Reducing maternal deaths

EKG monitor

Earlier in the week I criticized the ProPublica/NPR piece on maternal mortality (What ProPublica didn’t explain and possibly didn’t even know about maternal mortality).

We must create regional centers for maternal intensive care just as we have done for newborn intensive care.

Because ProPublica failed to explain changes in reporting of maternal mortality, failed to explain the changing causes , failed to explain the outsize contribution of race and failed to explain the inherent deadliness of childbirth, they presented a fundamentally misleading picture of the issue. But there is disturbing fact that they got absolutely right: 60% of maternal deaths are potentially preventable.

In order to understand how these deaths could be prevented, we need to understand what causes them.

IMG_2388

The chart above shows the leading causes of pregnancy related deaths. These causes can be roughly divided into three groups, pre-existing medical issues, complications of pregnancy, complications of hospitalization.

Let’s start with the easiest group first, complications of hospitalization. Deaths due to infection and thrombotic pulmonary embolism make up the bulk of these deaths. They aren’t strictly due to hospitalization; they have always been leading causes of death because childbirth puts women at risk of infection and pregnancy puts women at increased risk of blood clots. But there are easy to implement methods that can dramatically reduce both, including checklists and proper aseptic technique to reduce infection and low dose heparin and compression boots to reduce blood clot formation. A lower C-section rate could contribute to a reducing both complications as well. This is the low hanging fruit of the maternal mortality problem, easy to grasp and easy to correct. We will never be able to abolish all infection and blood clots in pregnancy, but we can do a lot better.

The second group is complications of pregnancy like hemorrhage and hypertensive disease (pre-eclampsia and eclampsia) as well as strokes resulting from high blood pressure. Both hemorrhage and hypertensive disease are endemic to pregnancy. Neither can be entirely or even mostly prevented (at least not yet); they must be treated. And before they can be treated, they must be diagnosed.

We know that a certain percentage of women will hemorrhage after childbirth just like we know that a certain percentage of women will developed hypertensive diseases of pregnancy. Diagnosing those problems as early as possible requires an high index of suspicion, careful monitoring, and the immediate application of technology. This is where algorithms, drills and tool kits come into play. No one should assume that a woman won’t develop childbirth complications; everyone should be alert to the a fact that they are both common and inevitable. Algorithms can help providers make an early diagnosis.

Hemorrhage and pre-eclampsia are often full blown emergencies where minutes count. Tool kits allow providers to have all relevant diagnostic and treatment technology at hand. Drills help providers utilize that technology expeditiously. They are often the difference between life and death.

Cardiomyopathy is also a complication of pregnancy but not nearly so common as hemorrhage and pre-eclampsia. It is relatively rare and therefore most providers may have never seen it. Nonetheless it is one of the fastest growing causes of maternal death. Unfortunately:

Early, rapid diagnosis of peripartum cardiomyopathy is not the norm. It took 7 or more days to establish the diagnosis in 48% of women, and half of those had major adverse events before the diagnosis was made…

In this situation the most important elements are high index of suspicion when women complain of shortness of breath or chest pain and rapid consultation with cardiologists and other specialists.

The final group is pre-existing medical conditions. Childbirth is now more common than ever in women who are older, heavier and suffering from a greater number and range of pre-existing medical conditions. In many cases, such as heart disease and kidney disease, pregnancy and childbirth can put tremendous strain on already weakened organs. Specialized intensive care is the key to preventing maternal deaths.

We long ago recognized the value of specialized intensive care in saving the lives of critically ill newborns. That’s what led to the creation of neonatal intensive care units (labeled Level I, II or III based on the type of technology available), neonatologists, and routine regional transfer of newborns to higher level NICUs. A premature or critically ill newborn will be transferred to a Level III nursery if born at a hospital that only has a Level I or II nursery.

It’s hardly surprising that we addressed the intensive care issue in newborns first. Death rates for newborns are approximately 100X higher than for new mothers. It is surprising that we have never addressed the issue of maternal intensive care units, maternal intensivists and routine regional transfer of critically ill mothers at all. Mothers are dying as a result.

Only the rare obstetrician is trained in intensive care. No obstetrician should be trying to manage pregnant women with pre-existing medical conditions on his or her own. The appropriate specialists should always be involved hopefully before complications develop and certainly after.

Most intensivists trained in the care of adults are typically unfamiliar with the specific issues that arise in conjunction with pregnancy. We should create regional centers for maternal intensive care just as we have done for newborn intensive care. We should rank them by available technology and we should routinely transfer women to higher level centers to deliver there preferentially or when they develop complications after birth.

We’ve all read countless articles in the mainstream press about efforts to reduce pregnancy interventions, but there is precious little effort being made to reduce maternal deaths. New mothers will continue to die until we develop the will and deploy the technology to prevent these eminently preventable maternal deaths. Let’s stop wringing our hands, and start working.

  • Ob in OZ

    Thanks. This is exactly what is needed. Unfortunately MFM has become ultrasound, with very little maternal medicine being taught. This subspecialty has lost its way.

  • Gæst

    What would the difference be between a maternal ICU and an antenatal ward?

    • Basically an intensive care unit would be for severe, acute patients (most of whom would probably either at erm or postpartum) and an antenatal unit insures that patients can be monitored over a considerable period for observation or lower level interventions prior to birth. For example, an ICU would be the place fot someone who had a severe hemorrhage resulting in DIC, while an antenatal unit would be appropriate for someone with sporadic mild bleeding due to a complete placenta previa.

      • Gæst

        Thanks. I was put in the antenatal unit for two separate overnight occasions, is why I asked. Both times were for observation related to pre-eclampsia.

        • Melaniexxxx

          Usually ICU/HDU patients have 1:1 nursing care – so if your pre-eclampsia had decompensated, or you had HELLP or eclamptic seizures, ICU would be more appropriate. Once you recovered you would be able to be ‘deescalated’ to the regular AN ward.

          • Gæst

            I was held in the post-op ward for about eight hours, and they were going to have me there overnight because there was a shortage of beds in the antenatal ward. It was awful – at one point my bed was left in an upright position, and it was not the kind I could adjust myself, and I had no way to call a nurse except to try and yell. Because it was post-op, the only permitted visitor was my “spouse” (which I did not have).

            Antenatal ward I was in a broken bed that also could not be adjusted, but at least I had a call button. However, it was awkward to be roomed with a woman who was losing her baby while mine were (presumably – no one from the NICU would visit post-op or antenatal to talk to me) fine in the NICU. Sometime the next day I was put in the mother-baby ward. There, they roomed me with another mother whose baby was in the NICU. My television was broken, which I personally did not give a fig about, but there was a baby care/shaken baby/etc. video that I was required to watch so the nurses were all upset about that. In the NICU, they said I could visit or call anytime (on the third day they explain this), but in spite of that I am asked to leave on several occasions when doctors are doing their rounds – presumably so I don’t hear confidential information about other babies nearby, because I sure would have liked to hear information about *mine*. There aren’t enough chairs for every bassinet there, and often the nurses assigned to my twins weren’t anywhere to be seen, so I had to drag my own chair over – 3 days post c-section. And if I’m in the NICU when doctors do rounds in mother-baby they freak out about where is this patient? And if I’m there when meals are served, they don’t leave my meal for when I get back. The person who files birth certificates also expected me to be in my bed and not the NICU.

            So either they really need a maternal ICU at that hospital, or if they had one it would be just as awful, who knows.

          • Young CC Prof

            Yeah, that wouldn’t be maternal ICU. Maternal ICU is for women who are not just experiencing complications, but really desperately ill, either before or after giving birth.

            That hospital just sounds like it needs a proper system for NICU mothers who are still hospitalized. Ideally they would have beds of their own nearby, some new units actually have family NICU rooms, but that’s not always feasible.

          • Gæst

            The NICU isn’t even on the same floor as the antenatal and mother/baby units.

          • demodocus

            Ugh. At least in the labyrinth I had my NICU grad in, it was a reasonable hobble on the same floor between the antenatal section and the NICU.

          • Gæst

            They do have a dedicated elevator for staff and mothers to use to get down there.

          • demodocus

            Well, that’s something.

  • Young CC Prof

    A lot of maternal deaths in the USA aren’t due to failures of critical care, but failures of primary care: lack of access to medical care that prevented problems from being identified while they were still manageable.

    There are STILL women with no maternity coverage. There are, in some areas, not nearly enough obstetricians who take Medicaid. There are women’s health clinics closing right now.

    Let’s not forget to consistently do the simple stuff.

    • demodocus

      Now, now, don’t be hasty. Medical care is a privilege and the more poor people who die, the fewer us God Fearing Good People have to pay for
      /sarcasm, in case someone cannot tell.

  • evidencebasedbreastfeeding

    Meanwhile, in other news:
    http://www.uclan.ac.uk/conference_events/12th-international-normal-labour-and-birth-research-conference.php

    12th International Normal Labour and Birth Research Conference (Oct, 2017).
    “This is the twelfth international conference in a series that is
    designed to disseminate research, theory, art, drama, policy and
    practice relating to physiological childbirth. The conference will
    address social, cultural, physiological, psychological, emotional and
    spiritual aspects of labour and birth.”

    Wonder what exactly “normal” birth is, and why all other forms of birth are “abnormal”.

    And why it is important to have a conference about only normal birth. Rather than how to make birth as safe as possible for mothers and babies? I mean, if something has happened (or hasn’t happened that should have happened) that increases risk for mum/baby; doesn’t that merit a great deal of attention to make sure all interventions are as evidence based and safe and effective as possible? Shouldn’t that be the focus of conferences, given that the day of childbirth is the most dangerous one a mother will experience in her life (other than the day she herself was born)? – apparently.

    Feeling hopelessly discombobulated now.

    • AndreaRealMPH

      Dontcha know, there are “too many” conferences about medicalized birth and not enough celebrating normal birth!
      Grrr, I’m with ya.

      • evidencebasedbreastfeeding

        No, I don’t know.
        As long as women and babies are dying in childbirth or suffering needless morbidity as a result — probably, I would imagine thousands ever day worldwide – there are NOT ENOUGH conferences about what we need to do and learn in order to avert that harm.
        As long as these deaths and harms occur we shouldn’t have a single conference celebrating the joy that some women experience in their joyful perfect births, because it’s like pissing on the graves of those who couldn’t get medical help in childbirth or for whom that medical help was in some way insufficient, too late, or suboptimal.
        Or is that just scroogey?
        My COI: I had one normal birth and one abnormal one. Everyone turned out great. Thank you for good evidence-based medical and midwifery care.

        • AndreaRealMPH

          I’m with you on the more conferences to prevent mother-baby deaths. Artists gonna art no matter what, but I could see where a loss mom may lose it on that one.

    • Charybdis

      Why would they think that disseminating “theory, art and drama” has any place in an “International Normal Labour and Birth Research Conference”? The ‘theory’ I can give a pass to, to a certain extent, until/unless it moves into the “happy thoughts and positive associations only, please. Negativity will cause issues requiring nasty interventions.
      But “art” and “drama”? Belly casts of histrionic mamas-to-be in some elaborately staged and dramatically lit piece of performance art? Not so much.

    • AnnaPDE

      Why don’t they have something about the drama and art of C-Sections? Now I feel like I missed out on something incredibly important. Should I have pantomimed to my OB while she was cutting me up? Should we have painted tribal patterns on my belly beforehand? Should my son have done interpretive dance instead of just looking around the room with an expression somewhere between disgust and condescension before letting out a cry?

  • Amazed

    OT: Please wish me luck. Blood donating isn’t well-developed here and it’s common for people who will have a surgery to have to find some of the blood themselves. I got a morning call from my cousin. The father of a friend of hers will be here for a surgery on Monday and I’ll try to donate blood today. The problem is, being in a monthly cycle, I’ve been on nothing but yoghurt and fruit these last two days and the warming that comes with May generally makes me reduce fat dramatically to feel good. I’m building myself up with foods and drinks before I go later today but please wish me luck to be approved because if they find me too lacking in diet or something, they will not take my blood.

    • MI Dawn

      Good luck! My daughter donates a lot, but has been turned down at times if her hemoglobin levels are good enough. (I can’t donate because, for some reason, my BP bottoms out EVERY time and it really annoys the Red Cross workers when they turn around and I’m as white as the sheet I’m on – even when lying down).

      • Amazed

        Thank you. Unfortunately, they turned me down about an hour ago. My hemoglobin levels are almost borderline and I am in a monthly cycle. They told me I could try again on Monday if the cycle does, indeed, end today. Unfortunately, I am not one of the women who simply spot their underwear. I mean, I do spot it but there are these huge outpourings even in the last day. The doctors would rather not take the risk that I might end up with two blood losses to recover from at the same time. I’ll try again on Monday.

        • Gæst

          I’m sorry you couldn’t donate. It isn’t your fault – you tried. It’s not about what you eat, but about those iron levels. I was nearly turned down once for irregular heartbeat, as well, but they are turning you down for your own good in those cases. I was also turned away once because I had an ear piercing that was too new, and I’m now permanently (?) disqualified due to having lived in the UK in the 90s for a bit – that’s to protect whoever might receive my blood.

          • Amazed

            Thank you. I know, I know it isn’t my fault but it makes me so angry that the structures here are so underdeveloped that we have to procure blood like we would have procured food for a loved one. And… buy it sometimes. There is a good number of people walking up and down the street in front of the blood centre and offering blood.

          • Melaniexxxx

            This is fascinating to me, sorry to be intrusive but some questions if you don’t mind! how do you know you can donate to your friend’s father? do you already know you have the same blood type?
            Also interesting re: the possibility of buying blood. Is that a common thing? And which country are you in?

            I think we are lucky – in Australia there is often a blood shortage, but nowhere near as severe as other nations. And you never know who you will donate to, it’s all put into a big pool etc, and i think it would be in fact MORE difficult to try to donate for a specific person because they would have to cross match you both etc. It’s illegal to buy blood

          • Amazed

            No problem at all! It’s quite simple indeed. The blood one donates isn’t the same that will go to the patient in need. With the shortages of blood, the hospitals just try to apply kind of pressure – like, unless it’s life or death, we can’t perform the surgery unless there is a certain amount of blood donated in the name of this specific patient. THEN, we’ll draw on our sadly limited reserves. Truth be told, I have yet to hear of someone actually being refused a surgery because no one donated but most people don’t question further and frankly, since I do believe in blood donation and I was raised in blood donating family, I never had the wish to investigate further – I just go and do it. Is it possible that they will actually refuse to perform the surgery? I don’t believe it is but I really don’t want to take the risk and I certainly wouldn’t have wanted to take it for a loved one.

            Buying blood is illegal here as well but when you’re in need, breaking the law seems like a very good idea. You’re very lucky in Australia indeed.

          • Melaniexxxx

            Ahhh wow, that makes sense! So it’s not like a direct donation but an incentive to ‘replenish the stock’ in a way 🙂

            Cheers!
            I donate when i can too, but about 50% of the time my Hb level is too low… eeep! we are indeed very lucky, I even had access to 2 units of blood at a very remote hospital i worked in recently,

        • Valerie

          I’ve never been asked if I’m currently menstruating when I donate blood (despite all of the other extremely personal questions). Is it really relevant? My understanding is that the protocols and limits they set are conservative because they don’t want volunteers to be injured and they don’t want bad press/lawsuits, so borderline levels are fine. I’m wondering if the doctors may be influenced by retrograde ideas about women and menstruation in advising you not to donate, and perhaps if you just don’t mention it, they will accept your donation. Good luck!

          • Amazed

            They don’t ask it but it’s preferrable if you mention it. The rules here are that it’s bad for you to donate earlier than at least a day after you’re “clean”. I was sorry for mentioning it and in fact, they might have accepted my donation without it if my hemoglibin levels weren’t borderline. But now I’m glad I mentioned it. I had a huge outpouring – fingers crossed that it’ll be the last I see of my cycle for this month – a few hours ago. I’m glad I don’t have two blood losses to recover from, instead of just one.

          • Valerie

            Yeah, it should be up to you, whether you feel like you are up for donating or not, with the practical reality of your cycle. Sucks to be held back by menstruation taboos, though- I didn’t even know blood donation was one of them.

          • Amazed

            Hehe, they don’t actually use the world “clean”. I used it because I honestly thought I was done with it for this month. Instead, I got myself AND the sofa very unclean. But yes, once having this mentioned to them, they ask questions. They made the right call by refusing to accept my donation because of these two things. A friend of mine was recently turned down because her dioptres are quite high. I never knew vision was a thing in blood donation.

            Perhaps it’s different in different countries? They do tend to lean on the conservative side quite heavily here. The irony is, I keep hearing how with donations being so few, doctors would take blood from anyone who offers when my mother, my father, two of my mom’s friends, my own friend and myself were turned down just in the last few months. It’s almost as if they don’t want to expose people to risk or something.

      • EmbraceYourInnerCrone

        They like even less when your BP bottoms out and you pass out and the needle pops out. Then I passed out again twice in the next 2 hours…Good times. Happened the second time I tried too.

  • Sue

    Has this paper been discussed here?
    Am J Obstet Gynecol. 2017 Apr
    Planned home births: the need for additional contraindications
    (https://www.ncbi.nlm.nih.gov/pubmed/28153656)

    Much more reliable data, analysis and interpretation than MANA.

    “We conducted a population-based, retrospective cohort study of all term (≥37 weeks gestation), normal weight (≥2500 grams), singleton, nonanomalous births from 2009-2013”

    “Planned home births had a higher rate of neonatal deaths than in-hospital births (9.35 vs. 3.59 NND per 10,000 deliveries). Pregnancies at highest individual NNM risk were those with 1. prior cesarean delivery (SR 18.01 vs 3.56 NND/10,000), 2. nulliparous women (SR 17.25 vs. 4.16 NND per 10,000 deliveries), 3. ≥41 weeks gestations (SR 13.14 vs. 4.38 NND/10,000), 4. ≥35 years maternal age (SR 10.61 vs. 3.17 NND/10,000). At highest risk for NNM were pregnancies of nulliparous women with ≥41 weeks gestation (SR 24.24 vs. 5.09 NND/10,000).”

    These people did not say, as Cheyney did, “not as bad as we thought”. They said “we should risk out these groups from home birth.”

    • Daleth

      Could you post the title and authors? The link for some reason doesn’t work.

  • Sue

    The data in the bar graph are very informative. We often hear about one of the risks of cesarean deliveries being anesthetic risks.

    Looking at the table, though, we see that 55 times more mothers die from amniotic fluid embolism (acknowledged as a rare event) than from anesthetic complications.

    • Merrie

      Not really the right comparison, though. How many have an anesthetic complication who survive it? It’s still worth discussing even if it’s not fatal or not often fatal.

      • MaineJen

        Absolutely, and when you sign the consent for anesthesia, all those risks are spelled out in black and white. It’s not hidden or a secret.

      • Charybdis

        Depends on what you call an anesthetic complication. I have horrible reactions to general anesthesia, due to the amount they have to give me to get me under and keep me there. Do I consider that a complication? I don’t, but others might and the hospital might categorize it that way.

      • Melaniexxxx

        Mmm, yes, and complications from spinal anaesthesia (most common for CS rather than GA) can be significant if not fatal!

  • Charybdis

    OT: I heard on NPR this morning that a tiny study (4 subjects, I think they said) has shown that orangutans will breastfeed their babies for up to 8 years. I wonder how far the lqctivists will run with that little tidbit.

    • Dr Kitty

      Orangutans are unusual for apes. They are solitary as adults, their infants are completely dependent on their mothers for longer than other apes, and the mother is often the only other orangutan the infant will see up close during their formative years.

      We’re more closely related to chimps and bonobos, who have large extended social groups, more robust parenting styles and who wean a lot earlier.

      Since almost few human cultures routinely breastfeed beyond 2, and very few beyond 3, I’d say we already know that humans shouldn’t nurse as long as Orangutans.

      • Charybdis

        True, but when the lactivists blather on and on about “all mammals nurse their babies” and mention things like “whales nurse their young for two years! Elephants go as long as 4 years! Chimps nurse up to 5 years! “, etc, this is just one more thing they can use to further their cause./eyeroll

        • demodocus

          and don’t forget that since human babies are born comparatively early in development, that means something too! Or something

        • Young CC Prof

          And kittens wean at 2 months. Maybe we should do that…

          • Charybdis

            How about the seal who weans after 4 days or the seals that abandon their pups after 12 days?
            Or the mammals that will eat their young. They don’t like to discuss that.

      • demodocus

        What we know and what the lactivists dilude themselves with are two different fishies.

        • Sarah

          Ah, fish. They have the right idea.

  • Roadstergal

    “lower C-section rate could contribute to a reducing both complications as well”

    Isn’t there a certain amount of trade-off? What is the difference in infection risk for a planned vs emergency C-section section? Is there a tip over point where trying to avoid c-sections leads to an increase in emergent ones that is riskier?

    Great article, thought-provoking!

    • Sue

      That’s the thing – what’s the point of reducing one risk by creating a worse one?

  • Amazed

    OT (Not quite): “Unless women can be assured of optimal care (the least
    use of medical intervention that produces the best outcomes given the
    woman’s individual case) in the hospital, if they are healthy, they are
    better off planning community birth with a qualified midwife because of
    their greatly reduced risk of exposure to medical interventions they
    neither need nor benefit from”

    It’s been a long time since I last visited sciencyandinsensitivity but Henci Goer never fails to disappoint. Stlll howling about them ebil interventions.

    https://www.scienceandsensibility.org/blog/safety-home-hospital-birth

    • RudyTooty

      She speaks from a place of high and lofty ignorance.

      • Amazed

        I disagree. I think she speaks from a place of delliberately obfscating the truth. For some midwives, I can believe they’re ignorant but Henci? She doesn’t know what the studies show? She knows very well and my forgiveness, she will never have. Lucky her, she doesn’t want it.

  • Mel

    I think training intensive care obstetricians is a great idea.

    I delivered at a really great hospital in Western Michigan – but there was a bit of a headache about where to put me after my CS. The hospital has at least 10 rooms set aside for high-risk L&D patients with one-to-one nursing; that’s where I was placed while the medical staff waited for my blood work to come back. It’s also where I met a fleet of resident OBs and more phlebotomists than I ever want to again – but that’s another story….

    The problem was where to put me after having a CS that foreseen to require one or more transfusions due to hemorrhaging from HELLP. The hospital had a floor dedicated to Special Care Obstetrics – mainly women on medically-supervised bedrest, NICU moms recovering from labor, and women whose baby had died – but the floor wasn’t set up to accommodate the 1-to-1 nursing I would need to manage my fluid dynamics after the transfusions and while still being on magnesium sulfate. So, I was going to the ICU which was highly skilled at fluid management, had one-to-one nursing, and was probably better hidden from the LCs – but the staff wasn’t as experienced with all the joys of postpartum moms and the rooms weren’t set up with a pump and refrigerator for milk storage.

    The problem was solved by my over-achieving platelets and uterus who held a team meeting and decided that they totally had this covered. To everyone’s surprise, I didn’t need a transfusion because I never started bleeding any more than a normal CS. This allowed me to be placed at Special Care OB right off the bat.

    I was really lucky. While I was very sick, my kidneys and liver held up much better than anyone expected from my blood work. My exercise-induced asthma decided to stay in abeyance. I was in good shape except for being AMA and overweight so I was able to get up and moving as soon as my epidural wore off.

    I’m sure having cross-trained physicians who could be called in on a more complicated case – what if I had had Type I diabetes, cystic fibrosis, sickle cell or an existing heart problem on top of HELLP? – would increase the level of care.

    For a start, you wouldn’t need a ton of trained intensive care OBs either. In Michigan, we would benefit from any – but having two in Western Michigan and four in Eastern Michigan would cover the vast majority of people in the state. That’s essentially placing two docs at each of the level 4 NICU hospitals and two up at Saginaw for UP and Upper Lower Pennisula patients who can’t be transferred down to Ann Arbor or Grand Rapids safely.

    • Anna

      What about anaesthetists? I’m an obstetric anaesthetist. In Australia (where I’ve trained) most of the large tertiary hospitals have a high risk obstetric anaesthetic service where the obstetric anaesthetists act almost like intensivists (and to a lesser extent obstetric physicians), co-ordinating and overseeing the care of the sicker parturients. We understand all too well the normal physiological derangements of pregnancy as well as pathophysiogy. Is this system seen in the US at all?

      • Sue

        Aus also has pregnancy hypertension specialists – usually renal consultants.

      • Dr Kitty

        Anna,
        Out of interest, what post-op analgesia do you write up for CS?

        The NHS in my area is interpreting “no codeine for breastfeeding women” to mean “no opioids for breastfeeding women” and sending women home day two post CS with just paracetamol and diclofenac, which is woefully inadequate for the vast majority, who then phone me (their GP) in tears day 3 because they are in agony.

        The male anaesthetic Registrar who told me at my pre-op assessment appointment prior to my (second) elective CS that maybe if I didn’t expect to feel severe pain this time, or perhaps watched some videos about CS to educate myself about the process and was less anxious, that “maybe I wouldn’t need opioids” got short shrift from me.
        To say that he had misjudged his audience was an understatement.

        • Young CC Prof

          ARRG! The codeine thing is because codeine is a precursor that metabolizes unpredictably, especially in children! Morphine doesn’t do that, a breastfed baby of a mother on a low dose of a drug like morphine isn’t going to have a freaking overdose.

          That’s got to be a deliberate misreading by people who don’t want to treat women’s pain, they can’t possibly miss the point that badly by accident.

          • Sarah

            Maybe it’s an eebil formula conspiracy.

          • Young CC Prof

            If breastfeeding meant no postop pain relief, I probably wouldn’t breastfeed, so yeah, that’s a formula conspiracy!

          • Dr Kitty

            Say the words “I think I’ll stop breastfeeding so I can get some proper analgesia” to an NHS midwife and watch how fast you magically acquire opioids.

            I gave them 3 choices.
            1) Put me down as breastfeeding, send me home without opioids and watch how many formal complaints to the hospital arrive, as well as complaints to professional bodies for ignoring maternal concerns and ignoring severe pain.

            2) Put me down as bottle feeding purely because of this policy, send me home with opioids and wait for the complaint to the hospital about breastfeeding being scuppered by poor analgesic options.

            3) Put me down as breastfeeding, fully aware of the risks of opioid analgesia and actively choosing it despite advice not to.

            They went for option 3.

            All was well, but I did not make any new friends.

          • Heidi_storage

            Did the fact that you’re a doctor cut no ice with them?

          • Dr Kitty

            As well as the ultra rapid metabolisers ( where the babies are at risk of overdose and it is common in Black African populations, but very rare in my white Irish patients) non metabolisers exist. About 10% of the UK population cannot turn codeine into a useful analgesic.
            I’m one of them.
            I’m also a horrible metaboliser of morphine and need massive doses to get effective analgesia.

            Fentanyl and Oxycodone work much better for me than codeine and morphine. Which is CP450 pharmacology, not a personal preference.

            It’s clearly documented in all my notes that if you want to give me morphine, it’s going to take scary amounts.
            I weigh 45kg. When I had a torted ovarian cyst it took 26mg of IV morphine to get my pain from an 8 to a 6, which was the point when my old notes arrived and I got drugs which actually work for me.

            Not a problem outside OB- I get Oxycodone, my acute pain is managed, everyone lives happily ever after, and no, I’m not addicted to opioids.

            Obstetrics treated me as an obstructive, hysterical, drug seeking harpy who had no concern for my baby, and which I did not appreciate.

        • Sarah

          What a bawbag, to use the language of your people.

        • AnnaPDE

          WTF? My (female) OB/Gyn here in Oz happily prescribed me some oxycodone and another “two people have to sign for it and watch me take it” painkiller for the first 5 days, and then I could take a dose for another week home… And no one even batted an eyelid about my son breastfeeding with that. (Not that he got a lot of milk transferred, but they didn’t realise that…)

        • Anna

          That sounds pretty barbaric…at my institution CS patients get intrathecal morphine intra-op, as well as paracetamol and parecoxib. Post op regular paracetemol and diclofenac with prn oxycodone +- tramadol. Some anaesthetists also add a few days of low dose oxycontin or Targin into the mix as well. Unfortunately the hospital tends to discharge them around the 48 hour mark and I couldn’t tell you what they go home with as the O&G rmo does the discharge script. Other hospitals keep them for longer (5 days post op was the norm at the private hospital where my son was born via CS) and no issue getting access to opiates, at least as an inpatient.

        • Melaniexxxx

          I just did and Obs RMO job in Aus and CS patients would get 3 days of 10/5 targin with PRN oxcodone and tramadol, along with regular ibuprofen and paracetomol.
          If they needed more, we gave them more! The usual spiel from me was that if they couldn’t do a small cough or sit in bed without pain they should take more analgesia.

          Didn’t help though when they went to the pharmacy sometimes – we had multiple women coming back in agony in distress because their local pharmacist refused to dispense their script saying if they had PRN 5mg oxynorm (max QID) their baby would ‘stop breathing and die’

          GRRR

      • Mel

        I’m not certain. I was treated by a standard anesthesiologist .

      • Melaniexxxx

        I’ve worked in obs in Australia too and had the support of an ObsMed physician (ie: RACP) for complex cases, thankfully! I wonder if that isn’t a thing in the US….

  • BeatriceC

    I guess I was extremely lucky to have knowledgeable high risk pregnancy doctors take over for my last two kids. I’m pretty sure if I had a regular OB I wouldn’t have survived YK’s pregnancy. And that’s not a slam on my regular OB. I actually loved her. But she knew when she was out of her element, and I got better care for that.

    • Heidi_storage

      Makes sense to me. Isn’t it a mark of competency to understand the limits of one’s expertise?

      • Sue

        That’s why true medical professionals collaborate with other team-members – not like renegate HBMWs.

  • Angie Jamison

    This article was very well written. It contrasted another article I read recently on the same subject. This one offered up solutions to the problem, whereas the other seemed to be angry that more emphasis was placed on baby instead of the mother. It even went so far as to make veiled attempts at blaming the baby. I felt as if some of the issues they brought up could easily be avoided. According to this, I was right.

  • demodocus

    So, long story short, there’s a widening gap for the me’s (relatively old and fat) of this world to fall through between ob and icu doctors’ knowledge?

    • Amy Tuteur, MD

      Right, but older and heavier is only a small part of the problem; pre-existing chronic disease is the real game changer. No obstetrician is trained to manage cardiovascular or renal complications and most ICU doctors aren’t aware of the tremendous physiological changes in pregnancy and at delivery.

      • Kristi Berry Pedler

        Not only ICU docs, but most non-OBs have no clue about normal vs abnormal values in pregnancy. I’m looking at you, ER docs.

        • Sue

          Boo to you! Physiology of pregnancy is part of the core Emergency Medicine curriculum, as is trauma in pregnancy, PIH, asthma in pregnancy, bleeding, bedside ultrasound…

          • Dr Kitty

            But you have to get an ER doc who is done that bit of the training.
            It may be part of the core curriculum, but it isn’t given on day 1 in the ER.

          • demodocus

            This is why I trust ER docs over CPMs or Mom’s home remedies. (Granted, so did Mom, her home remedies were for making you feel a smidge better after a mosquito bite or a regular cold). On the other hand, I got sent to L&D instead of the ER when my firstborn jumped on me while pregnant with my secondborn.

          • Kristi Berry Pedler

            That is true. But in general, ER docs don’t like dealing with it – and many times don’t by turfing the patient off to L&D ASAP – no matter what the complaint (15 weeks with a cough – to OB! 19 weeks with diarrhea – to OB! It’s almost like they don’t want to treat a pregnant patient). So it was in residency and at every other place I have had privileges after training.

            I am an OB doc in podunk Ohio. I have some horror stories about ER docs…and not just at my current hospital. My personal favorite is from several years ago the ER doc at an even more rural place done screwed up but good. Our friend HIPAA doesn’t allow me to say more.

          • Melaniexxxx

            Oh dear, yes… so many pts sent straight to L&D without even an ECG just because the pregnancy word was mentioned….

            The ED sass when being sent right back the fuck downstairs because direct entry midwifes aren’t the best people to assess things like broken bones or acute chest pain was real!!