Wednesday, May 17, 2006

Dr Crippen posts an anecdote

Dr Crippen, whom I linked to below for a post about "madwives", now posts an anecdote:

“Two-o'clock in the morning, and I was in the late stages of labour with a midwife struggling to save the life of my baby boy as an ambulance rushed us through the deserted streets of south London to Lewisham Hospital.

I was seven centimetres dilated and she had pushed her hand right up into my vagina, trying in vain to keep his head from crushing the umbilical cord carrying oxygen to his brain.

She kept her hand there for 56 minutes, even as I was being wheeled at high speed along the corridor into theatre, and right up until the moment my baby was lifted up and delivered by Caesarean”

The baby died.

What I find most remarkable about this tragedy is that the mother, a midwife, made the following comment in an article that she wrote: [The baby]“would not have been saved even if I had given birth in a hospital”

That is an absurd comment to make, but I don't think it is difficult to figure out why she said it. Obviously, the baby might have been saved in a hospital. When I was in training, the goal for "crash" C-section was 5 minutes into the operating room and 120 seconds from skin to baby. We didn't always reach the goal, but we were usually not very far off. In contrast, this baby went at least 56 minutes without adequate oxygen.

If the mother acknowledges that this baby could have been saved in a hospital, she would have to assume some guilt for her decision to deliver at home. She cannot accept the burden that she contributed to the death of her own baby. She doesn't simply persist in a private fantasy that the baby could not have survived in a hospital, which undoubtedly gives her comfort. She actually wrote about it in a newspaper, as if to convince the public at large that she was not responsible. How very, very sad.

32 Old Comments:

MM posts an anecdote:

Last year a just born newborn baby was put into a coma and may be forever in a vegetative state because the hospital nurse accidentally asphyxiated him by force with a mask of CO2. Gee, that would not likely have happened in a planned unassisted birth. Have we learned anything about the safety of hospital birth? Nope, it's just an anecdote. Every birth outcome becomes part of the big picture, and the big picture is that home birth and hospital birth are reasonable choices.

http://www.kgmb.com/kgmb/display.cfm?storyID=3693

By Anonymous Anonymous, at 2:55 PM  

This infant was surely killed by improper care.

If the hospital claimed the "the baby would have died at home anyway", wouldn't that seem odd to you?

You have missed the point of the post.

By Blogger sailorman, at 3:09 PM  

MM,

Let's compare the two events. The hospital event was malpractice, violating the rules of neonatal care. The nurse, doctor and hospital were likely sued and paid out millions of dollars to the parents to compensate them (not that there is enough money in the world to truly compensate them). The nurse may have been officially sanctioned. She may have lost her license.

The homebirth delivery was also malpractice, BUT homebirth midwifery actually RECOMMENDS and CONDONES such malpractice. People just shrug off these deaths as if they were no big deal.

FURTHERMORE, even when you include malpractice events in hospital deliveries the hospital deliveries are STILL safer than homebirth.

This is a very important point, MM. Throw in all the arrogance of some obstetricians, the poor judgments of some obstetricians and the outright malpractice of some obstetricians and hospital birth is STILL safer.

What is most remarkable about the anecdote posted by Dr Crippen is that even after the baby died and after if was apparent that the midwife and patient had made a terrible, deadly mistake, they still don't understand.

Can you imagine the hospital nurse saying that the decision to hook the mask up to CO2 was the right decision? Can you imagine the nurse defending herself by saying that it didn't matter that she hooked the mask up to CO2 because the baby would have died anyway?

That would be grotesque, but it is precisely what the midwife and the mother are doing. They made the biggest mistake they could possibly make and the baby died as a result. Yet instead of humbly acknowledging it, they are trumpeting the fact that they believe it really makes no difference!

Homebirth could be reasonable choice for some people in certain situations, but it is never a safer choice.

By Blogger Amy Tuteur, MD, at 3:11 PM  

Amy, it's an interesting choice for you to post an anecdote, when you've disallowed those of us who disagree with you from citing anecdotes. Once again, if this is to be a fair debate, please follow the rules that you've made for the rest of us.

Let's imagine for a moment that the woman in the story was planning to give birth at the hospital with an obstetrician. Let's say that she was 38 weeks and not in labor, and decided to visit her mother in a rural area, an hour from the hospital. Let's say her water broke at her mom's house and the cord prolapsed. Someone called 911, and a paramedic rushed in and tried to hold the baby's head off the cord for the hour's ride to the hospital. Would the baby's death have been the pregnant woman's fault?

By Blogger Anne, at 3:44 PM  

Anne:

"Amy, it's an interesting choice for you to post an anecdote, when you've disallowed those of us who disagree with you from citing anecdotes. Once again, if this is to be a fair debate, please follow the rules that you've made for the rest of us."

I am posting the anecdote as just that, an anecdote. I am not posting it in support of any claim, nor am I posting with the intent of using it as a substitute for research.

What I found remarkable about the anecdote was not that the baby died, since there is research to show that this can and does happen at homebirth, but that even AFTER the baby died, the mother refused to take responsibility for her decision and her contribution to the baby's death.

Sailorman asked a very pertinent question. If the cord prolapse had occured in the hospital and it had taken the staff 56 minutes to deliver a baby who subsequently died, would you excuse the hospital because the "baby would have died anyway"?

By Blogger Amy Tuteur, MD, at 4:00 PM  

Amy wrote:
"If the cord prolapse had occured in the hospital and it had taken the staff 56 minutes to deliver a baby who subsequently died, would you excuse the hospital because the 'baby would have died anyway'?"

No, I would not excuse the hospital in that case. Hospitals should be prepared to offer a crash Cesarean much more quickly than that.

It's an entirely different situation in the planned homebirth; the woman did not plan her birth to be within moments of an operating table in case of a very rare, life-threatening emergency. I'm assuming that she considered the risk acceptable in her case.

If I'm seated at a restaurant, place my order, and have to wait an hour before my food is served, that's unacceptable. If I'm at home, I get hungry, and I have to drive 45 minutes to the restaurant, I expect it to take about an hour from hunger to dinner. Very different scenarios.

By Blogger Anne, at 4:07 PM  

Anne:

"It's an entirely different situation in the planned homebirth; the woman did not plan her birth to be within moments of an operating table in case of a very rare, life-threatening emergency. I'm assuming that she considered the risk acceptable in her case."

Evidently not. The mother could have written an article that said, I think that homebirth is safe except that there will be certain rare cases in which something catastrophic will happen and the baby will die. I was willing to take that risk, and, unfortunately, I was one of the rare cases. Nonetheless, I still think that homebirth is going to be safe for most women.

That's not what she said though. Her article claims that her experience tells us nothing about the safety of homebirth since her baby would have died regardless of where it was born. If she is writing articles like that to misinform the public, then she is certainly giving misinformation to her patients.

Personally, I think the whole thing is grotesque. She is partly responsible for the death of her baby. Her baby died because she didn't and she still doesn't understand the risk inherently associated with home birth. It is simply ghastly for her to use the memory of her dead baby in that way.

By Blogger Amy Tuteur, MD, at 6:23 PM  

the story is tragic- I have also heard similar stories with better outcomes- and I have also heard of deaths reported as cord accidents that occur in hospital .
once a problem is detected- and a team is assembled it might only take 5 minutes to get a baby out- but from decision to incision I have never seen happen in 5 minutes even with everyone in the hospital. We have been repeatedly warned to not use our anecdotes and then here you go publishing someone else's-
How about a care provider telling you that they "replaced" a prolapsed cord more than once and then just went about their business until delivery?

By Anonymous Anonymous, at 10:26 PM  

I also disagree I believe the woman did take responsibility for her choices. I most often find that suing is a symptom of either mistreatment or patients not taking responsibility.
Can the hospital prevent every cord prolapse?
no babies ever die in the hospital who have a cord prolapse?
you are still working from a premise that hospial prevents and protects every tragic event-- and clearly it doesn't -
now what if this baby survived until 29 days post birth on respirators and such-- the result would be the same- the family does not have a live baby but it would no longer be a neonatal death.

By Anonymous Anonymous, at 10:43 PM  

I notice that there has been an emphasis in many discussions on how rare some of these complications can be. But besides rare, I choose to focus on "completely unpredictable." Low risk really means nothing to me. I really feel that anyone can be high risk in a moment's notice, even if catastrophic complications are rare.

By Blogger NeoNurseChic, at 3:06 AM  

Neonursechic:

"Low risk really means nothing to me. I really feel that anyone can be high risk in a moment's notice, even if catastrophic complications are rare."

That's absolutely true. That probably accounts in part for the excess neonatal deaths in every homebirth study. There are some homebirth midwives who ignore risk factors (postdates, for example), but there are others who appear to not to understand that "low risk" does not mean "no risk".

By Blogger Amy Tuteur, MD, at 7:06 AM  

Anonymous:

"you are still working from a premise that hospial prevents and protects every tragic event-- and clearly it doesn't"

No, that is the straw man premise that you have set up in order to be able to knock down. Here is my premise (supported by all the existing research data):

It is true that the hospital cannot save any baby. I think you would be forced to agree, however, that any baby who could not be saved in the hospital cannot be saved at home. Right?

So, although the hospital cannot save every baby, it can always save MORE babies than could ever be saved at home.

I will go even further than that to say:

Even when you add in any mistakes that are committed at a hospital, or any iatrogenic complications, the chances of neonatal survive is STILL greater at the hospital than at home.

By Blogger Amy Tuteur, MD, at 7:15 AM  

I do think that there are some mothers and babies that are "saved" by birth at home. So no I am not "forced" to agree.
I think that there is a different risk set for hospital births than home births.
exposure to anestiesia
which does multiple things- persistance of OP being one thing
increased exposure to infections ( lets just sample the critters on the walls)
increased c-section rate which has a maternal mortality to it
more likely to have birth injury due to how delivery is managed

By Anonymous Anonymous, at 9:12 AM  

"Even when you add in any mistakes that are committed at a hospital, or any iatrogenic complications, the chances of neonatal survive is STILL greater at the hospital than at home."

Let's say you are correct about neonatal mortality. What about infant mortality? What about maternal mortality? What about infant & maternal morbidity? What if there is no difference or a better infant mortality outcome with home birthed babies? If a baby survives a few weeks, you can just call it good? There is much more to be analyzed than neonatal deaths!

By Blogger Mama Liberty, at 9:38 AM  

Mama Liberty:

"Let's say you are correct about neonatal mortality. What about infant mortality? What about maternal mortality? What about infant & maternal morbidity? What if there is no difference or a better infant mortality outcome with home birthed babies? If a baby survives a few weeks, you can just call it good? There is much more to be analyzed than neonatal deaths!"

I agree. It would be interesting to see a long term study of cognitive development in babies born of low risk mothers in the hospital vs at home. To my knowledge, such a study has not yet been done.

We do, however, have tremendous experience with maternal anesthesia, maternal sedation, epidural use and other inventions. To my knowledge, no one has been able to demonstrate that any of these interventions are associated with anything that compromises health or cognitive development. The interesting thing would be to find out if the same thing is true of homebirth.

By Blogger Amy Tuteur, MD, at 9:51 AM  

although you have tons of experience giving mothers drugs- you haven't done the studies the long term follow up studies to see what exposure does- and it could be things in all directions
you know that there is a long term study on exposure to cigarettes, and marijuana - at least 20 years. you would think something so whole heartedly embraced by physicians as anesthesia would be studied on the long term-
and people who conduct studies are usually interesting - one of the guys who did the early epidural studies - said to me although they had -- results he would not personally recommend that women use it- this guy has gone on to now publish other research having to do with alternative means to improve overall health ( not related to birth)

By Anonymous Anonymous, at 1:01 PM  

For those who are against anesthesia, would you advocate that women not be allowed to have anesthesia if they so choose? That all women be forced to have unmedicated births?

Just curious....because in the hospital, we do allow for women to give birth without anesthesia. Anesthesia isn't forced on women for vaginal deliveries! However, if a mother requests it, it is something she can have to ease her pain....

And it's not like anesthesia is a new thing. I was born under epidural 25 years ago...and I'm not dead and was valedictorian. Anecdotal, yes, but still.....I think far fewer people would have made it to this point if anesthesia was as damaging as you are all proclaiming it is...

By Blogger NeoNurseChic, at 1:21 PM  

let me see every 15 minutes you have an "expert" asking you if you are ok and do you want to have pain relief-- so many nurses have not seen an unmedicated birth that they do not know how to support nor assess a non-medicated mom.
in the last year we have been requested to teach and have been teaching a labor assistance class for OB nurses because they do not know how to do anything other than to give drugs. The other hurdle is the doc who prefers his women medicated as well- being on the inside you know very well what I am talking about.
I also have a question about congenital anomalies in the Amish population- do you see many where you work in Pen? I understand that there is a study/ attempt to start collecting data similar to the genetic info for Jewish populations-

By Anonymous Anonymous, at 1:46 PM  

neonursechic:

I am a doula and I would NEVER withhold pain medication from a laboring woman. It is a personal decision for everyone. I advocate choice for every woman - but especially educated choices.

I myself do not wish to have medication during childbirth. I also do not wish to be kept in bed or have an IV or constant fetal monitoring or not be able to eat and drink during labor.

If I were to give birth in a hospital that required an IV and EFM, which would confine me to bed, I would likely become so miserable that I would very MUCH want anesthesia. It isn't that epidurals are being forced on women - it's that the entire typical hospital routine is something of a railroad track. There is not much choice left under the circumstances many hospitals put laboring women into.

If you are in a hospital that does not have routine IVs or EFM, that's fantastic! They are becoming very rare.

By Blogger jenn, at 1:55 PM  

Anonymous:

"although you have tons of experience giving mothers drugs- you haven't done the studies the long term follow up studies to see what exposure does"

Wrong again. There are plenty of studies. No, I am not going to look them up for you. You can use Google Scholar just like I can.

By Blogger Amy Tuteur, MD, at 4:29 PM  

I think you need to look at pub med to hell with scholar- everything has a cost

By Anonymous Anonymous, at 9:50 PM  

Wanted to point out this interesting comment from the Dr. Crippen thread.

My second son was born while we were living in Scotland and it was fascinating to see the differences in the maternity care system. Homebirth is well integrated into the UK system of care, and every year (as the linked comment points out) there is a national assessment of all maternal deaths and all stillbirths and infant deaths. The results are published for anyone to read.

Under this system, it ought to be straightforward to determine whether homebirth leads to too many dead babies. I do not have access to the 1997 report, but it is summarized here. Combined stillbirths and neonatal deaths occurred at a rate of 0.84/1000 in the homebirth group and at 1.06/1000 in the low-risk hospital group.

In March 1999, Zander and Chamberlain published a BMJ article stating that "No evidence exists to support the claim that a hospital is the safest place for women to have normal births." A professor of ob-gyn wrote to object, citing studies from the US along with the Bastian study from Australia (again, I agree with Bastian's conclusion that high-risk homebirth carries an elevated risk of perinatal death, and I advise you not to hire a midwife who DOES NOTHING in response to fetal distress). I am struck by the unanimity of the responses to Dr. Drifer, from professionals of varying stripes: the UK stats don't support the idea of homebirth as unsafe.

By Blogger Jamie, at 1:42 PM  

Jamie,

I would be curious to read the 1997 report in full.

Really, I'm usually only looking at 3 things, which you can probably predict by now:

1) how well they did the assignment of groups, and risks, and

2) how they decided which deaths to include or not include, and

3) How they did their stats.

I have no idea what the 1997 study ACTUALLY did. But (this quote taken from the linked site) someone seems to think they did this:

"The women were matched for age (within 5 yrs), number of previous children, where they lived, and past obstetric history"

These are all important factors. I know these are not all the factors--and I don't think they're even the "four most important" factors--which affect the neonatal mortality rate.

Smoking, drinking, drug use, race....

This is VERY interesting to me, because I don't actually know what the answer is for this particular data.

SO I'll make a deal. Let's see if we can agree in principle:

THE DEAL: For every study which shows equal death rates, and which properly apportions deaths as being 'birth site related' (we can do this ourselves, if the authors give the data):

If the data show that the women in the home birth group were MORE likely to suffer high neonatal death rates, I'll accept the study as showing that home birth is safer.

If the data show that the women in the hospital group were MORE likely to suffer high neonatal death rates, you'll accept the study as showing that hospital birth is safer.

If the groups are really equal, we'll keep arguing.

Deal?

By Blogger sailorman, at 3:32 PM  

so I re-looked over the BMJ study and included in the home-birth deaths is a cord prolapse that happened in the hospital- the transfer of care happened in first stage of labor and upon ROM at the hospital cord prolapse--- so here is one that happened in the hospital and the baby died. What are the stats on a cord prolapse surviving even in hospital? another stat I would be interest in is vasa previa as this was another transfer of care ? could you have expected different outcomes in an originally intended hospital birth?

By Anonymous Anonymous, at 7:38 PM  

Am J Perinatol. 1999;16(9):479-84.

Current obstetrical practice and umbilical cord prolapse.

Usta IM, Mercer BM, Sibai BM.

Department of Obstetrics & Gynecology, University of Tennessee, Memphis, USA.

The aim of this study was to assess the contribution of current obstetrical
practice to the occurrence and complications of umbilical cord prolapse.
Maternal and neonatal charts of 87 pregnancies complicated by true umbilical
cord prolapse during a 5-year period were reviewed. Twin gestation and
noncephalic presentations were common features (14 and 41%, respectively).
Eighty-nine percent (77) of infants were delivered by cesarean section of which
29% were classical and 88% were primary. The mean gestational age at delivery
was 34.0 +/- 6.0 weeks, and the mean birth weight was 2318 +/- 1159 g.
Obstetrical intervention preceded 41 (47%) cases (the obstetrical intervention
group): amniotomy (9), scalp electrode application (4), intrauterine pressure
catheter insertion (6), attempted external cephalic version (7), expectant
management of preterm premature rupture of membranes (14), manual rotation of
the fetal head (1), and amnioreduction (1). There were 11 perinatal deaths.
Thirty-three percent of the infants (32) had a 5-min Apgar score < 7 and 34% had
a cord pH < 7.20. Neonatal seizures, intracerebral hemorrhage, necrotizing
enterocolitis, hyaline membrane disease, persistent fetal circulation, sepsis,
assisted ventilation, and perinatal mortality were comparable in the
"obstetrical intervention" and "no-intervention" groups. Most of the neonatal
complications occurred in infants < 32 weeks' gestation. We conclude that
obstetrical intervention contributes to 47% of umbilical cord prolapse cases;
however, it does not increase the associated perinatal morbidity and mortality.

PMID: 10774764 [PubMed - indexed for MEDLINE]

By Anonymous Anonymous, at 7:49 PM  

Br J Obstet Gynaecol. 1995 Oct;102(10):826-30.

The mortality and morbidity associated with umbilical cord prolapse.

Murphy DJ, MacKenzie IZ.

Department of Obstetrics and Gynaecology, John Radcliffe NHS Trust, Oxford, UK.

OBJECTIVE: To examine the management of cord prolapse and its morbidity and
mortality. DESIGN: Retrospective study of consecutive babies born after cord
prolapse, identified using the Oxford Obstetric Data System, and those with
registered handicap, identified by the Oxford Region Register of Early Childhood
Impairments. SETTING: District maternity hospital managing more than 6000
deliveries annually. SUBJECTS: One hundred and thirty-two babies born after the
identification of cord prolapse in the John Radcliffe Hospital between January
1984 and December 1992. MAIN OUTCOME MEASURES: Survival rates, condition at
birth assessed by Apgar scores at 1 and 5 minutes and blood gas values on cord
blood samples, and incidence of major handicap at three years of age. RESULTS:
The incidence of cord prolapse was 1 in 426 total births. There were six
stillbirths and six neonatal deaths. One baby died as a result of birth
asphyxia. The uncorrected perinatal mortality rate was 91 per 1000. Of 120
survivors, only one baby was known to suffer a major neurological handicap.
Electronic cardiotocographs aided the diagnosis of cord prolapse in 41% of
cases. Apgar scores were better with a shorter diagnosis to delivery interval,
but cord gas results did not correlate well with Apgar scores or the diagnosis
to delivery interval. CONCLUSIONS: Cord prolapse occurs with a relatively stable
incidence in this population irrespective of changes in obstetric practices.
Despite the high incidence of ominous cardiotocographs, low Apgar scores and
acidaemia on blood gas analysis, the fetal outcome is not as poor as might be
expected and mortality is predominantly attributable to congenital anomalies and
prematurity rather than birth asphyxia.

PMID: 7547741 [PubMed - indexed for MEDLINE]

By Anonymous Anonymous, at 7:51 PM  

J Reprod Med. 2005 May;50(5):303-6.

Umbilical cord prolapse in current obstetric practice.

Boyle JJ, Katz VL.

Department of Obstetrics and Gynecology, Good Samaritan Hospital, Corvallis,
Oregon, USA.

OBJECTIVE: To assess the incidence, risk factors and outcomes of umbilical cord
prolapse in current obstetric practice. STUDY DESIGN: This study was a
retrospective chart review at both a community hospital and a tertiary referral
center. RESULTS: There were 52 cases of cord prolapse in our patient population,
for an incidence of 3.0/1,000, similar to that in the literature. Of viable
singleton pregnancies with frank prolapse, the rate was 1.6/1,000. In this
series we found an approximately 40% higher rate of frank cord prolapse in
induced patients at the community hospital than in the general population. Other
than 2 fetal deaths related to extreme prematurity, all mothers and infants did
well. CONCLUSION: The higher incidence of cord prolapse among women with
induction of labor in this population merits further study. The lack of
significant morbidity and mortality in the study suggests that modern obstetric
practices may influenced the natural history of umbilical cord prolapse.

PMID: 15971477 [PubMed - indexed for MEDLINE]

By Anonymous Anonymous, at 7:57 PM  

J Gynecol Obstet Biol Reprod (Paris). 1996;25(8):841-5.

[Cord prolapse. Review of the literature. A series of 50 cases]

[Article in French]

Dufour P, Vinatier D, Bennani S, Tordjeman N, Fondras C, Monnier JC, Codaccioni
X, Lequien P, Puech F.

Service de Gynecologie-Obstetrique, Hopital Jeanne de Flandre, CHRU, Lille.

OBJECTIVES: Identify the role of cord prolapse in modern obstetrics by
estimating the frequency of this obstetrical accident, its conditions, prognosis
and treatment and by analyzing factors favoring development of cord prolapse.
METHOD: From a retrospective study of 50 observations of cord prolapse occurring
in the department of obstetrics from January 1985 to June 1994. Results were
compared with those reported in the literature. RESULTS: The frequency of cord
prolapse was 0.21% over the 10-year period. Cesarean section was required in 72%
of the cases, and obstetrical manoeuvers were used in some of the vaginal
deliveries (28%). Neonatal mortality was 20/1000. Predisposing factors were
breech presentation, prematurity, twin pregnancy and multiparity. CONCLUSION:
Despite much progress in obstetrics, the frequency of cord prolapse has not
changed over time. The consequences are not as lethal as in the past, because of
progress in diagnosis and neonatal resuscitation. Fetal prognosis remains
however severe.

Publication Types:
Case Reports
Review

PMID: 9026515 [PubMed - indexed for MEDLINE]

By Anonymous Anonymous, at 8:08 PM  

Obstet Gynecol. 2004 May;103(5 Pt 1):937-42.

Vasa previa: the impact of prenatal diagnosis on outcomes.

Oyelese Y, Catanzarite V, Prefumo F, Lashley S, Schachter M, Tovbin Y, Goldstein
V, Smulian JC.

Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and
Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School/Robert Wood
Johnson University Hospital, New Brunswick, New Jersey 08901, USA.
YinkaMD@aol.com

OBJECTIVE: To evaluate outcomes and predictors of neonatal survival in
pregnancies complicated by vasa previa and to compare outcomes in prenatally
diagnosed cases of vasa previa with those not diagnosed prenatally. METHODS: We
performed a multicenter study of 155 pregnancies complicated by vasa previa.
Cases were obtained from the Vasa Previa Foundation and 6 large hospitals.
Comparisons were made between groups based on prenatal diagnosis status and
neonatal survival. RESULTS: The overall perinatal mortality was 36% (55 of 155).
In 61 cases (39%), vasa previa was diagnosed prenatally; 59 of 61 (97%) infants
from these pregnancies survived compared with 41 of 94 (44%) in cases not
diagnosed prenatally (P <.001). Median 1- and 5-minute Apgar scores in cases
diagnosed prenatally were 8 and 9, respectively, compared with 1 and 4 among
survivors in cases not diagnosed prenatally (P <.001). More than half (24 of 41)
of surviving neonates born to women without prenatal diagnosis required blood
transfusions compared with 2 of 59 diagnosed prenatally (P <.001). Multivariable
logistic regression analysis showed that the only significant predictors of
neonatal survival were prenatal diagnosis (P <.001) and gestational age at
delivery (P =.01). CONCLUSIONS: Good outcomes with vasa previa depend primarily
on prenatal diagnosis and cesarean delivery at 35 weeks of gestation or earlier
should rupture of membranes, labor, or significant bleeding occur.

Publication Types:
Multicenter Study

PMID: 15121568 [PubMed - indexed for MEDLINE]

By Anonymous Anonymous, at 8:11 PM  

Anonymous:

"? could you have expected different outcomes in an originally intended hospital birth?"

I appreciate that you went to all the trouble to read the original paper and then to find other papers on the topic. That is excellent!

However, the original paper shows that the cord prolapse was discovered in the hospital. In other words, the cord was being compressed at home (that's probably why the patient was transferred). The fact that the baby did not survive in the hospital indicates that it could not have survived at home. It is not clear if the cord prolapse could have been discovered earlier in the hospital.

In the second case, the vasa previa ruptured at home and the patient began hemorrhaging there. (Vasa previa is a rare condition in which major blood vessels run through the amniotic membranes. As the membranes begin to bulge through the cervix, the vessels can rupture and mother and baby can bleed to death.) It is possible that this baby would have survived if the vasa previa had been diagnosed before labor by ultrasound or if labor had started at the hospital.

Either case, if managed at home, would have resulted in a dead baby.

By Blogger Amy Tuteur, MD, at 7:57 AM  

so no the cord there is no evidence either way- cord may have been low and something was detected - abnormal dips or weird variables that is why there was a transfer- in first stage- with artificial ROM at the hospital the cord prolapsed out and at that point would have been compressed and the baby died- in the hospital- the point being that no matter where this birth was intended to occur this baby probably would not have survived- the point that Doctor Crippen tries to make is that babies survive in the hospital when they have cord prolapse- and yet the studies from the UK show it is not quite 50/50 .
I would guess that premature infants might actually fare better on the cord prolapse end of things more so than full term because there may be room for cord and baby in the canal without the cord being compressed as much- a term baby with the force of a contracting uterus is a lot to hold back and try to prevent compromise-
as for vasa previa I am not sure where that rupture was either- maybe in transport- but even discovered in the hospital in labor the death may not have been prevented-

By Anonymous Anonymous, at 11:05 AM  

"As the membranes begin to bulge through the cervix, the vessels can rupture and mother and baby can bleed to death.) "

now this is vasa previa not placenta previa-
with vasa previa it is the vessels of the infant connected to the umbilical cord that are in the membranes that then travel to the placenta or a vessel that travels off the placenta and across the membranes the vessels are in front of the the baby's head at the cervix- it is just fetal circulation that is compromised - there would not be maternal blood loss-
a separate but similar problem is placenta previa where the placenta is attached to the mother either completely over the cervical opening or marginally over the cervical opening(os) as the os opens it breaks the attachments to the placenta so compromises maternal circulation as well as some infant circulation

By Anonymous Anonymous, at 11:25 AM