Born in the USA (14 page)

For a time in the 1950s and 1960s, our maternal mortality rates were going down, but it has been shown that the decrease resulted from basic medical advances, such as the discovery of antibiotics and the ability to give safe blood transfusions. It was not due to high-tech obstetric interventions, though many obstetricians are inclined to give technology credit for the improvement.

More recently, there has been an increase in obstetric interventions and simultaneously an increase in maternal deaths and an increase in conditions such as autism, attention deficit disorders, and learning disabilities in children in the United States. A study commissioned by the California legislature and conducted by researchers in California reported in 2002 that the number of children with profound autism in that state has tripled in little more than a decade. Studies conducted by the federal Centers for Disease Control and Prevention show similar increases in autism in Georgia and New Jersey.
⁷⁶
At this time we do not know the cause of autism nor do we know why an increasing number of children have the condition. However, we do know that this surge in autism coincides with a surge in ultrasound
scanning, epidural block, pharmacological induction of labor, and C-section. Professional and community organizations that focus on these neurological disorders should be screaming for research to determine if there are correlations between obstetric interventions and these disorders.

I remember discussing labor induction using Cytotec with Dr. Luis Sanchos-Ramos, an obstetrician practicing in Florida, on a National Public Radio program in 2002. He said that he had used Cytotec on more than five thousand women to induce labor, and I asked him if he had done any follow-up on the children born from these five thousand Cytotec inductions. He admitted that he had not—and neither has anyone else. The gap between actual obstetric practices in the United States and what scientific evidence indicates obstetric practices should be continues and will be slow to change until there is sufficient pressure—from women, scientists, politicians, and the media—to force more evidence-based practices.

Admission to the hospital places patients in a dependency relationship in which frightening questions of bodily integrity, of life versus death, are
not
negotiated, but decided within the strict definitions of a biomedical ideology.

BARBARA ROTHMAN, PROFESSOR OF SOCIOLOGY AND AUTHOR

Assumed unsafe until proven safe (precautionary)

Assumed safe until proven unsafe (anti-precautionary)

OPPOSING PRINCIPLES OF MEDICAL PRACTICE

Two weeks before Ms. S is due to give birth, she and her husband leave their three young children with their grandmother and go to the local hospital in their small town. The year is 1999. Ms. S is having occasional contractions, and they want to find out what's going on, though they are not overly concerned. Ms. S has had three normal births, with no cesarean sections, and considers herself a childbirth veteran.

At the hospital, a nurse examines Ms. S and determines that the contractions are too infrequent and irregular for her to be in active labor. The nurse calls Ms. S's obstetrician, Dr. K. The obstetrician orders that Ms. S be admitted to the hospital, though she has expressed a strong desire to go home. Four hours later, Ms. S still badly wants to go home. The nurse calls her doctor again and asks if it's okay for her to go, but it appears the obstetrician has a plan, as he orders that she be kept in the hospital.

Three hours later Dr. K arrives, examines Ms. S, and finds that she is indeed not in active labor. He inserts twenty-five micrograms of Cytotec into her vagina to induce labor. Ms. S is aware that something has been inserted, but the obstetrician does not tell her what or even that his goal is to
induce labor. Nor does he tell her that the drug he put inside her is not approved by the FDA for use in inducing labor and has serious risks.

Ms. S is put to bed and an electronic fetal monitor (EFM) is hooked up. Though continuous monitoring with EFM is not necessary for a normal labor, it is important when inducing labor with a powerful drug known to have serious risks, such as Cytotec. In Ms. S's case, however, the EFM is left off much of the time

Dr. K visits again four hours later. He gives Ms. S another dose of Cytotec. The monitor is now on, and within an hour it shows that Ms. S's uterus is contracting far too rapidly for the baby to get a good supply of oxygen—a condition known as uterine tachysystole or uterine hyperstimulation. Nurses' notes state how rapidly the uterus is contracting, but there is no mention of hyperstimulation or any other indication that the nurses recognize that the situation is potentially hazardous to Ms. S and her baby.

Four hours after the second dose of Cytotec is administered, the monitor shows both rapid uterine contractions and a dangerous change in the baby's heart rate. Nevertheless, Dr. K, who is not there to check his patient, orders over the phone that Ms. S be given Pitocin, another drug used to induce labor. Although it is not unusual for an obstetrician to add Pitocin when inducing with Cytotec if the labor is not progressing, it is dangerous to do it when the patient is already experiencing continuous rapid contractions, as it seriously increases the risks.

When the obstetrician returns, he ruptures Ms. S's bag of waters, or amniotic sac membranes. A few minutes later all hell breaks loose. The baby's heart rate becomes so slow that it is obvious that the baby is in extreme distress. Dr. K tries to help the baby by stretching Ms. S's cervix to look for the umbilical cord. Meanwhile, Ms. S begins to complain of shortness of breath and chest discomfort. The obstetrician tells her to push, while a nurse tries to tell him that Ms. S is in no shape to push, as she is gasping for air and turning blue.

Dr. K, however, is not focused on the woman; he is focused on the baby. He applies forceps and, after three pulls, gets the baby out and hands it off to a waiting pediatrician. He then turns to the mother, but at this point she is unresponsive and can't be aroused. It has been twenty minutes since both Ms. S and her baby went into severe distress and shock. Dr. K gives Ms. S CPR and oxygen, but there is no response. He calls “code blue,” an emergency signal that tells hospital personnel to come immediately. But there is nothing more that can be done. Ms. S is dead.

Meanwhile, the baby is not breathing and has an extremely slow heart
rate. An hour and a half after the baby is born, a call is made to a larger regional hospital that, unlike this hospital, has a neonatal intensive care unit. For some reason, instead of sending the baby to the larger hospital by ambulance, a one-hour ride, hospital staff keeps the baby at the smaller hospital while the larger hospital sends an ambulance to pick the baby up, wasting precious time. The baby is having seizures and still needs help to breathe. Later the baby is found to have severe brain damage with cerebral palsy due to lack of oxygen during labor and birth.

The autopsy of Ms. S showed amniotic fluid embolism (AFE), a condition that can occur when amniotic fluid (the water in the sac surrounding the fetus) leaks into the mother's bloodstream. Debris that has collected in the fluid during the pregnancy—baby's skin cells and hair—blocks the small air sacks in the mother's lungs, leading to shock and a collapse of heart and lung functions. For amniotic fluid to leak into the bloodstream and produce blockage, there must be a break in the normal anatomical barrier that keeps the fluid separate from the mother's blood vessels. Overly strong uterine contractions can break this barrier and cause microscopic lacerations in the uterus or cervix. Cytotec causes unusually strong contractions. AFE has a high mortality rate, about 80 percent, and is one of the known risks of using Cytotec on a pregnant woman.

In another case, an eighteen-year-old African American woman we'll call Ms. Q was expecting her first child. She received her prenatal care in a local health clinic, some distance from her home in a rural area in the South. She was assigned to a young, newly trained obstetrician, who decided to induce her with Cytotec because it was one week beyond her due date, though, as I will explain later in this chapter, this is not a valid indication for inducing labor unless the baby is in trouble, and tests showed that her baby was doing just fine.

Ms. Q arrived at the hospital and was given Cytotec. Within an hour she started having contractions and within two hours she was having contractions too frequently—hyperstimulation, which can cause fetal hypoxia (lack of oxygen). Four hours after admission, she was given more Cytotec, which was dangerous since her contractions were already too frequent. Eleven hours after admission, she was given even more of the drug. By then she had been having excessively rapid uterine contractions for several hours, and there were dangerous changes in the baby's heart rate, indicating severe fetal distress. Later the doctor gave Ms. Q Pitocin, stimulating her uterus even further, in effect whipping a nearly dead horse.

During the last hour before birth, after what was now more than twenty-four
hours of uterine hyperstimulation, which blocks oxygen from getting to the baby, the monitor showed that the baby was in extreme distress. The baby was moribund (that is, unresponsive and dying) at birth and died thirty-five minutes later.

A few minutes after the birth, Ms. Q began to bleed profusely from her vagina. The hemorrhage could not be stopped, and as she was going into shock she was given a blood transfusion. Her uterus had become completely floppy, which is a disaster because when the placenta detaches from the inside of the uterus after birth and comes out the vagina, there's an open wound inside the uterus where it had been attached. Normally, the uterus contracts down to stop the bleeding, but if the uterus does not contract, the bleeding becomes severe. Hospital staff massaged Ms. Q's uterus and gave her more powerful drugs to try to make her uterus contract, but to no avail. Tragically, Ms. Q died a few hours after giving birth. As with Ms. S, the autopsy gave the cause of death as AFE. Between 1997 and 2004, nineteen cases of AFE after Cytotec induction were reported to the FDA.
¹
I personally know of more than twenty-five cases in the United States in the past ten years in which a woman has died at or shortly after childbirth after labor was induced with Cytotec, and in all these cases the official cause of death was AFE.

Were these deaths preventable? There is general consensus that a significant proportion of cases of maternal mortality are preventable, as they result from bad obstetric care. A crucial question in Ms. Q's case is why her uterus was floppy, leading to the hemorrhage. In
Williams Obstetrics
, a leading obstetric textbook, the following sentence is in bold type: “The uterus that contracts with unusual vigor before delivery is likely to be hypotonic [floppy] after delivery, with hemorrhage from the placental implantation site as the consequence.”
²
More than twenty-four hours of severe uterine hyperstimulation definitely qualifies as “contracting with unusual vigor,” so the decision to induce labor using Cytotec must certainly be implicated in the hemorrhage.
Williams Obstetrics
also states that vigorous contractions in a woman having her first baby can lead to circumstances in which AFE is likely to develop.
³

The rate of women dying around the time of birth has been increasing in the United States for twenty-five years. What about the rate of AFE cases? Evidence suggests that AFE-related deaths are increasing as well.
⁴
It is clear that the increase in AFE cases in the United States is connected with the increasing use of uterine stimulant drugs, such as Cytotec, for labor induction.
⁵
Another possible reason for the increasing rates of AFE deaths
is that this diagnosis is being used by doctors who are trying to cover up their mistakes. This possibility will be discussed in
chapter 7
, on obstetric litigation.

Chapter 1
began with a real-life Cytotec induction story, about a family in Oregon. In that case, the baby died, and the woman's uterus ruptured and was removed, so she can have no more children. So here we have three innocent families whose injuries will never heal. How did this happen?

Given that a fundamental principle of medical practice is “First, do no harm,” new drugs and other interventions must not be used until they have been adequately tested for safety. However, when we study the history of obstetrics in the United States, we find ethics that are anti-precautionary and more akin to the Wild West or what might be called “vigilante medicine.” American obstetricians consistently use new interventions without waiting for the judge, claiming that to wait for adequate research on safety takes too long and impedes “progress.” But the idea of progress in obstetrics is to a great extent a myth. The maternal mortality rate in the United States is not going down, it is going up, and the slight fall in the rate of babies who die around the time of birth (perinatal mortality) in the past ten years is due not to a decrease in the percentage of babies who die before they are born, but rather to a slight decrease in the rate of babies who die shortly after birth, which can be attributed to neonatal intensive care, not obstetric care. There has been no improvement in the past twenty years in the rate of babies born who are too small—a major cause of neurological handicap—and in 2004 the rate went up. Nor has there been any lowering of the rate of babies who develop cerebral palsy.

Meanwhile, we have one iatrogenic (doctor-caused) obstetric tragedy after another. The 1930s saw routine X-ray of the woman's pelvis during pregnancy before research proved that it causes cancer in the baby. In the 1950s, the drug diethylstilbestrol (DES) was widely used during pregnancy in the hope that it might stop vaginal bleeding (it didn't), before research proved that it causes defects in the baby's reproductive organs. In the 1970s, doctors used thalidomide on pregnant women, again in the hope that it might stop vaginal bleeding, before studies showed that it causes deformities of the arms and legs in babies. There seems to be a new tragedy every twenty years, and in the 1990s, right on schedule, we had Cytotec being used to induce labor. It seems that the only thing we ever learn from obstetric history is that we never learn.