Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Research on Zika continues at an accelerated pace. This last week Zika news includes the release of a new three-in-one test to test for Zika, Chickengunya and Dengue. Researchers say this cannot keep up though without an emergency spending bill from Congress. 

Puerto Rico has become a strong cause for concern. The director of the CDC has visited recently and expects “ hundreds of thousands” to be infected by Zika, among whom are thousands of pregnant women. Puerto Rico is believed to be an important route of infection to the United States. 

In Brazil, newest numbers show 29 % of Ultrasounds on babies born to Zika infected mothers show fetal anomalies with “ grave outcomes”. The newest research shows the prevalence much publicized defect called misrocephaly, but it is also becoming clear that other kinds of problems are likely Zika-related. These would include: lack of amniotic fluid, other forms of fetal brain damage, blindness,and stillbirth. 

There are 273 cases of Zika in the US States and 282 cases in the US territories including Puerto Rico. 

A small randomized controlled trial published in March of this year studied 78 first time mothers and their second stage of labor. The second stage is the time from becoming completely dilated to pushing the baby out. The old guidelines allow first timers pushing well to take 2 hours without epidural or three hours with epidural. Study subjects were allowed to push for one hour greater than current guidelines. In this study, when they did, C sections rates were cut in half without any other adverse effects noted  in either mother or baby. The authors remarked that the study was underpowered to detect small but clinically important differences. It does however, suggest that first timers were being “cut” as we say, too soon. 

As an Obstetrician, I would note that I have seen this study reported in the press. Many assumed that this meant that caregivers should now let patients push longer. Finally I got at look at the study itself. Nowhere in the press did it mention that all of the women in this study have epidurals. This makes it more difficult for many people to push effectively. Now it makes sense to me that more time made for more safe vaginal births. Certainly in many cases,  second stages with low quality epidural-influenced pushing should not be expected to make as much progress as second stages in women with strong epidural-free pushing. More time should be given for these patients. Normally, in a real labor population, some people have epidurals and some do not. Labor length averages are going to be influenced by his. However, If every single patient in a small study has an epidural, result swill skew toward the effect of the epidural-ized labor. Obviously. 

The old labor guidelines were made in the days before epidurals. In those cases, the women were probably unmedicated and thus pushing for all they were worth. In such cases, the old time allowances were probably appropriate. The idea is that, if your patient was going to deliver vaginally  safely, she should be able to do so within the old time allotments. Furthermore, if you persist in pushing her longer, you set yourself up for a variety of bad situations like stuck shoulders, a traumatized baby, or a traumatized mother, or a very late and thus risky C section. Hard coordinated pushing should result in continued progress of some degree. If it does not, the safety of vaginal birth should be questioned.

There are various signs we watch for during labor to tell if the baby can safely be delivered vaginally. It is so much more than the time duration of pushing. We watch the fetal heart tones, the evolving shape of the baby's head, the movement of the baby in response to the mother’s particular push in whatever particular position she is in. We factor all this in. I may know someone is stuck after only one hour, and I may let someone else safely go for four. It is a matter of not only knowing the labor guidelines, but but knowing the reasons behind them and knowing your particular patient very well. 

In the way cool department, researchers are using an iPhone app to begin a study of postpartum depression. They will be looking at a possible genetic predisposition for PPD. Using the iPhone will allow them to more easily get the enormous numbers (100K) they need to produce quality conclusions. 

In the good news department, Vox report that several more states, Missouri, Hawaii, Washington, South Carolina and Tennessee are considering bills to allow pharmacists to prescribe birth control pills. Ob/gyns support these bills because of the well established safety of these medications. 

The Supreme Court is hearing arguments about the ACA’s (Affordable Care Act) contraception mandate. A religious group called “ Little Sisters of the Poor”, one of the plaintiffs, are nuns, and they argue “ the birth control provision violates the laws of God.”

Governor Mike Pence of Indiana has signed a bill prohibiting abortions even for birth defects. He did this despite opposition from several of his female pro-life Republican colleagues in the House. Has he heard of the Zika virus ?


Stay tuned for more breaking news from the world of Ob/Gyn next week on Medical Monday.