Episode 7.6 Maternal Mortality Declining? Plus skin closures and listener questions
In this episode, we discuss which laparoscopic ports need to be closed and how. Plus, we discuss more evidence that the current narrative about maternal mortality in the US is false. Finally, we answer listener questions about oxytocin protocols and the history and utility of the Bishop’s Score.
00:00:02 Closing Laparoscopic Ports
00:13:32 The Maternal Mortality Rate Debate
00:21:04 Maternal Mortality Misconceptions and Progress
00:30:30 Maternal Mortality Misconceptions and Data Accuracy
00:39:27 The Bishop’s Score
00:45:41 Debating Oxytocin and Labor Policies
Links Discussed
To stitch or not to stitch: the skin closure of laparoscopic port sites, a meta-analysis
Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations
Pelvic Scoring for Elective Induction
Association between Elevated Intrauterine Resting Tone during Labor and Neonatal Morbidity
Transcript
Howard 00:17
Antonia.
Antonia 00:19
Howard.
Howard 00:20
What are we thinking about on today’s episode?
Antonia 00:22
Well, there’s a new article about maternal mortality, so we’re going to talk about that. It’s been generating some buzz and we’ve got a few listener questions. We’re going to answer too. But first, what’s the thing we do without evidence?
Howard 00:35
Well, how about closing laparoscopic port incisions with suture?
Antonia 00:39
Okay, so we talked about laparoscopic port placement last time, I think. Traditionally, people will close five and definitely 10 millimeter incisions with a subcuticular suture, either a monocryl or vicarol or the equivalents of that, and some people will actually staple these instead. But I know you just put derma bond on them, even the 10 millimeter incisions, and we’re not talking about the fascia yet, just the skin incision, right?
Howard 01:07
Yeah, we can talk about fascia as well, but yeah, I’m just talking about skin incisions here.
Antonia 01:12
Okay, so what’s the evidence say on this?
Howard 01:15
Well, just using derma bond on these incisions or again the equivalent of superglue, basically is something that I’ve done for years and years, but there’s actually several studies, so let’s discuss some of them. I’ll put a link to a 2019 randomized controlled trial where derma bond only was used, compared to absorbable monofilament sutures for closing laparoscopic incisions at the time of colisosectomies. They used two different methods for looking at the cosmetic results between the two groups and they also looked at the rate of dehiscence of the wounds. They had 70 patients in total and they found better cosmetic results with the derma bond group and no difference in the rate of dehiscence, at least at one month. And this was similar to an older study going all the way back to 2004 that had the same outcomes and also showed, of course, that the derma bond closure was faster about 200 seconds faster than sewing. And, for good measure, I’ll include another link to a larger randomized trial that was done in 2003 that again showed the same results.
Antonia 02:12
Okay. So it sounds like this is actually a consistent finding for going on over 20 years now in the literature and I suppose it makes sense that you would have a better cosmetic result because you’re not putting in a foreign body and copying that foreign body inflammatory reaction under the skin. And ultimately, if you were going to use suture and dressing and then you just use dressing, then that’s going to be less expensive, especially if you have three or four ports you’re closing and especially considering the savings in operative time besides just the cost of the suture. But it’s interesting that so many surgeons and gynecologists still persist in closing with suture and dressing despite these studies being out for decades. And I know that I was not aware of these studies for the longest time.
03:03
From the very beginning of my residency training I was trained to put in a stitch and then dress it with either a steri strip or gods or the derma bond glue, and at the time it made enough sense to me that I never thought that I’m going to go search and see is this the best practice or not. But I was taught to favorite the steri strips over the derma bond because I was taught that the derma bond is so expensive. The steri strips are cheap, but I was never taught that the suture was unnecessary, but apparently it is for laparoscopic sized incisions. So we can put a link to a large meta analysis that was published in 2022 and it reviews 12 of the studies that concluded that either glue or adhesive paper tape which is probably similar enough to steri strips, that either of those alone was faster and cheaper than suture and had the same or better outcomes.
Howard 03:57
I think some of this, honestly, is just that students in junior residents who are involved in a case, they want to get them to do something, and so closing the laparoscopic ports with suture is something for them to do. For many med students, it’s the first and maybe only opportunity they have to sew and suture during a surgery. So surgeons just feel like they’re throwing their student abound or maybe they’re junior resident by letting them close these ports, but it’s just not the right way to do it. We don’t do things to patients so that students and junior residents have an opportunity to practice, and this works just as well for both five and 10 millimeter incisions. It actually works with incisions that are larger than that. It’s just that the larger the incision gets, the more difficult it is to maybe approximate the age as well while putting the glue on.
Antonia 04:41
So that probably is the logic even why a surgeon would suture themselves, even if they didn’t have a med student. They were trying to at least give them something to do. But it’s that they want to approximate the edge as well and they think that the suture is the best way to do that, Because it’s not just that you need to hold the skin perfectly while applying the glue, but also while it dries, which sort, depending on the brand, it can be like 90 seconds, so it can feel like a really long time. And I know now that I could make it look really nice by throwing just one suture in and then I’ve tied it down in a second and my hands are free and then I apply whatever dressing just as an extra bonus. But in my mind I know I have the suture there.
05:25
So even if the dressing didn’t hold, the suture would. But the studies show it does still leave them with that foreign body in their skin and the foreign body reaction as their skin heals and the suture dissolve. And while I was training there definitely were times where the suture didn’t seem to approximate the incisions well and somehow every time we’d even try again and it would even look worse or the suture not, would bunch up all wrong and then, as they healed, two or three weeks out, it would the monocryl edge would cope through and it wouldn’t be long enough to actually clip it, but they would have this slightly sharp part of their scar. So all of that kind of in the end still argues against suturing.
Howard 06:09
Well, there’s some tricks for re-approximating the skin without sutures though.
06:14
I use a clamp like a curved hemostat and then also maybe a small ads and pickup, elevate the edges of the incision, then gently place the hemostat to just approximate the edges while I let the glue set up, and usually about 30 seconds is enough, even though that’s not the cure time. It’s not going to fall apart. And then I’ll slide the clamp off and slide it open and just gently and slide it in the same direction that the incision is made. If you were cutting it with a scalpel so that it doesn’t spread the edges, just gently pull it away from it. And it works really well. And for umbilical incisions you can usually just elevate the edge of the incision with an ads and clamp, hold it again for about 20 or 30 seconds while the glue sets up, and they’re fine and again they look better and they take almost no time. Usually I can do two or three of these at once the I’m holding one and holding another one while the student glues, and the whole thing takes under a minute.
Antonia 07:08
That I think we can agree on easily enough. But what about the fascia then? So I was taught to close anything one centimeter or greater because of the risk of hernia through the fascia. So is this consistent with the evidence or no?
Howard 07:22
Well, I’ll put a link to a 2020 review article that talks about closure of fascia from the journal surgical endoscopy. This was a systematic review of studies that included over 18,000 patients and they concluded that trocarcyte hernias occur less often with non-bladed trocarse compared to bladed trocarse, for any size, and that closing five millimeter and 10 millimeter ports didn’t change the incidence of trocarcyte hernias compared to not closing them and therefore shouldn’t be done. Not closing them reduces the operative time, the risk of needle stick injuries and overall procedural cost. They also found that midline locations were likely to result in higher rates of trocarcyte hernia. So those are things that we know, but they didn’t find that closing the 10 millimeters was advantageous.
Antonia 08:05
Okay, so we should be closing fascial incisions that are bigger than 10 millimeters, regardless of location.
Howard 08:12
Yeah, and in gynecologic surgery it would be relatively rare to need anything larger than a 10 millimeter trocar, and the most common reason why I think this happens is with larger bags that are used to remove adnexal masses. Or I suppose if you’re doing an open Hassan type cut down method, you’re going to have obviously a larger incision that you need to close.
Antonia 08:32
Yeah, well, I was thinking about, like, why were we taught you need to close 10 millimeter incision? And well, I think one reason might be as a precaution, because some of our some of our size 10 trocars, said 1012 on the packaging. So I’m thinking that could have meant that they were actually 12 millimeters wide in order to accommodate a 10 millimeter tool. But then I was thinking, even if that wasn’t the case, the other reason probably is that I think a 10 millimeter fascial incision can get inadvertently stretched to be wider over the course of the surgery, especially if there’s any tension between the skin entry and the fascial entry. So especially if there’s more space between the skin and the fascia, like maybe someone with a lot of subcutaneous tissue, then that angle gets offset and then every time we’re pivoting the tool or the camera around, we’re pushing against the skin and pushing against the fascia.
Howard 09:30
So well, that can happen. Obviously, in the studies that we’re talking about, all those patients had surgery with 10 millimeter trocars and they got moved around and they still found no advantage. So theoretically, of course, that can happen, but there’s some things that we know we can do to minimize that as well. And so in training programs maybe it’s more likely to happen than non training programs due to some of those factors you’re supposed to place a trocar perpendicularly to the fascia, then angle it down, like we discussed in the last episode. So if you start angling before you go through the fascia, then every time you move your tool you’re pivoting the skin opening against the fascia opening and therefore making both of them a little bit wider.
10:09
So wrong technique could make them a little bit bigger and that’s a subtle difference. But again, the studies they didn’t measure how big the fascia was after use. It’s probably the case that most 10 millimeter poles are a little bit bigger, but nevertheless they didn’t find an advantage in closing them.
Antonia 10:25
I wonder if part of it, too, is like we need to train these residents how to close with the little closure device. I know we had a case presentation I wasn’t involved in, but there was a robotic surgery patient that had initially eight millimeter incisions and ended up getting a hernia through one of those sites and we figured that in that case there probably was tension between the skin and the fascia and there was no tactile feedback of how much tension there was because it was a robot.
Howard 10:56
So well, it’s not that hernias don’t occur ever in five millimeter, eight millimeter or 10 millimeter incisions. It’s just that they occur at the same rate whether you close them or not. So we’ve talked about this before, where we have an overreaction. So we find a hernia in an eight millimeter or 10 millimeter and then we just decide, golly gee whiz, we should close them all. That doesn’t necessarily help. That’s why you have to use a randomized trial to determine. So it’s not that hernias aren’t going to occur, it’s just that putting that suture in there doesn’t prevent.
Antonia 11:24
Yeah, and I don’t think I don’t recall that our conclusion was well, now we have to close all the eight millimeter incisions. It was just more about the tension, yeah, yeah. So I think the bottom line here is don’t suture the skin incisions it is like 10 millimeters or smaller and also don’t suture the fascial incisions 10 millimeters or smaller, unless maybe you think you’ve really stretched it way a lot more open than 10 millimeters, but you shouldn’t if you’re using proper technique. So okay, let’s get into some new articles. I know you are super excited to talk about the new article in the AJOG, the Gray Journal, regarding maternal mortality.
Howard 12:06
Yeah, there’s a very impressive article, actually released online and advanced in March 12th rather than in the edition, and it’s created quite a stir so far with lots of media and social media and internet coverage, and it elicited a response from the interim CEO of ACOG that we should discuss. So I’ll put a link to this article, which is entitled Maternal Mortality in the United States. Are the High and Rising Rates Due to Changes in Obstetrical Factors, maternal Medical Conditions or Maternal Mortality Surveillance?
Antonia 12:34
Yeah, so this topic is something we have already spent quite a bit of time talking about over the last two to three years on this podcast, and then also offline or other formats, and it’s interesting how this new article has gotten so much attention, because since our previous discussions, there hasn’t been any new updates and it doesn’t reveal anything new. It just seems to have gotten more notoriety now than some of the articles in the past. So why don’t you tell us what this article concluded?
Howard 13:06
Well, they’ve done a more robust analysis than some of the other indirect evidence that we’ve talked about on here before, and so maybe that’s one of the reasons why it’s getting more attention and we can review some of those recent things we’ve discussed briefly here today as well. I do think that the response to this article shows the sort of rising tide of awareness that something is amiss and that maybe the emperor is not wearing his clothes, and I think that’s what you’re seeing going. On this current paper, they reviewed the basic assumption that maternal mortality has increased by 144% from the year 2000 to 2020. Now these rates were 9.65 maternal deaths per 100,000 live births roughly around the year 2000, up to 23.6 deaths per 100,000 in 2020. That is the maternal mortality crisis that we talk about and see a lot about and that scaring patients and everybody else in every other headline. This latter number is used by politicians this 23.6 by politicians, by the media, by anybody he wants to criticize the US obstetric system and emphasize this maternal mortality crisis, including by our own colleagues who use it to get funding for projects and research and things like that. So you hear a lot about it.
14:23
Now the authors analyze various reasons why that bottom line number reported by the National Vital Statistics Systems.
14:29
Methodology has changed and specifically they talk about the impact of the pregnancy checkbox implementation on death certificates that we’ve discussed before and other issues that might inaccurately reflect the actual rate of maternal mortality over that time period. So instead they propose an alternative formulation and under their alternative method, the maternal mortality rate was calculated to be 10.2 for 100,000 around the year 2000 and compare that to 10.4 per 100,000 live births in the year 2020. But, importantly, deaths from direct obstetric causes, which has a different definition, decreased from 7.05 per 100,000 to 5.82 per 100,000 live births over that time period. So, specifically, deaths from direct obstetric causes includes things like hypertensive disorders, hemorrhage, parapsy, embolism all those things they found decreased over that time. However, death related to adherent placenta, some renal causes and cardiomopathies, as well as preexisting hypertension, increased. They also noted that mortality had increased among non-Hispanic white women, yet decreased among non-Hispanic black and Hispanic women over that time, though of course the disparity still exists, particularly in some cases, like with cardiomopathy, but that shows a narrowing of the gap between white and black maternal mortality.
Antonia 15:56
Yeah, so all of that agrees with literature we previously discussed over the last couple of years on this podcast already, and it makes sense that maternal mortality and morbidity related to adherent placentas would have increased over that time because the cesarean delivery rate is increased and that’s a direct correlation there.
16:17
We’ve also had an increase in the rates of just obesity in the population, as well as hypertension, over that same time period. So it also makes sense that death related to renal diseases and just the preexisting hypertension could increase as well. But also we’ve been implementing safety bundles relating to a lot of the traditional causes of maternal mortality and these have successfully decreased the chance that a woman will die in childbirth in the hospital. So the direct maternal mortality rate of 5.8 per 100,000 librates is fairly comparable now to countries like Finland, iceland, japan and even better than the same rate in countries like France and Germany, and that’s important because these are countries that were often compared to negatively regarding maternal mortality and we’ve also pointed out before that disease. Specific mortality rates for pregnancy complications like pre-anthamphysia, for example, are similar or, for some diseases, even lower in the US than in Finland, which is often considered one of the best countries in the world to get birth.
Howard 17:31
And the happiest country in the world right, yeah.
17:34
I read an article again about that this past week. But, yes, the analysis tends to agree with things we already know. And that direct maternal mortality rate of 5.82 that they calculated. That is meant to correspond to what is calculated in these other countries. And to give you some flavor about that, the maternal mortality rate in countries like that you mentioned are typically hover around six, so between six and seven. And then the best country is, like Finland, a little bit less than six. So the 5.82 is comparable to those European countries.
18:07
Estonia has the best maternal mortality rate in the world and has a lower rate, but those numbers get difficult too. Again, it’s all a problem of comparisons and apples and oranges comparisons, but there’s no reason to think that that 5.82 per 100,000 is not comparable. And then you get into specific types of cases, because the truth is, if we were going to compare US maternal mortality to, say, norway’s or Finland’s, well, we’d have to adjust it for the patient population that we have. We’re dealing with a more obese, older, sicker patient population. So that’s the importance of looking at specific causes of death from things like, say, preeclampsia or hemorrhage, where we do really well compared to all these other countries.
Antonia 18:49
There’s a couple other important publications from the last few years that also support these conclusions, so why don’t we just review those quickly?
Howard 18:58
Well, we previously talked about a paper in the May 2021 Green Journal that concluded that quote. Rigorous studies carried out by the National Center for Health Statistics show that previously reported increases in maternal mortality rates in the United States were an artifact of changes in surveillance. Now that paper alone is very interesting because it illustrates that just taking into account the changes in our surveillance systems and the checkbox, just that alone is enough to account for the reported rising rates of maternal mortality over that time period. So that’s an important paper that’s contributed, I think, to the current work in this study and that rising awareness of what’s going on here. But last year we also talked about an even more compelling paper.
19:37
We discussed this in episode 513. And this was an article published in JAMA Network entitled Trends in Maternal Mortality and Severe Maternal Morbidity during Delivery-Related Hospitalizations in the United States from 2008 to 2021 by Dorothy Fink and colleagues. Now that paper looks specifically at severe maternal morbidity and mortality at the time it discharged from the hospital. In other words, it focused more on the deaths that would occur in that time period that have a direct obstetric cause or that are delivery-related, and they found that severe maternal morbidity and mortality have been decreasing significantly over the study time period and that the previously existing racial disparities at the beginning of that time period have equalized over that time period.
Antonia 20:22
We did discuss that article in detail. That’s also where we discussed the deaths of Tori Bowie, the runner, so if you haven’t heard that episode and you’re interested, then please go back and listen at some point. But that study is another source of information that shows that birth in American hospitals has become increasingly safe and increasingly with less and less racial disparities at least significant racial disparities over the last 20 years, and that puts it on par with the safest birth statistics of anywhere in the world Right, but there seems to be this disconnect between how the media and, of course, acog talk about maternal mortality in the United States.
Howard 21:04
They continue to emphasize that we’re in the midst of a crisis based upon these rising numbers, with the vital statistics rates, at least, that are published, rather than paying attention to the breakdown of those numbers and thinking of reasons why the numbers might be changing.
Antonia 21:19
Yeah. So with this recent Gray Journal article, ACOG immediately put out a statement last week that was just really critical. Instead of taking it as good news that things are actually better than we’ve been saying all along, they seemed almost upset that the authors would dare question the idea that we’re living in some horrible mortality crisis.
Howard 21:42
Yeah, my very jaded perspective is that there’s a lot of funding into maternal mortality research and looking at the rising rates has been a passionate calling for a number of academics for the last decade or so and this has led to some good things like the safety bundles and other the AIM initiatives, things like that. But we also have to step back and acknowledge that those things are working, that the AIM bundles and our emphasis on safety over the last decade and a half have been working. That article from the JAMA network did show a significant racial disparity in hospital deaths related to pregnancy 20 years ago or so, but it showed also that we’ve closed that gap and eliminated that disparity, at least in the hospital set.
Antonia 22:21
Yeah, at some point those researchers might be able to shift focus and not just continue to say the same thing over and over again and make a living that way. But I don’t know, that is jaded. I’m sure there’s more to it than that. But disparity does still exist racially. But, as we talked about in that prior episode, it’s more related to things that occur outside of that 42-day window around birth, but still within that first year postpartum, and so they tend to be more related to social determinant, and these are important things that we need to work on and research. So we shouldn’t be giving American women the idea that the hospital is such a dangerous place to give birth. We all know that social support for pregnant women and for parents of young children it’s probably not as good as it could be in the US, so why not put more focus on that, especially if that’s one of the big unself factors in our maternal mortality rates?
Howard 23:21
Yeah, I think that’s one of the frustrations, among obstetricians at least, is that ACOG and others who have meant to represent us let it slide, almost that we’re the ones doing a bad job when these things like what you just mentioned are beyond our control, these social-determined issues in particular. Our country may have a problem with the post-42 day to 365 day maternal mortality rates, but they’re going to be more related to issues like that that are different in European democracies. In the United States, just out of curiosity, you’re back to work how many daycare wait lists are your sons on right now?
Antonia 23:55
Yeah, they’re on a lot. I think I’m just not in the best city for daycare, apparently. But, on that note, even in Finland, where if I lived there I’d still be on maternity leave for almost a whole year still, and then after that I’d probably get a spot guaranteed at some regional daycare facility with highly trained, educated caretakers. Over a third of Finland’s more maternal mortality rate in suicides. But looking at the numbers, I know it’s hard to compare, especially with such a small population compared to a huge population in the US, but if you extrapolate it would equal to about 10 times higher rate than the rate of maternal suicides during pregnancy or within the first year of birth.
24:42
And this is the happiest country in the world, like many years in a row. So I can’t really explain this number. I’ve lived in Finland and I don’t really understand it. So I don’t know. Is this a problem that’s unique to Finnish people and the country that they just need to figure it out internally, or could there be some more generalizable issues at play that maybe they could look to other countries, including the US, to gain some insights on? But the point is that this seems like a more social, determinant type of cause of death, and yet they already have really good social support.
Howard 25:17
So yeah, well, and that’s where our research needs to be right Instead of continuing to act like the US hospitals and US obstetricians are. The problem with maternal mortality. If we focus on the actual causes that are preventable and the ones that extend outside of that 42-day window, you’re going to get into mental health almost exclusively. It’s mostly mental health, and even Finland with its social support systems struggles in that regard, so let alone the United States. But that’s where we need more research and it’s where we don’t need $16,000 per 10 drugs that don’t do anything. We need actual research to help with these issues, and I don’t think we’re at a point where maternal mortality research gets defunded and deprioritized because it’s at some absolute low threshold that can’t be surpassed.
26:04
There are a lot of papers looking specifically at what percentage of maternal deaths were preventable and how, and the conclusion has been that at least 50%. Some higher, some lower, but at least 50%. So even removing the idea that we’re so much worse than other industrialized nations and we have to catch up, we can still talk about the high proportion of preventable maternal deaths, and that should still serve as a strong ongoing motivator for more research and funding and the absolute number of women per year they will have a preventable death isn’t super high in a raw number, but remember, for every woman who almost dies there’s another 60 that come near death at least. So we’re not just preventing deaths, we’re preventing other severe morbidities when we make progress in preventing these illnesses and these deaths. But again, placing excessive blame and emphasis on the hospital setting actually increases the number of home births, which we know are riskier, and only serves to increase maternal and perinatal mortality. So misinterpretation and misrepresentation of the maternal mortality data can cause tangible harm to mothers and babies in the United States.
Antonia 27:05
Yeah, I think it’s good that there is still a lot of interest in research going into this topic now, but it is concerning that ACOG and others are having such a negative response to positive data. If the facts no longer support your assumptions, then don’t just reject the facts, but check the assumptions, and it seems like they’re a little bit stuck on this right now with this response to the article.
Howard 27:30
Well, I think there are a few often repeated assumptions or narratives about maternal mortality in the United States which lack a firm scientific foundation and serve to ultimately cause harm to public health and pregnant women as they lose confidence in the US healthcare system and then, of course, damage your reputation of women self-specialists in the United States. So, specifically, the claims that I think lack scientific evidence are the following four things the first one is that US maternal mortality has been increasing over the last several years or decades. The second one is that this maternal mortality crisis is largely the fault of the US healthcare system, and birthing hospitals and OBGYNs in particular. The third one is that the gap between white and non-white maternal death is increasing and or is a unique problem in the United States. And the fourth one is that the US maternal mortality rates are among the worst of the quote advanced nations in quote of the world.
Antonia 28:29
Yeah. So those four assertions are all disputed by these publications, most recently the Gray Journal one, and the three reports we’ve just mentioned show that the US mortality maternal mortality rate, is decreasing, but our ability to detect and record all of these cases is increasing at the same time, which does make it artificially look like it’s increasing, when really we’re just seeing more of the true cases. So it’s important to know that it is actually still decreasing and that we are making progress.
Howard 29:03
Yeah, why can’t we celebrate our successes?
29:07
In my hospital system, we recently implemented a system to help decrease the rates of hyperglycemic and hyperglycemic events for hospitalized patients, and I see the reported data for this each month, and over the last month, it looks like our number of adverse events related to insulin therapy skyrocketed.
29:26
But the reality of it is that we just created a new system that accurately and records all of the events that occur. Prior to that, we just had individualized reports, maybe of the worst cases. The truth is, we probably have less actual events occurring than we did six months ago or a year ago, but because we’re focusing on it and because we’ve created a reporting system that captures all of these events, it makes it look like the rates have increased, and that’s exactly what’s happened with maternal mortality. We have the best reporting system and the most inclusive definition, or comprehensive definition, of what we count as maternal mortality of any nation in the world, and because we do such a good job at counting maternal mortality, then we have a very thorough picture of it, and consequently, though, we have a higher number than when we weren’t doing as good job counting it, say, 20 years ago, but that doesn’t mean our rates are increasing just because we’ve implemented a better tracking system and a better way to capture all of these deaths.
Antonia 30:30
Yeah, and the second assertion you listed up there, that was about the US healthcare system and our birthing hospitals being culpable for all of these maternal deaths. I know we’ve talked before about how rural hospitals shutdowns are negatively impacting women, as are the increasing abortion restrictions, but nonetheless the direct obstetric mortality rate argues that we’re doing really well despite these shortcomings. And of course, it’s still important to fight for access to reproductive healthcare and just basic healthcare, or else we really will see a rise in those preventable direct obstetric deaths. But for right now, the paper in the JAMA Insights shows that we have made a lot of progress in maternal mortality and morbidity in the hospital setting, and it’s the stuff that we actually have control over. So the delivery process, the prenatal care, the immediate postpartum care, so all of that we’re doing as well as anybody possibly could, but it still seems to get portrayed as inadequate in the media.
Howard 31:37
Yeah, and then the third issue, the third fallacy, is this gap between white and non-white maternal deaths that it has been increasing or is uniquely a problem in the United States? And that’s not true either. The gap is decreasing by all these measures, particularly in the hospital and immediate postpartum period, again, where we have some control, and according to that JAMA Insights article, it’s apparently equaled out. But this gap is not unique to the United States. We still have a smaller gap between black and white maternal mortality, even taking the comprehensive view that we take in the United States, than other European countries report. It’s just that you don’t see a lot of reporting from the United Kingdom or Germany or France or other multiracial democracies about their disparities. So it has the appearance that this is a uniquely American problem. But the data does exist and we’re doing better than they are.
Antonia 32:28
I think the last item you listed is probably the most harmful one, and that is that the claim that we have the worst maternal mortality rate of any high incombination. But again, when we look at the same diseases and the same causes of death, then in those comparisons we’re as good or better than almost every other country in the world. So this false assertion is purely based on us counting more things as maternal deaths than other countries that we’re comparing ourselves to.
Howard 32:58
Yeah. Can you imagine how the narrative would flip if France or Germany researchers were coming to the United States to determine what we’re doing so well compared to their crisis of maternal mortality? And that seems funny to say, just because we’ve had this forced down our throats for decades, that we’re 27th in the world, or whatever. And it’s just what happens when you compare apples to oranges and don’t use the same systems to define definitions and record these cases. You’re going to get confusion. But ACOG and others should look to accurately reflect this information. We need to create new terminologies and agree upon a system internationally if we want to make these such comparisons. We need to stop giving folks the impression that we have a bad obstetric system in the United States.
Antonia 33:44
We do have a crisis of substance abuse and homicides and perhaps even suicides in this country to a lesser extent. But until we recognize that that’s what we’re really talking about in these maternal mortality statistics, then we’re not going to make a lot of progress in fixing them. When we talk about maternal mortality, we tend to want to focus on hemorrhage prevention and things where we have a little emergency drill for, but when we do that we miss the whole ball game by ignoring where do the disparities actually exist, and we also scare patients into thinking that they should have more dangerous home births or that they should just shun the recommendations of their doctors just because we’ve been discussing it.
Howard 34:33
The suicide rate in the United States is 16.1 per hundred thousand and the suicide rate in Finland is 15.3 Per hundred thousand, let’s talk about happiness in Finland sometime.
Antonia 34:44
Yeah, yeah, because somehow it seems to be disproportionately. We waited on mothers and actually and I don’t know how much overlap there is but the mortality rate for Young mothers in Finland under 20 years old was by far the highest higher yeah yeah, and that also. I don’t have a good explanation for that either.
Howard 35:06
So well, we can’t be telling women not to come to hospitals in the United States to give birth and scaring them because of these false Assumptions. And so, again, listen to the Tori Bowie episode, which is 513, and we discussed that concept in more detail, because I think that it’s Arguable that Tori Bowie’s death occurred due to misreporting of this data.
Antonia 35:24
I want to just read out some quotes from the statement that ACOG released in response to the paper in the great journal that we’ve been referring to. So it doesn’t direct, it doesn’t outright discredit anything in the paper, but it does attempt to recontextualize it and maybe paint it in a more negative picture. So this so I’ll just read it that it says quote a new manuscript published in the American Journal of Esthetics and Gynecology Regarding US maternal mortality rates and surveillance confirms what we know, which is that we need data to drive change. However, this publication paints an incomplete picture and fails to highlight what we should be focusing on regarding maternal deaths preventability, discarpancies exist when data are derived from multiple sources and, overall, our data systems could be improved. We live in a country with a fragmented health care system and it will take continued and significant investment to make improvements to our surveillance systems. To reduce the US maternal mortality crisis to an overestimation is irresponsible and Minimizes the many lives lost and the families that have been deeply affected. That’s the quote I’m going to read.
Howard 36:32
Yeah well, I think all that’s true and I actually think, if you go through the whole statement, there’s nothing that’s not factual in the statement. It’s all about tone. To accurately record how many women are dying in pregnancy or from pregnancy related causes doesn’t minimize anyone’s death.
36:48
And to act like we’re not overestimating maternal mortality rate is also irresponsible and, more importantly, we may actually be contributing to deaths if you buy my theory about Tori Bowie’s death by scaring people with harmful misinformation. So I do think we’re allowed to question the agenda of folks who want to paint the US maternity system in a negative light In comparison to other countries, when the data suggests the opposite.
Antonia 37:11
Well, this publication has been getting a good amount of attention, so I think we can multitask here, because we can talk about the problems that are especially bad in the US compared to others, like the obesity and substance abuse and gun violence and the Disparities among those racial disparities, socioeconomic disparities and we can work to improve our maternal mortality rates in regard to those things, and at the same time, while doing all of that, we can also acknowledge that the US obstetric health care system has done outstanding work in reducing maternal mortality from direct obstetric causes and leads the world in many ways in the separate, including in how comprehensively we count every maternal death. Yeah, exactly.
Howard 37:56
Well put and back to this idea of preventability, which is also the focus of that statement from ACOG. I want to know how we are to focus our efforts on prevention when most of our maternal deaths occurred beyond the initial hospitalization and beyond the first six weeks after delivery. So spending even more money on Hemorrhage prevention or new thromboembolism protocols or Other things related to immediate causes of obstetric deaths will likely do nothing to change the disparities. We’re seeing a maternal mortality in the United States because the disparities aren’t happening there. So when we have good data, we can and should go after the real causes, and currently we’re doing that. We’re working on peripartum cardiomyopathy, which we discussed a few episodes back. That’s often missed in patients who present after birth with hypertension to the emergency room and other symptoms of cardiomyopathy, and it also includes, as you said, the epidemic of gun violence and substance abuse. That affects women of reproductive age at a higher and disproportionate rate than the other population and Disproportionately among different races.
Antonia 38:58
Yeah, and those are definitely things that will require Some kind of input and collaboration with people outside of our profession. We’re not trained really in how to address Gun violence or anything related to that. So I’ll say, to be continued, because this is clearly an an ongoing thing and I’ll Hopefully look forward to seeing more good articles about this. But for now let’s shift over to a couple of reader questions for the rest of this episode. So I’ll take the first one. This one’s this one’s got a little koala emoji. It says, hey, ob from Australia, I’m an ONG resident, but I guess that’s how they we should do that. Yeah, yeah, I just want to do OG by itself.
Howard 39:40
Oh gee yeah where the OG is yeah, okay, well, this listener says I found your podcast about two years ago and I’ve been avidly listening ever since. Thank you.
Antonia 39:52
Okay. They go on to say I’d love to hear more about the Bishop score, the medical history behind the eponym, and whether it really helps predict labor outcomes, especially in the gray areas where the patient is maybe two to three centimeters dilated and able to be a Romed, although they may not technically be quote favorable, at least according to the Bishop score. This is signed breaking water in Bat Creek.
Howard 40:19
Okay, very Australian, yeah, very. So why don’t you do the?
Antonia 40:21
eponym part of the question, because I know you’re all into those misogynistic patriarchal eponyms. Okay, all right, here we go again.
Howard 40:29
Well, okay, Well, edward Bishop is. It’s a man, what can I say? Developed his score specifically to assist the chance of failure with induction of labor. So he was from New Hampshire in the United States and went to Dartmouth, graduated medical school in 1937 and then mostly worked in his career at Philadelphia at the Pennsylvania Hospital. He wrote his paper regarding his score in 1964. He later ended his career at Chapel Hill where he moved to 1972 at UNC, finally retired in 1983 and died in 1995.
40:58
Now we didn’t use prostaglandins and things like that for induction and the time he wrote this paper back then, and so Also the c-section rate, of course it was very low when he wrote that paper in 1964 compared to today and he wanted to understand how Induction was affecting these ladies and he came up with this scoring system and he really felt personally at the time that nolipris patients Should not be induced, at least for elective reasons, because their rate of c-section was so high. So he developed the scoring system to try to quantify and understand that as best as possible. Yeah, so he published his paper on this scoring system in August 1964 in the green journal and we’ll link to that so you can read the description below.
Antonia 41:37
If you read it, you’ll see that it’s quite typical for science in the 1960s. It’s more of a qualitative than a quantitative paper and it is Common sense in what it reports, which is that the more dilated and soft the cervix is, the more likely you are to labor. And then other studies showed also that the more dilated and soft the cervix is, the more likely you are to labor. And then other studies showed also that the more Going along with his scoring system, the more likely you are to have a successful induction. So the contribution really is just adding it a more objective way to describe the characteristics of the cervix. That then allows us to do more quantitative research and Create algorithms for patient care. We’ll also link to a 2013 systematic review that looked at 40 articles that included almost 14,000 patients total, and they concluded that the bishop’s score is actually a poor predictor for the outcome of induced Liberat trim and should not be used to decide Whether to induce or not.
Howard 42:48
Well, I bet that’s a hot take to many listeners and our friend from down under wasn’t expecting, maybe along with a lot of our listeners who might routinely be even required to document a bishop’s score by their hospital. And I know some hospitals have a consent form that requires documentation of the bishop’s score for elective inductions when counseling a patient about induction. And a big emphasis is put on that to try to discourage Induction of women with unfavorable cervixes. But that’s the truth is that it’s not that useful. In my own hospital I’ve resisted these efforts to impose that routine bishop’s score Assessment, particularly with some sort of consent process that is used to counsel the patients about the purported success of induction, because it’s not evidence-based.
43:34
Hospitals want to attack the problem with unnecessary cesareans and the truth is the problem is not what the bishop’s score is, it’s and in the result of the ultimate rate of vaginal delivery, but the problem is whether or not we’re using appropriate methods of induction. So if you have a little bishop’s score and you’re just using pitocin bishop’s score of two, let’s say and you’re giving them pitocin, you’re probably going to have a higher c-section rate, especially if you’re impatient. Then if you use prostaglandins or a foley or something for ripening. But knowing the score itself Doesn’t predict whether or not you’re going to have a vaginal delivery.
Antonia 44:11
It just helps us know how we should induce them so if you’re considering inducing somebody because they’re Either they have a medical indication or they’re just at term, then of course you can induce them. But their cervical exam should be dictating how you induce them. So the listener asks specifically about someone who is two to three centimeters dilated but otherwise unfavorable. So I’m guessing they mean that cervix is otherwise long and Maybe not very soft but still able to have their membranes ruptured, and they highlighted that as a gray area.
44:47
There was a modification of the Bishop score that gave more points if for a multiple versus a nullip. But I think how most people use that modified Bishop score today is that basically, if it works out to a score of four or less in a nullip or three or less in a multiple patient, then you need ripening, maybe a fully catheter balloon or a misoprostol. But then if you have a higher score, let’s say six or higher, then you could just go ahead and start with oxytocin and membrane rupture. So the gray area really is where exactly is that cutoff and how do you, how would you use the score to make those decisions? But we shouldn’t counsel patients that they have a higher rate of failure because of their Bishop score. We should just make sure that we’re using the appropriate methods of induction.
Howard 45:37
All right. Well, I have a question as well. So here we go. Dear Antonia and Howard, first of all, I love your podcast Sounds like I wrote this. It’s refreshing to hear people who clearly care deeply about our profession and are willing to think critically about what we do.
45:52
I recently took over as medical director of our labor and delivery unit and I’m working on updating all our policies. I’m struggling with a lot of pushback from nursing, especially around oxytocin, electronic field monitoring and contractions. It appears that a1 has some really interesting conservative, not evidence-based and honestly just made up feelings on some of these topics and I’m struggling to find a way forward that makes my nurses feel safe and heard and also ensures that patients Receive quality and evidence-informed medical care. Can you speak specifically about the idea of elevated urine resting tone? My nurses refuse to up-titrate oxytocin if the resting tone is elevated.
46:29
Also curious about your opinion on titrating oxytocin when contractions are too frequent but MVUs are still less than 200. This usually occurs when they have some uterine irritability, and so the nurses say that they’re tachycystolic, but the MVUs are very low, often less than 100. I did find one very new paper on resting tone, but this appears to be a recommendation that has been an a1 textbooks for decades and I can’t find any other evidence to support this and we’ll put a link to the article that they’re discussing. I appreciate any insight you might have and thanks for all. You do love Nursing dystocia in New Hampshire.
Antonia 47:04
I think that name is too good for you to have come up with it.
Howard 47:08
Yes, I realize not very creative, but yes, this person did come up with their own name to save me having to be creative. So thanks for pointing out my lack of creativity to the listeners.
Antonia 47:19
No problem.
Howard 47:20
Yeah, I do think questions like this are really hard. It’s a great question and one that illustrates, you know, the real-life intersection between competing interests, between nurses and physicians and hospitals and safety folks and Quality folks and things like that in very complicated topics where there are not clear-cut things. We’ve talked about the general conservatism around oxytocin due to medical legal issues, not necessarily scientific ones. Oxytocin is frequently cited in medical malpractice lawsuits, but that’s just because it’s an intervention and then the risk management folks get nervous about oxytocin Because it’s so frequently cited. It’s the most frequently cited thing in med mal lawsuits regarding obstetrics. So, however, this conservatism around oxytocin actually leads to increased cesarean section rate. So the plaintiff’s attorneys, we have them to think for contributing to maternal mortality by increasing a c-section rate due to conservatism around Oxytocin. On the whole, just generally speaking, the literature supports higher doses of oxytocin, although this can be taken too far. Anything can be.
48:28
It can be true that higher dose of oxytocin increased your risk of non reassuring fetal tracings and we’re not talking about this pit to distress type of approach. An example this might be starting an induction on pitocin at 8 am and then by 12 pm they’re on 30 of pit. They might need a c-section before the end of the day for non reassuring fetal heart tones, unless they manage to beat the doctors Sort of arbitrary clock and precipitously push the baby out before dinner time. But that low and slow drawn out pitocin protocols that have found their way into our system. They’re also not the right thing to do. It might look like starting at 8 and by 12 pm they’re only on three or four of pit and that’s a recipe for being a labor for two days and then getting a section for labor arrest or perhaps other non reassuring fetal heart tracings or just maternal requests due to exhaustion. The problem, either way, is folks not focusing on the numbers needed to treat or harm and the risk reduction numbers related to oxytocin and what’s going on with Fetal distress and things like that, and instead just talking about an association between more pit and bad things.
49:38
So being in labor at all, compared to not being in labor, is associated with increased risk of fetal distress. I know it’s obvious when you say it, but it’s an increased risk of a neonatal hypoxia, neonatal ischemic enchephalopathy and every other negative thing you can think of, including uterine rupture. So does that mean that women should not be in labor? There’s some doctors out there who think they shouldn’t be. They should all get section right.
49:59
So just saying that there’s an increased risk of uterine rupture or Fetal hypoxia or whatever with higher doses of oxytocin compared to lower doses of oxytocin is not actually the relevant fact. It’s also true that there’s a lower rate of cesarean delivery with higher doses of oxytocin, and Cesarians are more dangerous for women. So we have to look at total outcomes and we have to balance them. The right amount of oxytocin for the right patient is how much she needs. If she’s obese, she’ll need more than a thin patient, and there are dozens of other factors like that, including many we don’t know how to quantify, and all those will influence how much oxytocin is appropriate for a particular patient. The dose should be titrated up until labor is progressing Accordingly or until there’s a red flag that says we shouldn’t go beyond that, like non reassuring fetal tracing or tacky systolic.
Antonia 50:50
Well, in this case that what the listener sent in. It sounds like the nurses are saying that increased uterine resting tone is one of those red flags and the paper that Our friend nursing dystocia in New Hampshire cited from the American Journal of Perinatology Last year did find that increased resting tone was associated with neonatal morbidity.
Howard 51:14
It did indeed, but I think that paper shows the foolishness of this whole line of reasoning. So first of all the paper talks about measuring that with an intrauterine pressure catheter to detect this increased resting tone. But the a1 guideline in most cases just relies upon manual palpation to the uterus, trans abdominally, to detect this increased resting tone. Now they defined and hyper tonus a1 does as greater than 25 millimeters of mercury or pressure and anything less than 20 to 25 millimeters they define as normal. But there’s simply no study that I’m aware of that says that external palpation is able to detect or discriminate between Less than or greater than 25 millimeters of mercury, a resting tone of intrauterine pressure.
Antonia 51:58
Yeah, I would think that’s no more able to than just the external Toco yeah would be able to. So, as a whole, this idea is built on a false premise that palpation is effective for discriminating a resting tone above or below 25 millimeters of mercury. So okay. So what if we’re only making this call according to an IUPC?
Howard 52:25
Right. So the new paper does use, as I said, intrauterine pressure catheter for an objective measurement, but it actually found that greater than 12.3 millimeters of mercury, so half of the 25, that was their threshold that they used to define increased resting tone and it was they found it was associated with adverse outcomes, at least from a statistical perspective.
Antonia 52:44
But you’re saying that that sort of in contradiction to this article. If the resting tone is 12.4 millimeters of mercury or higher, then holding back on pitocin still will not improve outcomes and may actually worsen outcomes.
Howard 53:02
Exactly because if you do that, you’re going to see a significant increase in the cesarean section rate. At the same time, I think if you do have Resting tone based upon an IUPC greater than 25 millimeters of mercury, well, you probably should investigate what’s going on before you increase the oxytocin, and that’s where the A1 recommendation comes from. Are they actually having a tetanic contraction that needs to be treated? What’s the fetal tracing look like? Is there concern for placental abruption or uterine rupture? Is the IUPC just giving a faulty reading? But that’s not what’s actually happening in real life in most cases, and nurses are just assuming that, based upon Palpation with your hand, that there isn’t and relax enough resting tone in between contractions. So the real fight here is over whether or not palpation is adequate to assess resting tone.
Antonia 53:48
Yeah, and as far as I’m aware there’s not currently a described pathology of the uterus that is Analogous to diastolic dysfunction of the heart, so in other words it an inability to Relax chronically throughout the process of labor. If that was a thing and it was discovered, then I’m sure there would be studies also on how best to manage it. But as far as our current understanding goes, either there’s acute hypertonus that’s caused by an acute event which should be managed acutely, so maybe an abruption or uterine rupture could show up like that, or then there’s not hyperton. There’s either appropriate tone with normal contraction pattern, or there’s inadequate tone, inadequate contractions. So none of the above, aside from the acute events, call for reducing or holding back on pitocin. When there’s an acute event you’ll shut off the pit until you figure out what the issue is and then resume. But if everything else looks reassuring everything else except that the IUPC is showing a higher resting tone then really the only thing I would do is maybe troubleshoot the IUPC, because this is probably an artificial problem that we’re only going to be making worse by backing off on the pitocin and then drawing out an otherwise normal labor process. So this is probably also a lesson not to use the IUPC unless it’s necessary for another reason, like you need an amniotic fusion or you can’t trace externally.
55:19
So what about the part in her question? I assumed it’s a female. Could be a male. Sorry.
55:27
Sorry. What about the part in the question about the uterine irritability being misinterpreted as tachysystole?
Howard 55:34
Before I answer that, I will say that just a basic science concept that some of the listeners may not be aware of and maybe where the 25 millimeters comes from. But the intramyometrial pressure, if you were to put a pressure needle in the muscle of the uterus and measure it, is roughly two and a half to three-ish times the intrauterine pressure. Now that means if you have an intrauterine pressure of 25 millimeters of mercury then you could have an intramyometrial pressure of 75 millimeters of mercury, plus or minus. Now the intramyometrial pressure is important because the mean arterial pressure of the spiral arteries, which is reflected by the mean arterial pressure of the mother’s blood pressure at any given time med students are loving this stuff that will tell you basically the perfusion gradient for blood through the spiral arteries. So if you’ve got an intramyometrial pressure of 75 millimeters of mercury and you have a mean arterial pressure of, let’s say, 90, you have very little perfusion gradient and very little exchange of blood in between contractions, and maybe not any, depending on what those numbers actually are. So you do want the uterus to rest in between because during a contraction, when the intramyometrial pressure may rise to 50 or 60 or 70, well there’s no perfusion, there’s no gradient existing because the intramyometrial pressure is greater than the mean arterial pressure of the mother for basically the whole contraction, or almost all of the contraction. So you need that resting time in between. That being said, do you know what will happen if that’s happening? You’ll see late decelerations pretty quickly, so it’s not like that’s just going to happen for hours and not show a pattern of late decelerations and so that’s the tell of the tape. Ultimately, and otherwise, as you said, it’s probably just a false reading from the IEPC, if it’s not any cute problem.
57:29
Now, as far as this pattern of uterine irritability and calling that tachysystole, you see that a lot, in particular, I think after prostaglandin, particularly misoprostol induction. In fact, a lot of the tachysystole reported with misoprostol is just that, which is also why it doesn’t translate into worsening at all outcomes. Compared to other methods of induction in clinical studies, misoprostol have the effect of creating a low amplitude but high frequency uterine pattern and you could interpret that as tachysystole. But here’s where palpation should help. You know that these are not meaningful contractions and it’s just irritability If the contractions are barely palpable and the patient doesn’t complain a significant pain, or if you might have an intrauterine pressure catheter and it shows that these are not strong contractions, then yes, the pitocin should be increased.
58:17
I think it would be obvious but maybe it isn’t that uterine irritability and contractions are not the same thing. These sorts of things are cultural to different nursing units and that’s why you see some labor and delivery units have a very high cesarean rate and others have a very low cesarean rate, because many of these labor management protocols are subject to local institutional norms and culture and experiences. Nurses at one labor and delivery unit might find the idea hilarious that oxytocin shouldn’t be up-titrated with a uterine irritability pattern, while nurses at another unit might find it malpractice to do so. But that’s a difference in culture, not science. The bottom line is that said, he showed uniformly that higher dose oxytocin, again titrated adequately to develop a functional contraction pattern, is better than lower dose oxytocin protocols, and that the concerns about the safety of the higher doses are largely the result of risk management attorneys trying to impose oxytocin protocols on our patients.
Antonia 59:14
All right, well, I hope that answers the question. Hopefully Let us know what you think and thanks again for sending your questions in. The Thinking About OBGYN website will have links to all of the things that we talked about and come back in a couple weeks. We’ll be back again with another episode.
