Thursday, August 29, 2013

A few observations on cord clamping, jaundice, and infant imprisonment

This is not the story of my daughter's birth.  To understand that story, you must have a child of your own.  One moment, there are x people in the room.  The next moment, there are x+1 people in the room, the +1 being an amphibious creature that just fell out of the rain spout and suddenly is yours.  Nothing could have prepared me for that surprise, and it gave me a fit of laughter.

But back to the topic at hand, a few observations.  First, when is the best time to cut the umbilical cord?  After reading quite a bit about this (here's my favorite source of sources), I don't have an extremely strong opinion.  I appreciate that the doctor gave me the freedom to decide when to cut.  I waited about a minute.  One possible reason to not wait too long is that getting too much blood into the baby can contribute to jaundice.  More on that in a moment.

Within 24 hours after the birth, various doctors and nurses had poked and prodded and measured our baby several times.  The data was good, and our baby was doing great.  'Let's go home today,' we said.  'Not so fast,' they said.  'Your baby is our patient.  We won't discharge her for at least another day.'

And that was that.  Our baby was quite literally imprisoned in Magee Womens Hospital in Pittsburgh for the next 24+ hours.  If we had tried to simply walk out with our baby, a security alarm would have gone off, the doors would have all locked, and we would have been treated as criminals, just like Douglas Kennedy.

The imprisonment of my baby angered me quite a lot.  To be fair, our prison was not as uncomfortable as some other prisons, but a prison is a prison.  We all would have been happier and less stressed out if we at least had the option to go back to our comfortable home.  I dream of living in a free country someday.

Freedom is a rather lofty and abstract goal.  Returning to earth, let's keep talking about the medical system.  Before releasing us from prison, the doctors required us to schedule an appointment with a pediatrician for the very next day.  Baby's bilirubin levels were slightly high, around 12 mg/dl.  Doctors worry about bilirubin because of some association (correlation, not necessarily causation) between bilirubin and a potentially severe form of brain damage called Kernicterus.

But Kernicterus is extremely rare; according to this article, perhaps only about 5 in 100000 babies were afflicted even before doctors started paying attention to the connection to bilirubin.  To put this in perspective, the chance that your baby will die in its first year from all causes combined is something like 680 in 100000 (i.e., 6.8 out of 1000).

By the fourth daily test (our third post-hospital visit to the doctor), our baby's bilirubin had stabilized at about 16 mg/dl, making her slightly jaundiced.  Jaundice is common, or even normal:  60% of full term babies are said to have jaundice.  Given this prevalence, common sense might hint that there is some neonatal benefit in having a slight bilirubin excess.  Indeed, bilirubin has recently been demonstrated to have extreme antioxidative effects.  I concur with this guy's suggestion that otherwise-healthy babies should not receive special attention before the bilirubin level crosses about 25 mg/dl.  By contrast, the American Academy of Pediatrics starts shitting its pants about possible lawsuits at about 17 mg/dl (see figure 2), which happens for about 5% of babies.

These experiences -- the imprisonment and the excessive monitoring and testing -- point to at least one sad truth:  The medical system has become too concerned with minimizing the risk of extremely rare worst-case scenarios.   That might sound weird -- how can someone be too concerned?  The problem is that life is not black and white.  People are alive in varying degrees.  The person is more alive who is more engaged with his family, more energized to follow her curiosity, and more free to make his own decisions.  The hyperactivity of the medical system is a tax in every sense -- on family time, energy, and finances.  When doctors becomes too concerned about unlikely bad events, it is in these subtle ways that the medical system quite literally subtracts from our lives.


Blogger Jennifer Jo said...

This is a My Turn article. Or at least a newspaper article. Seriously. SO well said.

6:55 PM  
Anonymous karen said...

Interesting, given that I just went through this on my OB rotation. I have to counter some of what you say here, though. patients are able to leave against medical advice. It is not a prison. The opinion of the doctor would be for both mom and baby to remain for two days following a vaginal delivery more so because the chance of hemorrhage, which is one of the leading causes of maternal death. The bili levels usually don't peak until the baby has already been discharged.

Did you have a birthing plan? If so, the hospital staff should have honored that. My first delivery was a natural child birth with only intermittent monitoring, the lights were off, there was little talking per patient's request, the dad helped deliver/catch the baby, the assessment took place on mom's chest, cord was not cut until it stopped pulsating, no vaccines were given, no ointment to eyes.

I'm curious, why if you feel this way about OB care in the hospital setting, did you decide to give birth there? Why not have baby at home with midwife? Or at a birthing center with a midwife?

7:24 PM  
Blogger Freakwenter said...

Karen, thanks for your comments.

I'm happy to hear that the hospital you work in is not a prison. If indeed Womens Magee was not imprisoning us, perhaps certain individuals went against protocol, because I could not find a way out. I begged and pleaded with the pediatrician to remove the security band from my baby's leg so that we could get past the security system, but he refused, and only the pediatrician can authorize the removal of the band at Magee. It was pretty traumatic. I cried a lot after the pediatrician left.

Aside from the imprisonment issue, the birth was quite nice, and our wishes were generally respected. I can say a lot of nice things about Magee. Also, I tend to have substantial respect for doctors' opinions -- this was more about having the freedom to choose.

We would have considered a home birth in PA, but the regulations here make that particularly difficult. No midwife licensing system exists in PA, which means that we could not have had many of the not-over-the-counter drugs on hand that midwives normally like to have, and insurance coverage would have been out of the question.

Two midwife centers exist in Pittsburgh. One is at Magee, and has the same imprisonment issue as the rest of the hospital. There is also a very nice independent operation downtown, but about half their patents end up being sucked into the hospital system, whenever there is the slightest hint of a complication. Of course everyone has to cover their asses.

I'm not blaming any single person. I just think there is something sick about the system and if we can all agree on that much, we may also start to agree on possible ways to improve things.

7:50 PM  
Blogger Esther G said...

I understand this feeling! Lily was in the NICU for two weeks. The entire second week was just protocol: once a baby is healthy with no "alarms", they want to monitor them being healthy for an entire week before letting them out. I don't know if there is research to back that up or not, but I hated feeling like I didn't have custody of my daughter. I had to be told when I was allowed to visit, feed, change, and hold her.

7:54 PM  
Anonymous karen said...

That sucks, Zachary. I am sorry they were like that!! Yah, every hospital is different, but I'm guessing more are like yours than like mine. I had a really wonderful experience in OB for the most part. I definitely agree w/ you that the medical system needs an overhaul in a lot of areas. I move onto psych next, so am interested to see that environment...

8:00 PM  
Blogger Rosanna said...

What a frustrating experience.

We left AMA about 12 hours after baby's birth--but we had a fairly sympathetic hospital, I was set up to get lots of postpartum checkups from the midwives at home, and we had a pediatrician who would do a house call. And even with *all that* lined up, we had to pester the hospital staff pretty relentlessly to get all the "yes, we know you think this is irresponsible" papers signed and the alarm anklet removed. It would have been pretty easy for them to delay the bureaucratic stuff indefinitely if they had wanted to bully us into staying.

I hope you are all settling in now!

9:12 PM  
Anonymous sk said...

Ditto to JJ (except Newsweek is no more). Subsequent to your link to Douglas Kennedy, insert lines 3-5 of your reply to Karen.

7:06 AM  
Blogger andreajoy said...

First of all, congratulations, Zach! I was not aware of all these major events in your life. You'll be an awesome dad! And second, I am SO sorry you had to deal with all that *nonsense*... we found that the most important thing is to find someone to be with you during the birth experience who shares your philosophy of birth: i.e. birth itself is a natural event, not a medical emergency. We used a birth center with midwives and a doula, all of that persuasion -- midwives and doula would've accompanied us at hospital should something have constituted an emergency & we'd needed intervention. But having said all that, your loving attention & affection for your daughter will surely overcome any wrongs done her at the outset. She's set up for a great life. Would be thrilled to meet her some day! Let us know if you're ever in the DC area!

7:40 AM  

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