Lotus Birth: The Answer or Just Another Fad?

Have you heard of the latest birthing fad?

It’s called the “Lotus Birth”. I thought it had something to do with the lotus flower, but apparently it’s just the name of the first woman to encourage the practice.

What is Lotus Birth?

A Lotus Birth is one where the umbilical cord isn’t clamped once the baby is born. Unlike delayed cord-clamping, the cord and the placenta remain attached to the baby until it falls off. This can take anything between three and ten days.

What are the claimed benefits?

The biggest reasoning given for this concept is based on the fact that the placenta is formed from the same egg-and-sperm that gives rise to the baby, and therefore it is part of the baby, and therefore it must not be violently severed from the baby.

There’s a largely metaphysical argument, relating to the baby being calmer, being more gently introduced to the world, and feeling closer to its mother.

(Hey, here’s an idea: practise Kangaroo Mother Care. That should help Baby to feel REALLY close to Mom.)

I could say that my cord was clamped and I don’t experience lingering trauma; but that would be as unscientific as the evidence for LB.

What are the health implications?

What really gets my goat is the so-called health benefit of lotus birth. Proponents claim that it reduces risk of infection, because there’s no open stump.

No. You’re right. There’s no open stump.

THERE IS A FREAKING OPEN PLACENTA!

Have you seen a placenta lately? The whole thing is a portal for infection.

It is said that the placenta must be liberally covered with coarse salt to prevent infection. Why, pray, is that then any better than protecting the stump from infection?

Isn’t it better for the baby in the long run?

Studies show* that babies with delayed cord clamping have higher intermediate-term HB, which is great. These babies are also, however, at risk for complications from polycythaemia, including jaundice.

Nevertheless, delayed cord clamping has some health benefits. But only when the delay is up to a 10-20 minutes, after which the cord clamps internally and stops pulsating. So then it literally is just a dead weight. Like a necrotic toe that’s really no use. And a risk to the remaining living tissue.

For bonus marks: What’s wrong with this picture?

That’s right. The baby is above the cord. Which means if the cord hasn’t been internally clamped yet, there will be a retrograde flow into the placenta and Baby actually loses blood.

If it’s after ten minutes, the blood in the placenta itself has started to clot and is of no benefit to the baby.

Also, have you smelled a placenta recently? It stinks really badly. It’s impractical to carry around. It’s a piece of raw meat.

Conclusion

Delayed cord-clamping has some proven health benefits, whereas Lotus Birth has none. You want to do something on a whim, believing that it will make your child happier in the long run, fine by me. But do not go around claiming that keeping your child connected to it placenta til it rots off is a health benefit. You will just irk anyone with some understanding of basic life sciences. Albeit an as-yet unqualified opinion, I would not encourage this practice – and I have received similar feedback from my consultants.

*References:

1. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes,Susan J. McDonald & Philippa Middleton, Cochrane Pregnancy and Childbirth Group
2. http://www.lotusbirth.net/

Pouring My Heart Out About Birthing Plans

I’m not going to whine today. I’m not even going to be diplomatic.

Because I’m annoyed.

Because I believe in the rights of the patient, and because I love obstetrics and neonatology I’ve been reading a lot of blogs where women share their birth stories.

And a lot of them write about how they felt cheated out of a normal vertex delivery. Because their labour didn’t progress. Because the CTG showed decelerations. And so the doctor rushed them to theatre, and delivered their baby in one piece, and saved Mommy and Baby’s life.

And that makes Doctor horrible. For saving two lives.

I believe in listening to a patient’s wishes. I believe in trying as much as possible to stick to a mother’s birthing plan. But I also believe in saving lives. And I will not stick to someone’s birthing plan if it will cost their life, or impede in any way upon their or their unborn child’s livelihood.

Dear mothers, if you do not like your doctor’s opinion, get a second opinion. If a doctor saves your life, or gives you a live healthy baby, try to see the bright side. It’s not that difficult.

Women and their babies DIE daily in developing countries because they don’t have access to theaters and C-sections or even the knowledge that a section is required.

If a doctor ignores your wishes without good reason, if he is a paternalistic arse, find another doctor.

Just know that had something gone wrong, you would have blamed the doctor, and would quite likely have good reason. So be grateful for your happy bouncy baby child. Please.

Blog it for Babies: About How I Almost Wasn’t

In keeping with my general broodiness and my current Neonatology rotation, I couldn’t let “Blog it for Babies” go by.

BIFB is an attempt to raise funds and deliver equipment to a clinic in Bangladesh, where infant mortality is extremely high. They want to raise awareness too, so if you can’t afford to donate (like me), just be aware.

BIFB encourages bloggers to write about their own birthing experiences and reflect on how things could have been different. I don’t have children (being a student), but both my and my sister’s births were extremely difficult, so I’ll share that.

We were born in a time where many non-white South African citizens did not have access to good healthcare. I’m pretty sure that if I were of a different race, or if my struggling parents had not managed to give birth at a private facility, my mom and I may not have made it.

Mom’s pregnancy went well. I was her first, so she did everything by the book. As with a primigravida, labour progressed somewhat slowly, but surely. There was no cause for concern until I was supposed to be crowning and things weren’t going as anticipated.

I was in occipito-posterior position. Normally, babies are born occipito-anteriorly. This basically means that instead of the sharpish backside of my head crowning, my forehead was the presenting part.

But that’s not always a problem. Last year during obstetrics I delivered two occipito-posterior babies. My head was poorly flexed, so much of my face was presenting. If you think about physics, this is not conducive to an easy passage.

Mom had a wonderful obstetrician. He did shout at her often, she recalls. There were times when he shouted that if she did not stop pushing now, she would break my neck. And then there were times where he threatened her with a C-section if the baby didn’t come now. After all that exertion she did not want to be wheeled to theater.

First an episiotomy happened. When that didn’t help, they decided to attempt a ventouse delivery. That’s basically delivering the baby by means of a vacuum. It’s not an easy procedure and can often lead to a massive subaponeurotic bleed.

Fortunately it was successful.

Things that could have happened in the absence of good doctors:

• they could have not realised that something was wrong and tried to deliver without further interventions
• they could have not performed an episiotomy, leaving Mom to experience a third-degree tear
• the episiotomy could have been poorly looked after, leading to infection
• I could have died

The same thing recurred with the birth of my little sister four years later, so the doctors diagnosed cephalopelvic disproportion and my little brother (four years after that) was born via C-section.

My family, even in South Africa, were so blessed with access to good healthcare. If possible, please donate to any organisation that helps mothers and babies. And if not, count your blessings and be aware.

Teaching People To Walk Better

This past week, Stellenbosch University has been celebrating the successes of the Hope Project (about which I have written before).

In two years, the SU has made leaps and bounds of improvements in the fields of healthcare, legal aid, agriculture and science. For more on all that, you can check out these two sites or read the virtual paper here.

I’m particularly enamoured by the story of Hillary Lane, who was born with Cerebral Palsy and had significant gait disturbances and pain such that she preferred not to walk.

The SU Faculty of Health Sciences has a Motion Analysis Centre, and a lot of their upgrades have been made by means of the HOPE Project. Using the technology at this centre, Lane’s gait could be improved in such a way that she completed the NYC Marathon in 2011. 42 Kilometres. Something I, fully able-bodied, am not sure I want to attempt.

I like this. I think it’s great for the Allied Health Sciences (who are often scorned by old-school doctors) and I think it is great for the CP-community.

But, this is not my story to tell. Watch the clip below to hear more about it first-hand.

Meet the Phantom (not of the Opera)

You do not need to be a medical or nursing student to have heard the term “phantom pregnancy”. Pseudocyesis is pretty much when a woman’s body believes she is pregnant. Only, she’s not. Her abdomen will distend. Some will even claim to feel the baby kicking.

And here’s the kicker (sorry, couldn’t resist)… true phantoms are not a case of attention-seeking. The mother really believes she is pregnant. Her body agrees.

But that’s not really what I am interested in today.

Friend in Third Year is on obstetrics now and during a practical session on Leopold-maneuvers, an obstetrician started telling them about phantom pregnancies. They are rare, but I guess not unheard of.

Said obstetrician was once called in for a complicated birth that was referred from a rural clinic. She noticed that she couldn’t figure out the fetus’s station. She couldn’t even figure out on which side the spine was (which is usually easy-ish).

Then she couldn’t pick up a heartbeat on the CTG (basically a fetal heart-monitor).

She then figured to start at the beginning, and ordered a pregnancy test. Which came back negative. And last but not least, the sonar came up empty.

Did I mention the lady was in actual labour?

I’m not poking at the would-be mommy. I have sympathy for her.

I have no sympathy for the practitioner who diligently plotted SF-measurements and never figured out that the pregnant abdomen definitely did not feel pregnant.

Weird, right?

Delivery in the Lab

A page from William Hunter's 'The anatomy of the human gravid uterus exhibited in figures', published in 1774.

Our last day of autopsies today and I finally took a deep breath and asked my question: “Do you ever get pregnant mothers? Do you look at the babies?”

Yes.

Sometimes the pregnancy is an incidental finding, tiny 12-week old fetuses.

Sometimes they pregnancy is almost term.

They won’t usually dissect the fetus, but they look at it: take measurements and inspect the placenta.

Coincidentally, there was such a mother today. She died at home of massive haemoptysis (most likely TB-related) and the healthy baby died along with her.

They brought the uterus to us, unopened. Another amazing bit of anatomy, seeing it lying in relation to the other organs.

An incision was made as if a normal caesarian section. There was something heart-breaking (call it my own broodiness), when baby’s head popped out, covered in vernix.

The forensic pathologist announced, “It’s a girl” and my heart ached for the father (if he is around) and the deceased mother, and even for the baby girl who was never held.

Le Document Pour MB.ChB.III

The inspiration for this document came during my second year while studying for an end-of-block test. At the same time, the then-first years were studying for Pathology, aided by “Le Document”. Somewhere in this time period I looked at a fellow second year, threw my hands in the air rather dramatically and exclaimed,

“I wish I had a Le Document for Second Year!”

Le Document pour MB.ChB.II can be found here. It focussed mostly on holistic wellness during a tough theoretical year. Third year is a whole new ballgame, with students finally set wild in the clinical environment. Theory modules are unfortunately still a reality and at my school, third years are haunted by Neurosciences and Musculoskeletal System.

I throughly enjoyed this year and fortunately I had some older friends who had some handy tips. Thus, some advise for new third years:

Do not freak out if you struggle to draw blood. Practice will make perfect. Accept any challenge, but look out for patients with good veins – they will boost your confidence.

Do not freak out if nurses know more than you do – chances are they have been practicing  longer than you have been alive. Respect them: they can either help you a lot, or make life extremely difficult for you.

ARVs are not a joke. Stressing for an HIV-test isn’t either  Never fool around with a contanimated needle or specimen.

OBSTETRICS: wear a mask when delivering a baby, amniotic fluid does not taste very nice. Always remember tbe infection risk. Wear goggles or a visor and an apron too. Note that if a lady comes in crowning it is not always possible. Remember that the mothers do all the work, it is your job to help them. Remember you are working with lives, always. If told to deliver a multipara, check twice with a doctor or matron.

Ask to take a picture of your first baby, you will not regret the memory.

PAEDS: little humans are resilient, but not made of steel. Be sure you know how to do procedures on them – do not attempt to draw blood from a little human with a syringe. Do not perform a procedure in their cot – it is the only safe place they have. For your own emotional well-being, try not to get too attached. And beware the paediatrician - just because they love kids does not mean they love you.

INTERNAL MEDICINE: this rotation is competitive and exhausting. Try to be on your supervisor’s good side. Take initiative. Look interested. Go the extra mile. Wear comfortable shoes. Read up about all cases on your firm, not only those of your own patients. These are good principles anywhere, but especially important in Internal.

Never underestimate the importance of a good history and a basic physical. If you don’t know what to do, start there. Have a method to your investigation, and a structured presentation.

FAMILY MEDICINE: Do not scowl at this rotation, there is a remarkable load you can learn here , especially if you learn to respect the multidisciplinary approach. Be well prepared for site visits, take sturdy shoes and hand- sanitisers. Take the time to understand you patients’ psyche and sociology, there are not many blocks that cater for this.

SURGERY: not my favourite rotation. Apparently doctors fall into one of two groups: those who love surgery and those who despise it. Surgeons can be scary and temperamental, but try to learn as much as possible. Attend tutorials even if it is easy to slip out. Assist in surgeries even if other students are willing to relieve you of your duties. Do not stress about assisting, you will be told what to do. Most importantly, know how to scrub in and practise your suturing.

With so much practical, theory becomes mundane. Do not lose sight of your goal. Attend classes. If you get bored, look for blogs, student sites or books to pique your interest. For example, The Brain that Changes Itself promises to be a great addition to neurosciences. A Life in Pieces is exceptional for psychiatry. Three Letter Plague as well as Disease are gripping. Musculoskeletal system requires great effort. Colour in, draw, use your friends’ anatomy and don’t let the skeleton stay in the closet.

Third year is wonderful and can ignite your passion for medicine once more. However, you must take good care of yourself. Sleep often, eat well.

And don’t forget your stethoscope.

Medicine’s Contribution to Language

I love language and writing. And I must clearly love medicine (although that one took a little longer, much like Beethoven and his piano).

Did you know that the concept of gossiping actually originates in medicine?

Giving birth was considered a social event – ladies only, of course. A pregnant woman would invite some of her friends to attend, even a younger daughter if she was deemed “mature” enough. These participants in the labour process were called gossips and their chattering before, during and after the birth later became known as gossiping.

On a more serious note, I think that having a childbirth companion is so important and so often overlooked in public healthcare, especially in South African clinics where “outsiders” are kept outside for safety reasons. It helps to have someone to calm the mother down and rub her back so that health care workers can focus on getting the baby and placenta out in one piece.

Things you need in hospital

During my internal rotation I learned something devastating: the wondrous white coat is simply not big enough. During the four weeks I did not button my coat up once – and I don’t think it has anything to do with the few extra pounds I have gained this year.

1. Stethoscope: The favourite tool of medical students; the day your first stethoscope arrives is one of excitement (anyone who is blasé about it, is just suppressing their joy). Don’t forget it; I have once or twice and felt naked the entire day. I like Littmann, mine is a lovely raspberry colour.

I wear mine around my neck, but med-school lore apparently states that students should keep their stethoscopes in their pockets.

Aside: You can use your stethoscope to test reflexes if you forgot your patella hammer; but if you tell anyone I will vehemently deny any mention thereof.

2. Gestation wheel: we use these in obstetrics, but since we got a few pregnant patients on our Internal calls, I like to keep mine handy. You can get a template to make your own or buy a nice plastic one. Mine was handed out at our campus’ society day – quite a nifty hand-out.

 

Aside: these are awesome to have on-hand when calls get quiet or boring. We discovered that one of our friends was most likely conceived on New Years’ Eve.

3. Illegal hospital supplies: We are discouraged from taking supplies in the morning to have them ready when we need them. In a private hospital where different wards are owned by different professionals this is completely sensible. However, in our public set-up, it is often necessary. Some staff nurses are lax in restocking their supplies from the storeroom, which is problematic if you are out of 22-gauge needles and your 92-year-old patient needs bloods drawn immediately.

You also often find that in a specific ward, only one glove-size is available at any one time. When I find small gloves, I stock up; as do my clinical partners when they find size 8½ gloves.

The “piggy” in the picture is my own. It’s like a specialised syringe, I don’t know it’s real name.. In our hospitals they are a rare find – even rarer than piggy-needles, which baffles my mind. They are awesome though, especially if you need 20mℓ blood (or more). They are much nicer than syringes. Similarly, butterfly needles are much nicer than normal needles of you need a radial arterial blood gas.

The name tag is what students often use to label their stethoscopes. You should not steal from the hospital though.

 

4. Tourniquet: In South African hospitals, people often use gloves instead. Avoid at all costs: it HURTS (go on, try it). Once our Intern was helping me with a difficult blood-draw. I said, “You can use my tourniquet, it’s brand-spanking-new.” He laughed and said, “And so it shall remain, because it will be stolen before it ages.”

They are really easy to misplace, but fortunately also quite cheap. Mine is an ugly orange, but I’m hoping to get a pretty one soon, like the one on the side. Patient’s do often call us vampires…

5. Pupil torch: Admittedly this was a bit premature, as it will probably be of more use in trauma. This one is dirt-cheap, but we also haven’t been able to discover how to change the battery or the bulb. I guess you just replace the whole cheapie.

6. Measuring tape: Another thing I acquired for Obstetrics, but quite useful when your patient has a lymphadenopathy (or anything else, really).

7. Reflex hammer: I bought the expensive metal one, although the cheaper plastic ones are much better for the swinging technique required for testing reflexes. The metal one is semi-collapsible, which is why it won. It also has a sharp end for Babinsky-reflexes and a pin on the inside. In the age of HIV and other blood-borne disease we don’t use the pinprick anymore, instead we use wooden toothpicks.

This book is probably my favourite of all medical textbooks – and it fits perfectly in your white coat’s pocket. Learn how to use it with speed and, like the stethoscope, don’t go anywhere without it.

A note on diagnostic sets: they are awesome, but very expensive and they are usually available in all wards. Due to their value you might need to ask the chief nurse for access to it.

I have seen senior medical students pull other gems from their bags: scissors, adhesive tape and breakfast bars. Don’t forget extra pens and paper for notes, either. Undoubtedly, one needs a bag – a satchel. I’m still looking for my perfect one: it should have a sturdy strap that can be worn across the shoulders and have an easy-to-organise interior. And because I’m a girl it needs to look good too.

The search is on!

 

 

A Point for the Cold of Heart

I admit that much of my decision to study medicine – and not to drop out – hinges on the humanitarian aspect of this field. As a high school student, I wanted to study everything and to be quite honest I think I would have done quite well at most of it. So the decision had to be made based on what I would enjoy most. And my happiness depends largely upon a sense of purpose, of doing good.

So although the medical field is vast and constantly renewing and stimulating, my passion for it is renewed by this idea that I am helping people, saving people, making the world a better place. Because at some point I have convinced myself that somebody needs to save those who deserve saving.

The fundamental error with this thinking is that, logically, there must be a converse. For example, a lawyer may appeal someone’s death sentence based upon rehabilitation and remorse. By that principle, he will not defend anyone sentenced to death. He is a bad lawyer, an emotional lawyer, when compared to the lawyer who “specialises” in appealing the death penalty because that is what he does well. Note that this is not a reflection of their respective characters.

What happens when a doctor has spent his working life saving needy patients because he believes that they are deserving, and he is suddenly faced by a rapist that needs healthcare?

If our work is fired by emotions, what happens when those emotions are negative towards our patients?

During my obstetrics rotation, I saw pregnant women who had defaulted their ARV-treatment and brought into life children who, essentially, will be battling infections their entire lives. I saw women who drank straight through their pregnancies; despite previous miscarriages and children born with Foetal Alcohol Syndrome. I saw a woman who refused sterilisation even though she was told that another pregnancy would kill her.

I have seen mothers who do not bring their children to hospital in time because they are stone drunk.

A friend of mine was recently brought a six month old patient who had been suffering diarrhoea for six days. It was the first time that the mother was seeking medical attention. When he examined the baby, he found that it was stone cold and had been dead for six to eight hours.

The cold hard truth is that, faced by patients such as these… I do not have that desire to help them. They do not want help for themselves. They do not want help for each other. How am I to save people who take no responsibility for themselves?

The only solution is the academic approach. An approach I myself have called cold-hearted. But perhaps it is the only way to ensure that you provide the same standard of healthcare to all patients.

Lowest possible mortality and morbidity rate.

Highest possible success rate.

And the Hippocratic Oath that prevents your emotions getting in the way.