Sound Medicine -- May 18, 2002

Barbara Lewis and Dr. Kathy Miller talk to experts about:

Episiotomies
Cesarean section

Conjoined twins

Episiotomies at childbirth

Nearly 40% of all mothers who deliver babies vaginally receive an episiotomy, a surgical incision in the muscle and skin between the vagina and the perineum that widens the vaginal opening. The episiotomy not only speeds delivery, it is intended to be prophylactic, preventing the baby's head from making a jagged tear in the vagina. However, studies in recent years show that a naturally occurring tear actually heals faster than a surgical cut and has fewer complications and side effects. What's the reality?

We discuss it with Paul Schoon, MD, assistant professor of clinical obstetrics and gynecology at Indiana University School of Medicine, and on staff at Wishard Hospital in Indianapolis. In general, Dr. Schoon says, the procedure is unnecessary. He discusses exceptions, for example when there's evidence of fetal distress. Dr. Schoon relates the modern history of the practice and talks about recent scientific studies that focus on complications for the mother.

Resources

For a general overview, visit the BabyCenter's comprehensive section on episiotomies The information is approved by a medical advisory board.
Read an article in the July 2000 issue of Canadian publication The Medical Post detailing a report to the American College of Obstetricians and Gynecologists (ACOG) supporting a reduction in the number of episiotomies performed.
Read an abstract of an article in the March 2002 issue of Obstetrics and Gynecology showing the plummeting numbers of episiotomies being performed. Members of the American College of Obstetricians and Gynecologists (ACOG) can read the entire article online.

Cesarean section

The cesarean section, which accounts for nearly a quarter of all births in the US, has come under more scrutiny lately, especially with more women and obstetricians opting for the procedure. Some mothers request it in order to schedule their delivery time or to avoid pelvic floor damage, and doctors do them to avoid risk of complications during natural delivery, avoiding lawsuits. Also, is it true that "once a c-section, always a c-section"?

We speak again with Dr. Paul Schoon, this time about the risks involved in having a vaginal birth after a cesarean birth (VBAC). The uterus is weakened by the scar, he explains, and labor further complicates the situation. Dr. Schoon also talks about the increasing number of women around the world having c-sections.

Resources

You can find advice and answers to frequently asked questions concerning vaginal birth after cesarean sections at Childbirth.org.

What are the origins of this surgery? The National Library of Medicine presents an excellent article, "Cesarean Section -- A Brief History," written by Jane Eliot Sewell, PhD, for the ACOG.

Conjoined twins

A woman has about a 1 in 35 chance of bearing twins. If she releases two eggs instead of the usual one, and they are both fertilized by separate sperm, she will have fraternal twins. Or, if she produces one egg that separates after fertilization, she will have identical, or paternal, twins. In very rare cases, the single egg does not fully separate, resulting in two fetuses that share any variety of body parts and are conjoined. Ethical issues abound on whether or not to risk surgically separating conjoined twins, especially when choosing to sacrifice one to ensure the life of the other.

Successful separations are on the rise, however, and just recently Dr. Thomas Rouse successfully separated conjoined twins at Riley Hospital for Children in Indianapolis. Dr. Rouse, clinical assistant professor of surgery at IUSM, specializes in neonatal surgery and pediatric trauma.

Resources

Dr. Rouse's case ended well, but often the argument for surgical separation treads delicate ethical ground. The American Medical News journal presents two views on separating conjoined twins in a March 2001 Ethics Forum.

 

Upcoming program:
Harvard physician Dr. Walter Willet and his revamped food pyramid. How is it different from the old one?

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a. About 90 %
b. About 75%
c. About 50%

What's the answer?

In August of 1793 one of the worst epidemics in American history hit Philadelphia, when thousands of people were sickened with yellow fever. By October more than 100 people a day were dying. More than 5,000 died before the epidemic ended in November -- about 10 percent of a city that then had just 50,000 residents.

Although we don't have to worry much about yellow fever in the United States today, the primary factor in spreading that disease -- one that baffled the residents of Philadelphia -- is still with us, and something we still need to worry about. What's the mysterious cause of the disease?

The added weight and pressure of pregnancy can weaken pelvic floor muscles, stemming from such factors as:

• the changed position of the bladder and urethra;
• a vaginal delivery;
• having an episiotomy;
• and damage to bladder control nerves.

Women can minimize bladder control problems by learning to exercise their pelvic floor muscles.

Source: National Kidney and Urologic Diseases Information Clearinghouse