing to obtain a court order to force her to have a C-section to keep her baby alive. While she did not make the choices I would have made (insisting on a vaginal birth with such a risky condition), she found another doctor who supported her choices, and even offered to testify on her behalf at the court hearing.

Did Se understand the risks, or as some physicians have suggested, was she unable to really grasp the implications of her choice in order to give an informed consent?  I believe she clearly understood that she or her baby could die; I believe she felt that death would be preferable to the consequences of an incision in her body.

This is in contrast to the Florida woman who was court-ordered into hospital confinement and bed-rest at 25 weeks gestation. While I can understand the desire to save the baby’s life and health, I also think that the mother has the right to choose between two different options, and to seek a second opinion if she desires. Especially since (unless I’m mixing up stories, or getting something wrong), the bed-rest did no good, and the baby died three days later… which to me shows that the mother was certainly within her rights to question the validity of the bed-rest that the doctor was ordering. Actually, I might say that the doctor was merely suggesting it, with the performance of the act being dependent on the mother’s ability and desire to follow the suggestions, based on her understanding of the risks and benefits of bed-rest in her situation. Also, I might add that it is possible that the stress of being confined, against her will, in a hospital, away from her children, may have added a degree of stress to an already stressful situation, and was certainly not helpful and perhaps harmful to the baby.

Two different ways of handling a situation, one respecting a woman’s right to choose the medical care that she feels was best in her situation (though I couldn’t say that it was what was best for her child, since I do not believe in reincarnation — at least in her mind, the child’s death was not harmful to him, for the soul would come back in another body); and the other disregarding her intellect and understanding and right to a second opinion.