Archive for the ‘maternity’ Category

The death of a baby – the economic realities

Monday, June 6th, 2011

I recently wrote a blog about the grief that parents suffer when they lose an unborn child. At the risk of sounding crass, I want to now discuss the economics of lawsuits involving the death of an unborn child. For those contemplating taking legal action for the loss of their child, I hope this provides some useful information for you to consider.

Maryland courts have carved out specific rules for when an unborn child is considered a person capable of recovering damages in the event of death. The primary rule is that if a baby is actually born alive, no matter at what gestational age, that baby is considered a person with legal rights. So, if a 20-week baby is born alive and then dies one minute later, that baby is considered a “person,” and a lawsuit can be filed on behalf of the estate for that baby’s pain and suffering, otherwise known as a Survival Action.

(This leads to an interesting question – does a fetus feel pain? See Related Links below). The parents of the unborn child can also file what is known as a Wrongful Death action for their own economic and non-economic damages resulting from the death of their baby, primarily their grief and emotional loss over the death of their child. Survival actions and Wrongful Death actions are two separate claims, although they are usually pursued in the same lawsuit.

When a baby dies before birth, however, another question has to be asked: was the baby viable or not? Viability means that a baby is able to live outside the womb, even though he or she may require serious medical intervention. The current thinking is that babies are viable at around 22 weeks. The courts have made the rule that if an unborn child dies before the age of viability, that baby is not yet a “person” and has no legal rights. There can be no Survival Action and there can be no Wrongful Death action. If, however, the baby has reached the age of viability, then the baby is considered “a person” with legal rights, even if the baby was never born alive. Confusing? Yes it is.

The Maryland Courts were following the ruling in Roe v. Wade that a mother had a constitutional right to abort a non-viable baby. Therefore, a non-viable baby was not legally considered a person. If the baby was not a person, then no lawsuit could be filed on behalf of the estate of that baby, nor could the parents file a wrongful death action. So in order for a Survival Action or a Wrongful Death action to lie for an unborn baby, that baby has to have reached at least 22 weeks of gestation.

To make things even more confusing, the Maryland courts have carved out an exception to the above rules. Let’s consider the example of a non-viable baby (i.e., less than 22 weeks gestation) who dies before birth as a result of someone else’s negligence that injures the mother.

A common situation occurs when the mother (let’s say she’s 8 weeks pregnant) is injured in a car accident and suffers a miscarriage as a result. Looking at the above rules, one would think that no claim is allowed. However, the courts have said not so fast. In this circumstance, while the mother cannot recover for the grief of losing her child (because the child is non-viable and, therefore, not legally a person), she can recover for similar damages, including:

  • The depression, anguish, and grief caused by the termination of the pregnancy;
  • The manner in which the pregnancy was terminated;
  • Having to carry a baby which was killed by someone else’s tortious conduct; and
  • Having to witness the stillborn child or the fetal tissue that was to be her child.

I realize this itemization of damages sounds awfully close to the damages permitted in a Wrongful Death action – the very damages that are not allowed in the case of a non-viable baby. It is confusing, to say the least. The courts are trying to find a way to compensate a woman who is injured and loses her non-viable baby as a result of someone else’s negligence, while remaining true to prior precedent in this state that there is no Wrongful Death action allowed in the case of a non-viable baby.

Lastly, keep in mind that Maryland’s cap on non-economic damages applies to cases involving the death of an unborn baby. Economic damages (medical bills, lost wages) are usually very small in such cases. There are no lost wages because we’re talking about a baby, and the medical bills are usually small.

The value of these cases is in the emotional pain and suffering of the parents, and the physical pain and suffering of the baby (assuming a viable baby). Under Maryland law, the maximum allowable recovery for such a claim is $868,750 in a medical negligence action (assuming Mom and Dad both file a wrongful death action).

Under the hypothetical of the mother seeking recovery for the loss of a non-viable baby, the maximum allowable recovery is $695,000 if the allegation is medical negligence, and $755,000 if the allegation is non-medical negligence. (The Maryland Legislature has for some strange reason imposed different caps depending on whether the negligence is medical or non-medical, e.g., a car accident).

As for the question of whether an unborn child feels pain, please click on the link below for a blog by Brian Nash on this very issue.

Related Nash and Associates Links

Does a fetus feel pain

Hysteria over malpractice “crisis”

 

 

 

Home Births – Increasingly Popular But Are They Safe?

Saturday, June 4th, 2011

image from hobomama.com

Many little girls grow up fantasizing about what they want to be when they grow up; perhaps they want to be the President, or an artist, or a doctor, or an architect. Others might be daydreaming about being a princess or an astronaut. However, I do not know of many little girls who grow up dreaming about how they would like to bring a child into this world. Yet once these girls grow up into adults, many of them feel strongly about having a birth plan that is just as magical as all of their other dreams. Images of a comfortable labor or a display of womanly strength may play a role; perhaps they want music or a particular image available to them. Some want as few interventions as possible, while others would prefer an epidural at the hospital door. No matter what vision of childbirth a woman has, the desired end result is almost universally a healthy child.

Home Birth Rates Decreasing for Years…Now Dramatically Increase

It is no wonder that women often have strong feelings about what they want for their birth experience and how to best accomplish their goals. Historically, women gave birth at home. That practice changed and by the early 1950s, almost all women in the United States gave birth in a hospital setting. According to an NPR article about a recent study published in Birth: Issues in Perinatal Care, “the percentage of home births in the U.S. had been dropping slowly but steadily every year” from 1989 to 2004. Surprisingly, the trends reversed dramatically in the four-year period between 2004 and 2008. The study found a 20 percent increase in the number of women in the United States who gave birth at home between 2004 and 2008. Despite this increase, we are still talking about a small percentage of total births – less than 1 percent.

Increase is Mostly in Non-Hispanic White Women

A twenty percent increase is still a very large amount in a 4-year period. I was interested in the implications of this change. First, one of the most surprising (to me) findings in the study was that the change was not seen across the board. The article explained that “[m]ost of the rise was due to an increase in home births among non-Hispanic white women.” A New York Times article said that:

[t]he turnabout was driven by an increase of 28 percent in home births among non-Hispanic white women, for whom one in 100 births occurred at home in 2008. That rate was three to six times higher than for any other race or ethnic group.

I did not find any explanation or hypothesis for why this particular segment of the population was increasingly choosing home births over hospital births. Though the study does suggest that it was a change by choice as the article explained that “[r]esearchers found among the 25 states that tracked planning status in 2008, 87 percent of births that occurred at home were planned.”

Are Home Births Advisable? Are they Safe?

So, is the increase in home births a good thing? Certainly, I support a woman being comfortable and happy in her choice for a birth plan. I have given birth twice and know that it can be both one of the more uncomfortable and simultaneously one of the most overwhelmingly joyous moments of a woman’s life. A home birth affords a mother a setting that is likely more comfortable and certainly more familiar than most hospitals. And yet, as I mentioned earlier, women really just want a healthy outcome for both them and their baby. Can a home birth accomplish this goal?

Most of the medical community, certainly most associated with hospitals, say that home births are not the safest option for babies; however, neither are all hospital births.

Leading members of the medical community respond that hospitals — where 99 percent of all U.S. births take place, according to the CDC — are the safest places to have a baby, with modern medical interventions available.

The newborn death rate is two to three times higher for planned home births than for those that take place in hospitals, said George Macones, chairman of the committee on obstetrical practice at the American College of Obstetricians and Gynecologists, which has long opposed home births. Some home-birth advocates say such studies are flawed.

“There’s no question that if you come to a hospital, there’s a one in three chance you end up with a C-section, and it’s certainly true that some of them aren’t medically indicated,” Macones said. But at home, where there is less monitoring of the baby, there is more chance of a bad outcome, he said. “Obstetrics can be a risky business. Things can go wrong.”

From a Washington Post article

Home births, even those attended by a certified nurse midwife, do not provide the medical technology and care that can be present at in a hospital setting. Perhaps this is what many women may be trying to escape when choosing to give birth at home. I know that normally I would rather stay out of a hospital at all costs since hospitals may raise the risks associated with medical interventions and infections. Additionally, the high C-section rate at hospitals may also subject women to unnecessary risks. This is one of the concerns mentioned in the New York Times article:

Other research has suggested many women choose home birth because of concern about high rates of Caesarean sections and other interventions at hospitals, said the new study’s lead author, Marian F. MacDorman, a statistician with the National Center for Health Statistics. “The two trends are not unrelated,” Dr. MacDorman said.

Additionally, the NPR article reports that the new study published in Birth: Issues in Perinatal Care found that birth outcomes are improving for babies born at home:

Researchers … found a statistically significant improvement in birth outcomes for babies born in the home. Infants who were born preterm fell by 16 percent. The percentage of home births that resulted in infants with a low birth weight also fell by 17 percent…One reason for the better outcomes could be that more women are planning to give birth at home. Researchers found among the 25 states that tracked planning status in 2008, 87 percent of births that occurred at home were planned. MacDorman also suggested that midwives could be getting better at choosing low-risk women to be candidates for home birth.

Are Birth Outcomes at Home Improving Because Lower Risk Mothers Are Delivering at Home?

Now this idea is one that resonated with me. Perhaps the key to the safety of home births is which women are giving birth at home. I remembered reading a story in the Washington Post a couple of weeks ago about a local midwife who was convicted in a baby’s death. What stuck with me about this tragic story was that the mother did not seem (at least to me) to be a good candidate for a home birth. A couple of small paragraphs late in the article explain:

It was a case most obstetricians would call high-risk: The first-time mother in Alexandria was 43, and the baby was breech, which essentially means upside-down from the normal head-first position.

The baby’s position wasn’t the problem, Carr said; the problem was that the baby’s head became stuck.

Two women who supported the mother during the September delivery said in interviews that both Carr and the mother knew the risks involved in such a delivery. They both said everything was going well, until it wasn’t.

This sounds like a horrible accident that could have happened even with the best of intentions. However, another Washington Post article explained the details surrounding how the midwife, Karen Carr, came to be working with this mother:

[Law enforcement officials] said Carr was unlicensed in Virginia, agreed to perform a high-risk breech delivery in a woman’s home after other care providers refused, and ignored warning signs that the delivery was not going well.

Ultimately, prosecutors said, Carr allowed the baby to remain with his head stuck in the birth canal for 20 minutes and then, after delivery, tried to resuscitate him for 13 minutes before calling for emergency medical help. The boy never gained consciousness or displayed brain activity, and he died two days later at Children’s National Medical Center in the District when life support was removed.

The parents sought out Carr in August after nurses at a licensed birthing center in Alexandria said they could not deliver at home because of the fetus’s position in the womb; breech births are most often delivered by Caesarean section because the risk of complications from a breech delivery — in which the baby is positioned feet-first — are high, according to medical officials.

Carr agreed to do a home delivery and, prosecutors said, declined to call for help when things got out of control. A medical examiner ruled that the death was due to complications from a breech birth at home.

While the midwife might have been performing outside the standard of care, my question in reading these articles is whether it is reasonable for a midwife to agree to a home delivery for a high risk mother, who is of advanced maternal age, whose child is breech, and who has already been turned down for delivery by a licensed birthing center based on the risks. It seems to me that the midwife and the family were taking a grave risk with this child’s life – a risk that the parents must have at least somewhat acknowledged since they sought out the home birth after being turned away by the birthing center. To what degree is it the midwife’s responsibility to assist a woman who insists on a home birth despite the risks? To what degree is it her responsibility to refuse to participate if the risks to the child are unacceptably high?

Does Insurance Matter?

Finally, I wonder what role insurance will play in the increasing number of mothers choosing to give birth at home. Vermont’s governor just signed a bill into law that will require private health insurance companies to pay for midwives during home births.  According to the Forbes article about the new bill, Vermont joins New York, New Hampshire and New Mexico in this requirement. Vermont’s rate of home birth is the highest in the country at 3 percent. The bill is expected to lower costs for low-risk births for women who choose to birth at home. I wonder, however, whether the choice to have a home birth that is reimbursed by insurance will open the door to additional mothers choosing to birth at home even if the risks are high.

What Do You Think?

At the end of the day, it seems that home births may be a good option for some low-risk women who have the support of a well trained midwife and accessible medical back-up in case of problems. That being said, for those at higher risk, perhaps there need to be other safeguards in place.

What do you think? Are you or have you been involved in home births? How are woman normally empowered to have the birth they want if they are high risk? What can be done to make the choice safer for the baby?

Related Posts:

The Grief of Losing an Unborn Child

Laughing Gas Making Its Way Back into the Labor and Delivery Department

Week in Review (April 18 – 22, 2011) The Eye Opener Health and Law Blog

Saturday, April 23rd, 2011

From the Editor:

This past week, our blawgers (guess I’ll use this term now since we are legal bloggers) were busy on their keyboards once again. They covered a number of topics relating to law, medicine, health and patient safety. This week we posted a primer on aortic aneurysms and how they can present as back pain, a blog about “robot” anesthesiology, a disturbing post about how the recent threat of a federal government shutdown was averted but at a cost to those who are in dire need of healthcare, an interesting piece about laughing gas making its way back into the American medical scene for labor and delivery and finally, and a highly read piece on a not-to-often discussed topic but one of potential grave concern – shift switching by nurses and how this might impact patient safety.

Here’s our usual “quick summaries” for you to peruse, click on, read and comment:

Aneurysms – a deadly condition you need to know about!

Our in-house medical specialist, Theresa Neumann, wrote another highly educational and need-to-know piece about a condition that can present as back pain but which has deadly consequences for those who have this condition.

As Theresa’s research made us aware – “1 in every 50 males over the age of 55 have an abdominal aneurysm, this is a more common pathologic diagnosis than some others.  Men also corner the market at an 8-to-1 ratio as compared to women with abdominal aneurysms.”

As is the case with all of Theresa’s writings, we offer through her valuable information from someone who’s “been there” and “done that” in the clinical setting. Don’t miss her post entitled Aneurysms: A Potential Deadly Condition That May Present as Back Pain.

Who’s using remote control and a joy stick to put a breathing tube down your throat?

Mike Sanders brought to our attention a new practice of anesthesiologists – in Canada – that may soon be part of anesthesia management in the United States as well – using robotics to intubate patients. While you can certainly learn about the concept of intubation by reading Mike’s blog, basically, this is placing a small tube down a patient’s airway so that the anesthesiologist can control the airway and provide ventilation to a patient undergoing surgery.

Here’s an except -

Medical News Today is reporting that Dr. Thomas Hemmerling of McGill University and his team have developed a robotic system for intubation that can be operated via remote control.

For more on this fascinating new project by Dr. Hammerling and his team, read Mike’s post entitled Robot Anesthesiologists?

Government Shutdown Avoided – but who will pay the price for the “deals” that were cut?

The newest member of our blogging team, Jason Penn (fast approaching veteran blawger status) did a fascinating piece of the story-behind-the-story of the recent crisis our country faced when the federal government was on the verge of a shutdown. We all know about deals being cut in the back rooms of congress. We all know that the government avoided a shutdown this time around when the senate and house worked out a compromise that resulted in millions of dollars being earmarked for cuts in the budget.

Jason tells us what programs relating to healthcare will suffer as a result of these negotiated cuts. As some wise person once said, “why is it always those who are least represented who bear the burden of budget cuts?” Maybe it’s because they can’t afford lobbyists to protect them like those who need protection the least can.

Read Jason’s eye opening and no-punches-pulled report on just who will be the victims of the deals in his post of this past week Budget Crisis Avoided, But What About the Babies? Can They Live With $504 Million Less in Funding?

Will moms-to-be now be “laughing” their way through labor and delivery?

One of our seasoned blawgers, who every now and then is driven to report on the off-beat issues of law, medicine and healthcare, Jon Stefanuca, stepped up to the plate once again and took a swing at the return of an old-timer to the arsenal of pain relief for mothers-to-be undergoing labor and delivery – laughing gas!

As Jon’s piece in Eye Opener this past week tells us -

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future.

For more about this return of laughing gas to our obstetrical units, read Jon’s piece Laughing Gas Making Its Way Back Into the Labor and Delivery Department.

Nursing and Sleep Deprivation: Is it a risk factor for patient safety?

I suspect somewhere along the line you have done “an all-nighter” – whether it was getting ready for a big test, a social event, or for some other reason. Remember how you felt as you made it through that night or the next day? Have you ever done it several nights in the same week? How about doing it a few times one week and then do the same thing the next week and the next…. Well you no doubt get the idea. You’ve been exhausted, right? Well what about nurses, who have to do this for a living?

Nurses have lives too. They have children, home responsibilities and obligations, and some form of social life. What happens when they swap shifts or are asked to do “a double”?

Sarah Keogh was back blogging this past week and wrote a fascinating (and concerning) post entitled Nurses Switching Shifts: Does a Lack of Sleep Put Patients at Risk? We invite you to read Sarah’s piece and share your comments. Are you a nurse who lives this lifestyle? What are your thoughts about nurses being allowed to work multiple shifts or back-to-back shifts in terms of patient safety? Should there be restrictions on nurses’ shifts just as there (finally) are work restrictions on doctors-in-training?

A “Sneak Peak” of the week ahead

As part of our continuing effort to “get the word out there” on issues relating to health, medicine, patient safety and the law, we post from time to time more extensive research pieces called White Papers. Well, the time has arrived for another White Paper to be posted on our website. Marian Hogan has completed her piece on a very important topic – Patient Controlled Analgesia in today’s hospital environment. She examines how some hospitals are now heavily marketing a spa-like environment so you choose them over the competition. Yet lurking in the shadows of these facilities which promote flat screen TV’s, valet parking, in-room safes and the like is a very dangerous practice: placing patients on patient-controlled-analgesia (for pain relief) without vital monitoring devices and patient safety practices. It’s at the “printer” now; we hope to have it online this week.

From our blawgers you can expect reports on a disturbing fight between manufacturers and child safety experts over – blinds! After decades of controversy, you’ll find out where the battle lines are now drawn, who’s winning and who the real losers are in this war. Wonder how healthcare safety is doing since the report To Err is Human was published by the Institute of Medicine over a decade ago? Jason Penn will be providing an updated report card, which you should not miss. Alcohol and surgery – not a good combination! Jon Stefanuca plans on posting a piece that looks deeper in the obvious problems with this potentially deadly combination.

This is just a taste of what’s to come. I better wrap-up now. I’m working on finishing the third installment on Medical Technology and Patient Safety. Oh yeah, if time permits, I might even get to post a piece I’ve been working on this past week – a lawyer’s rant about our modern day love affair with mediation practices and trends.

As always, don’t forget - subscribe to the Eye Opener and tell your friends about us too! …and… don’t forget to join our social networking communities on Facebook and Twitter.

Hope you have a great weekend!

Makena: Drug to fight prematurity leads to major firestorm.

Thursday, April 7th, 2011

Last week, I started following a still emerging story about a drug that I had never heard of before called Makena. The medication is a synthetic form of progesterone that is used for women who have a high risk of prematurely delivering a baby based on having had a premature delivery in the past. The drug must be injected by these women weekly for 18-20 weeks of their pregnancy.

According to the Baltimore Sun, the controversy surrounding this drug began when the “…K-V Pharmaceutical Co. boosted the total cost of the drug during a pregnancy from about $400 to $30,000, igniting a firestorm of objections.” This was possible because originally the medication was created by a compounding pharmacy mixing it together for patient use. Then in February, the FDA granted K-V Pharmaceutical Co. the exclusive rights to manufacture the medication for seven years.

If raising the cost of the medication 75 times its original cost (from $10-20/dose to $1,500/dose) were not enough, the Baltimore Sun reports that the company then went on to “sen[d] letters to pharmacies threatening that the FDA would punish them if they compounded their own versions of the drug.”  However, the FDA, amid a loud outcry of complaints, has “…declared it would do no such thing.  In its statement, the FDA noted that the drug was important and K-V ‘received considerable assistance from the federal government in connection with the development of Makena by relying on research funded by the National Institutes of Health to demonstrate the drug’s effectiveness.’”

What has been so interesting are the implications of this story and the reactions to it. Clearly, the original decision by the pharmaceutical company to raise the cost of the drug 75 times the old cost is an attempt to make money from their exclusive rights. I can hardly imagine that there is any reason other than profit creation for this move given that they did not have costs associated with research and development or any other clearly identifiable costs. So, aside from my initial reaction of disgust that this might make it harder for women who need this medication to protect their children, I also thought about the bigger implications.

First of all, the cost issue is not so simple as it first appears.  As another article from the Baltimore Sun mentioned, “[t]he burden for many will fall on insurance companies, which may have to raise rates. The increase will also affect already strapped Medicaid programs.” The increased costs of drugs impact many Americans directly – those without insurance or those for whom even co-pays are a major budgetary struggle. However, the costs here also reach all of us. If the costs associated with the company’s increased profit are borne by the insurance companies and Medicaid, it also means that the costs are going to be felt by all of us who pay for health insurance or whose companies pay for health insurance and yes, by all of us, who pay taxes.

Secondly, for those women who do not realize that they could still go to a compounding pharmacy for this prescription and for whom it is not covered by insurance, the increased cost may mean that some woman will go without these injections. The Baltimore Sun article reports that:

About 500,000 U.S. infants are born prematurely each year. The March of Dimes estimates that about 10,000 of those premature births could be prevented if eligible women received Makena.

The implications here deal with both the health and safety of the unborn child who is now at risk of premature birth. But, unfortunately, they also have an associated monetary cost. The cost of a baby being born prematurely is also going to weigh on the insurance companies and is, therefore, going to be shared by all in the form of potentially increased premiums.

Given the intense criticism in the news, K-V Pharmaceutical Company moderately changed course in the last few days, according to Medical News Today and said they would bring the cost of Makena down to $690 per dose from the originally announced price of $1,500 per dose. While this is lower, this is hardly a significant adjustment given that the compounded version costs between $10-20 per dose. The March of Dimes, which originally backed FDA approval of the drug and was allowing the pharmaceutical company’s use of its name and logo, is apparently embarrassed by KV Pharmaceutical’s decisions. According to an article on the nonprofitquarterly.org, “…the March of Dimes is backing out of a sponsorship deal with the [pharmaceutical] company that sells [Makena]. Last Friday, the nation’s leading nonprofit focused on the health of pregnant women and babies said it would no longer allow St. Louis-based, KV Pharmaceutical Co. to use its name or logo in any of the drug company’s promotions.”

The response from the March of Dimes is not KV Pharmaceutical Co.’s only trouble as the Wall Street Journal is reporting that after the FDA announcement that it will not take action against pharmacies that compound the drug, and the company subsequently announced that it would cut the cost, the company’s shares fell 5.2%.  Reuter’s is reporting that this represents a drop of more than 20 percent.  Congress is also in an uproar about this issue.  The Reuter’s article says that elected officials are creating pressure for more to do be done on this issue.

What do you think should be done about KV Pharmaceutical Co.? Are they really any different from any of the other pharmaceutical companies? Is it relevant to consider that this is a so-called orphan drug and that the company has exclusive rights because of this? Do you think that allowing compounding pharmacies to create the drug for woman separate from the FDA approved drug is a sufficient solution? What about the bigger question of companies creating inflated prices for their products and having insurance (and all of us) foot the bill?

 

Having an epidural when you deliver your baby? 3 Questions to ask the doctor!

Monday, April 4th, 2011

Be your own advocate - ask questions!

Thousands of women will have an epidural today to help them through their labor, and many of them will have a running epidural after they have their baby delivered. This is especially true in the time period for those who have had a C-Section.

There’s no doubt that epidurals have been a wonderful tool for doctors to provide patients with relief from the pains of labor and the pain and discomfort following delivery – mainly after a C-Section.

Because they have become so commonplace in hospitals throughout this country – and the world – they seem to have been taken for granted as being “safe” – not just effective. For the most part – they are safe, but they clearly have significant risks associated with them.

Some reports claim that the overall complication rate for epidurals is 23%. These complications range from very minor (e.g. some nausea, vomiting, itching, headaches) to the most major of complications – death of the mother and/or her baby. In between these two extremes lie some very devastating injuries to both a mother and her baby. Just some of those reported are damage to the mother’s spinal cord leading to motor (ability to move legs) and/or sensory (ability to feel sensations) injuries, bowel and bladder dysfunction, foot drop and a host of other potential – thankfully rare – complications.

There is a popular book that many expectant mothers have considered their bible over the years – What to Expect When You’re Expecting, which is now in it’s fourth edition, according to Amazon.com. While no doubt this has been a valuable resource for many moms-to-be, one medical author takes some exception to the section on epidurals:

Epidural anesthesia has become increasingly popular for childbirth. The popular book, What to Expect when You’re Expecting, for example, portrays epidurals as perfectly safe. The risks, however, may be greatly underplayed.

It’s been many decades (four in one instance) since I personally went through the “birthing” process as a parent-in-waiting. I must admit, I have not purchased or read the latest edition of this book so I cannot vouch that this portrayal of epidurals being “perfectly safe” is still the message of this popular book. Obviously it was at the time of the quote by this Canadian medical writer.)

What expectations do YOU have for your special day?

I suspect that many of you are like I was in envisioning what your experience will be like when the day arrives. You have your bags packed, back-up coverage in place if needed, car gassed. The moment arrives and off to the hospital you go. You register, get in your room, the fetal monitor is applied, and you pass the time remembering (or trying to remember) all those things you learned in your birthing classes. Your epidural is placed and all goes smoothly. Finally, the time comes for you to deliver your new bundle of joy. You make it through some angst of birth, see your new addition through tears of joy and relief and get ready for the onslaught of family and friends, who want to see the new arrival to your family. After you and your baby are cleared for discharge, off you go to your home, ready to begin your “new life” of nurturing, educating, parenting – aglow with images of pride, joy and a world of opportunities ahead. Hopefully, that’s exactly how we all hope it works out for you and your family.

To increase your odds that this scenario plays out, I would strongly suggest that you not take for granted the part about your epidural going smoothly. While there are probably many other questions you may think to ask – or should think to ask – here are three suggestions I have for you based on my seeing (as a lawyer) what can happen when the epidural doesn’t go smoothly.

How an epidural is performed

Here is one example available on the internet (YouTube) to show you just how an epidural is done. Unfortunately, it is a bit difficult to understand the speaker (at least for me), but having looked at several videos, I think it gives you a pretty good idea of how this procedure is performed by the anesthesiologist.

httpv://www.youtube.com/watch?v=_WRccCADReY&feature=related

“Have you reviewed my medical history, Doctor? Is there anything else I can tell you?”

Some of the known risks of having epidural anesthesia are connected to your medical history. Sure, you’re assuming that the medical history you gave to your OB during the prenatal visits and to the intake nurse when you arrived at the hospital has found it’s way to your medical record. You’re also assuming that your medical history has been carefully reviewed by the anesthesiologist whose about to put the epidural in your back. Is it there? Has it been carefully reviewed? Ask! There are conditions (e.g. spina bifida, scoliosis, certain heart valve problems, sickle cell anemia, etc.) that can increase your risk of a complication from an epidural.  Are you taking or have you recently taken any type of anti-coagulant such as heparin or coumadin? Make sure your anesthesiologist is aware if this is the case since these drugs can increase the risk of a bleeding complication. You don’t want to have a collection of blood around your spinal cord – believe me!

“When should I expect to move my legs or bend my knees? How long will I feel numb?”

In most instances, epidural are given to provide analgesia – pain relief (sensory block) during labor and at times for post-delivery (C-Section) pain relief. They are not intended to block your motor function – that is, your ability to move your legs, flex your ankles, wiggle your toes, flex your hips or bend your knees. During a C-Section the drugs being used for delivery are many times different drugs from the ones you are getting via your epidural infusion. You will have a different block so that surgery can be performed safely. You will likely have both a sensory and a motor block! You need to understand the difference.

These anesthesia drugs (the ones given during your surgery) will usually wear-off (varies depending on the drugs and from patient to patient) in a period of 1 to 4 hours. You will typically be in a post anesthesia care unit (PACU) during your recovery phase from anesthesia.

Key: you should not be discharged from the PACU if you are unable to at least bend your knees. There is a scoring system (Bromage) that the nurses and personnel in the PACU will typically use after examining your ability to move your legs, bend your knees, wiggle your toes, flex your hips, etc. to determine if you can safely be discharged from the PACU or if you need to be seen by a specialist in anesthesia to determine if you have a potentially significant complication.

“What exactly should I expect to feel like if I have an epidural running after I deliver my baby?”

I simply cannot stress enough how important it is for you to understand exactly how you should be feeling after you have been discharged from the PACU to your room. Don’t ask your family or friends; they don’t know – unless they are anesthesiologists. There are so many free, uneducated opinions out there that are simply wrong!

One further piece of advice: do not ask the nurse what you should expect to feel like. There is absolutely no doubt that there are many  very experienced and highly capable nurses out there taking care of moms. Unless you intend to ask for and analyze your nurse’s background, training and experience in anesthesia, don’t do it. The drugs used in administering epidural analgesia can vary significantly. The dosing (concentration, volume per hour, etc.) can also vary. Only a specialist in anesthesia can answer your questions correctly!

Know what to look for so that if there is some change in your condition or you start to encounter a feeling or loss of function or sensation, you can tell your nurse or doctor immediately so that you can be examined right away!

I suspect many parents are so caught up in the labor process, or are so exhausted after the delivery or so caught up in the wonderment of having their baby that these issues relating to an epidural may not be very important. If you are in your 20′s, 30′s or 40′s, how important is it to you that may not be able to walk for the rest of your life? It can happen – rarely, thank goodness, but it can happen. I have been involved in cases in which this is exactly what happened! Frankly – I don’t want to see it happen to anyone else. It is incredibly tragic for a mom, a dad and their child – trust me!

One last point before we leave this discussion on post-delivery (post-operative) analgesia. Some hospitals (the number appears to be declining due to concerns about the inadequacy of monitoring) use what is known as Patient Controlled Anesthesia epidural analgesia. Simply put, this is a device (they vary depending on the manufacturer) permits the patient to push a button a infuse a pre-determined dose of drugs (e.g. bupivacaine and fentanyl) into the epidural space for additional pain relief. A patient is actually limited as to how much drug can be used in the course of an hour (determined by what in called a lock-out interval and maximum dosing parameters per hour). While a fixed lower amount of drug flows each hour (known as the basal rate), many patients may require more relief than the basal rate provides.

That being said, if you find yourself pushing the PCA button numerous times during the course of an hour, you should bring this to the attention of your nurse or doctor. Don’t wait for them to hopefully check the machine to see how many times you pushed in the last hour (many forget to do this!). Be pro-active. If you are pushing your PCA button a number of times in the course of an hour, even though you can’t really overdose yourself because of pre-set limits by the anesthesiologist, this may be an indication that something needs to be checked. For instance, the catheter may have become displaced; the drugs may not be distributing equally; you may be having some problem that someone needs to investigate. Don’t keep hitting the PCA pump; hit the call button!

Get information about the risks, benefits and alternative to an epidural!

Having been there (i.e. childbirth) as a father four times, I know – at least from my perspective – how difficult it is to concentrate on issues such as risks, benefits and alternatives involving an epidural. Common sense tell me the ideal time to have this discussion simply cannot be while mom is in labor. If that’s the only chance you have, then fine – take the time and make the effort and have a real discussion with the anesthesiologist. Even if you just cover the 3 items I have suggested above, that will take you a long way.

I have made this suggestion before, but I’ll make it again: make arrangements to meet with someone from the anesthesia department before you get to the hospital to delivery your baby. Don’t be shy or concerned that you don’t want to bother anybody. Bother somebody! There really are an awful lot of wonderful doctors and CRNA’s, who would be willing to meet with you, educate you and answer your questions.  It’s your health,  your body, your future – so protect it!

There clearly are more than “3 questions” you should ask. Many of you have been through this. Many of you have medical training and experience. What questions do YOU think a mom-to-be should ask about their epidural.

 


 

The Week in Review: did you miss last week’s posts on health, safety, medicine, law and healthcare? A sneak preview of the week ahead.

Saturday, March 26th, 2011

Eye Opener - Nash & Associates Blog

This week we are starting a weekly posting of our blogs of this past week, some key blogs of interest to our more than 6,500 monthly readers, and a sneak preview of what’s coming next week. We would really like for you to join our community of readers, so don’t forget to hit the RSS Feedburner button or subscribe to our blog, Eye Opener. We share with you our thoughts, insights and analysis of what’s new in the law, the world of law and medicine, health, patient and consumer safety as well as a host of other topics that we deal with as lawyers on a daily basis in trying to serve the needs of our clients.

For those of you on Twitter, Facebook and LinkedIn, we have a vibrant presence on those social networks as well. Hit the icon(s) of your choice and become part of our ever-growing social network community. Share your thoughts, share our posts, give us your feedback on what YOU would like to hear about.

This Past Week

Birth Defect Updates: Warnings About Opioid Use Before and During Pregnancy In this post, Sarah Keogh, explored a new report which is vital information for women who are pregnant or thinking about becoming pregnant. Opiods, narcotic pain killers such as morphine, codeine, hydrocodone and oxycodone, are a valuable part of a physician’s drug armamentarium, but they can have significant implications for a fetus if taken during pregnancy or even just before a woman become pregnant. Read Sarah’s important piece, be informed and learn why you should discuss the use of any such drugs with your obstetrician/gynecologist before taking them.

 

Doctors Disciplined by Their Own Hospitals Escape Actions by Licensing Boards. Who’s at Fault? Brian Nash, founder of the firm, writes about a serious problem with this country’s medical licensing boards, who have failed, at an alarming rate, to take disciplinary action against physicians, who have had their hospital privileges revoked, suspended or curtailed for issues such as sub-standard care, moral transgressions and the like. Public Citizen brought this story to light; we analyze the issue and share our thoughts on this serious patient health and safety issue.

Decreasing Obesity Risks in Children: Another Benefit of Breastfeeding A mom herself and an advocate for public health childhood obesityand safety throughout her legal career, Sarah Keogh reports on a recent study covered by the Baltimore Sun about the long-term benefits of breastfeeding for at least six months. The issue for many, however, is – how can a family of two income earners afford to do this? Does our society and the workplace really lend itself to this practice? Read Sarah’s compelling piece and share your experience and thoughts.

The Week Ahead

Sneak preview of what’s ahead during the week of March 28, 2011:

medical technology

Brian Nash begins a series on the issue of medical technology and patient health/safety. Is the medical community being properly trained in the proper and safe use of all the new medical devices that are hitting our hospitals, clinics and medical offices? Is the rush to have the newest, shiniest and “best” new medical device really advancing the safe and effective delivery of healthcare in our country? Here’s a sneak preview…

Dr. Roper and so many other dedicated healthcare professionals are faced daily with the same issue – “…challenged by the task of putting lofty ideas into practice at the local level. I remain very committed to the effort, but we are daily challenged to put the best ideas into practice.” Put another way – at least for me – taking public healthcare policy and practices and making a much better widget.

As these lofty concepts were debated, published and analyzed, technology streaked along with its new bells and whistles at what some might call an amazing – almost mystifying – pace. Did you really envision yourself 25 years ago sitting with your iPhone or iPad and scouring the world’s news, chatting with your friends and followers on the other side of the planet, watching the latest streaming video of March Madness or sharing every random thought you have on Twitter or Facebook?

Some top posts you may have missed

What happens when your surgeon has been up all night and you are being wheeled into the operating room to be his or her next surgical case? We looked at an article from The New England Journal of Medicine that addressed this patient safety issue and made recommendations for change.  See our posting entitled A Surgeon’s Sleep Deprivation and Elective Surgery-Not a good (or safe) combination.

Dr. Kevin Pho, who is the well known editor and contributor of KevinMD.com, wrote a piece in which he espoused his belief that medical malpractice cases really do not improve patient safety. Having read this piece and finding that this was just too much to digest, Brian Nash wrote a counter-piece entitled Malpractice System Doesn’t Improve Patient Safety – Oh Really? What this led to was cross-posting by Dr. Kevin Pho on our blog, Eye Opener, and our posting on his blog. Our blog post (as best I can tell) led to one of the all-time highest postings of comments by readers of KevinMD. One thing all participants in the “debate” learned – we are both passionate about our positions. Read what led to this firestorm.

 

Decreasing Obesity Risks in Children: Another Benefit of Breastfeeding

Friday, March 25th, 2011

Image from fooducate.com

In the United States today, one of the major health problems is obesity. The CDC reports that “[i]n 2009, only Colorado and the District of Columbia had a prevalence of obesity less than 20%.”  The number of both adults and children who are obese is huge and continues to rise dramatically.  The CDC website provides maps that show just how prevalent this problem is in our country. Particularly troubling is that “[t]hirty-three states had a prevalence equal to or greater than 25%; nine of these states (Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and West Virginia) had a prevalence of obesity equal to or greater than 30%).  This represents an enormous number of people in our country who are at risk for major health complications, such as “cardiovascular disease, certain types of cancer, and type 2 diabetes.”

While there has been an emphasis in our country on various ways to decrease these obesity statistics (including improving nutrition and increasing exercise), I wonder whether additional emphasis should be paid to children being given a great start to health. A recent article in the Baltimore Sun caught my attention. The article explains how diabetic moms, including those who had gestational diabetes during pregnancy but are not otherwise diabetic, are both more likely to give birth to a larger than average baby and also how their child is “more likely to become obese in childhood.”  The good news, the article explains, is that:

…a new study says that if you breastfeed your baby for at least six months, your child will be no more likely to put on weight than those whose moms are not diabetic.

This is just one more example of how breastfeeding for at least six months can dramatically improve your child’s chances of lifelong health.  Through breastfeeding alone, these moms can erase the increased risk that these children will become obese.

What they found appears to be a real advantage for breastfeeding: If the babies had been breastfed for six months or more, children born to diabetic moms looked nearly the same as the children of non-diabetic moms. And they were no more likely to be obese.

On the other hand, children who were breastfed for less than six months — and who had been exposed to diabetes in the womb — had significantly higher BMIs, thicker waists and stored more fat around their midsections than the other children in the study.

While I was excited to read about one more reason to support breastfeeding, I was concerned about whether this is a realistic choice for many families in our country.  Many moms who are committed to breastfeeding their children and who are successful at the start, do not continue breastfeeding for at least six months. The CDC Breastfeeding Report Card for 2010 says that “…3 out of every 4 new mothers in the United States now starts out breastfeeding… However, rates of breastfeeding at 6 and 12 months as well as rates of exclusive breastfeeding at 3 and 6 months remain stagnant and low.”  The national average is that while 75% of moms have breastfed, only 43% are breastfeeding at all at 6 months and only a mere 13.3% are exclusively breastfeeding at 6 months.  At 3 months, a time when infants would not have started solid food, only 33% of moms are still exclusively breastfeeding.  This means that there is a large drop off from what moms do when their babies are born and what they are doing by the time their babies reach 3 months.

However, the study about diabetes found that at least six months of breastfeeding was essential in protecting these kids from the increased risks of obesity. From both personal experience and anecdotal evidence, I suspect that many families are facing hard decisions about employment and breastfeeding. I suspect that a significant part of the large drop off between the numbers of moms’ breastfeeding at birth and those breastfeeding exclusively at 3 months has to do with employment. Given that the US lags so far behind other countries in paid parental leave, most moms have no choice but to go back to work full-time by the time their infants are 3 months (if not earlier).  Many moms face no choice at that point but to stop or severely limit breastfeeding, as few employers offer the time, space or scheduling to truly make moms successful at the difficult job of trying to pump while working.

I believe that the health care costs of treating individuals with obesity and all of the associated health problems should be examined against the costs of providing more complete support to new families.  What do you think?  Could employers better support breastfeeding in an attempt to increase the number of healthy children whose risks of obesity are lowered? Do you think that lack of paid leave or increased support in the workplace for breastfeeding is really the reason for decreased breastfeeding or are there other factors at play?

 

 

Birth Defect Updates: Warnings about opioid use before and during pregnancy

Monday, March 21st, 2011

Photo credit: Getty Images

Recently, I wrote about studies concerning the increased risk of birth defects caused by smoking.  A recent press release from the CDC draws attention to a newly discovered link between the use of certainly prescription opioid pain relievers by a woman shortly before conception or in the first trimester of pregnancy to an increase in birth defects.  Similar to the evidence about smoke exposure, the research identifies the period before conception and during early pregnancy as critical.  I think that these findings raise questions about the use of these drugs by woman of child-bearing age as the critical time period may be one when a woman is not aware that she is pregnant or going to become pregnant.

Use of these opioid pain relievers, such as codeine and oxycodone, “was linked to several types of congenital heart defects as well as spina bifida, hydrocephaly, congenital glaucoma and gastroschisis.”  According to the press release, the study, which was published in the American Journal of Obstetrics and Gynecology, “found that women who took prescription opioid medications just before or during early pregnancy had about two times the risk for having a baby with hypoplastic left heart syndrome (one of the most critical heart defects) as women who were not treated with these opioid medications.”   Overall the CDC statement suggests that the risk of these defects is not that large for any individual woman given the rarity of these conditions, but that it is important information nonetheless since the defects are very significant.

Cerebral Palsy rates dropping in U.S.

In happier news, overall rates of cerebral palsy are dropping in the United States.  The cause of the decline is linked to improved care during pregnancy and at birth.  According to Medical News Today, a new “…article published in The Journal of Pediatrics indicates that the rates of cerebral palsy have declined dramatically in the past 15 years.” This is exciting news not just because it means that many fewer children are born with a devastating injury but also because it is an indicator of a general improvement in the care provided to mothers and babies before, during and immediately following birth.

 

 

Nationwide Push to Curb Elective Early Deliveries

Wednesday, March 16th, 2011

Image by SoulPrintsPhotography

I recently overheard a mother talking about her child’s upcoming birth.  She was pregnant with her fourth child and was a few days away from her due date.  Another mother was asking her about whether she was concerned about when she would go into labor.  The pregnant mother explained that she was scheduled to have a planned caesarean section, since for medical reasons her prior three children had already been born via caesarean section.  What was interesting and surprising about this conversation was that the mother went on to explain that she was scheduled to give birth to the baby a week later, four days after her due date.

The mother clearly stated that she specifically requested a delivery date after her due date.  I was surprised and impressed by this mother’s decision and the explanation that she gave to the other mother about her choice.  She said that her first child was born by unscheduled caesarean section following an attempted induction two weeks after her due date.  She then had each of her subsequent children by planned caesareans – the next on the due date, the third a few days after the due date and this one planned for 4 days after the due date.  She explained that she liked to wait as long as possible before having the caesarean sections for each of her children.  I don’t know if this mom was up to date on the recent research in this area or if she had other reasons that she chose to delay delivery.  However, her choices seem very sound based on current research that shows that too many moms are having elective deliveries before their due dates.  These deliveries before a baby is full term can increase the risk of complications to mother and baby and lead to longer hospital stays.

A recent article on a Wall Street Journal Health Blog discusses the current nationwide push to inform mothers about the risks of elective delivery before 39 weeks of gestation.  Another Wall Street Journal article highlights what a large number of births this might impact as “’early term’ elective inductions…[now] account for about a quarter of births, up from less than 10% in 1990.”  The number of elective deliveries is large and so are the complications:

Now, a growing body of medical evidence indicates that gestation even a few days short of a full 39 weeks can lead to short- and long-term health risks. Public health officials, safety advocates, private insurers and employer groups are stepping up pressure to sharply reduce early term deliveries. The practice drives up costs of neonatal intensive care and leads to a higher rate of caesarean sections. C-sections are more expensive than natural deliveries and result in longer hospital stays and more risks for the mother, including infection. A study last year estimated that reducing early term births to 1.7% could save close to $1 billion annually.

The current research, including a study published in the Journal of Reproductive Medicine, is influencing a campaign to stop doctors and hospitals from allowing elective deliveries before 39 weeks to better protect mothers and babies, as well as to cut unnecessary costs.

What do you think?  I can certainly sympathize with mothers who are uncomfortable at the end of a pregnancy and are ready for delivery.  However, I cannot imagine that many mothers, faced with the information about risks to themselves and their babies, would not be willing to stay pregnant for another week or two.  I wonder if a clear and widespread public education campaign targeted at mothers would not dramatically decrease the number of elective early deliveries?

 

Pregnancy Gingivitis: Simple ways to avoid risk for you and your baby.

Friday, February 25th, 2011

I recently came across a website that offers a lot of really good advice for parents-to-be, and I’m happy to promote it on our blog. You may want to visit The Pregnancy Zone and bookmark it for future good reads. If you are a long-time reader of our blogs, you know by now we are really into sharing health and safety information with our readers. As we say on our Twitter page, we are lawyers trying to get the word out so you never need people like us

A recent post on The Pregnancy Zone brought to my attention a condition that, quite frankly, I was not all that familiar with - pregnancy gingivitis. Gingivitis is probably a condition that you are already familiar with. Simply put, it is a form of periodontal disease, which involves inflammation and infection that destroys the tissues that support the teeth, including the gums, the periodontal ligaments, and the tooth sockets. What I didn’t realize is that it has a real potential risk for moms-to-be and their babies. Watch this video by Dr. Jaimie Johnson for a better understanding of why it is important to not overlook this basic element of your prenatal care.

httpv://www.youtube.com/watch?v=c8Uip6hr3vM

So why is this so important? Premature delivery is the primary reason.

At least a couple of major studies have shown that there is a link between gum disease and premature birth. Researchers of one study who published their results in The Journal of the American Dental Association found that pregnant women with chronic gum disease were four to seven times more likely to deliver prematurely (before gestational week 37) than mothers with healthy gums.

Mothers with the most severe periodontal disease delivered the most prematurely at 32 weeks. The researchers’ study did not address if treating gum disease would reduce the risk of preterm birth, adding that more studies need to be conducted to answer this question. Their main findings, however, support the results of another study that also showed that premature, underweight babies were born more often to mothers with gum disease.

Source: WebMD:

What also drew my attention to this topic was a story of a mom, who suffered a stillbirth at full term. The best cause for how this could have happened, according to her doctors, was that the bacteria from her dental condition had directly affected the placenta, leading to the death of her fetus in utero.

What is a bit disturbing about the WebMD post is the statement that the study “did not address if treating gum disease would reduce the risk of preterm birth, adding that more studies need to be conducted to answer this question.” Clearly, some blogs and videos on this topic indicate that there is a treatment-risk reduction benefit. It does seem to make common sense, doesn’t it?

Would love to know if you have any information to share about any other studies, ongoing research and the like on this topic. Sure seems that – at a minimum – getting good dental care during your pregnancy is sound advice and surely worth the effort in case there is a direct cause-effect-treatment relationship perhaps is the case.