Obstetrics and

Pediatrics
Reading Assignments (24 pages)
1. Surgical obstetrical deliveries (Cesarean or C-Sections) (6+4 pages)
Note the things that determine the probability of an unnecessary C-section and ways to bring
this rate down; also the unexpected contributions of well-intentioned things like monitoring
https://www.consumerreports.org/c-section/biggest-c-section-risk-may-be-your-hospital/
https://opinionator.blogs.nytimes.com/2016/01/19/arsdarian-cutting-the-number-of-c-sectio
n-births/
2. male vs female OBs (5+3 pages)
See what you think.
http://www.latimes.com/health/la-me-male-gynos-20180307-htmlstory.html
https://www.kevinmd.com/blog/2018/03/many-female-obgyns.html
3. Breastfeeding (6 pages)
An overview that reviews current knowledge and then asks whether we may have gotten
carried away.
https://www.theatlantic.com/health/archive/2017/08/when-the-pressure-to-breastfeed-
puts-moms-and-babies-at-risk/536562/
Group Assignments 1/2
5. Surgical obstetrical deliveries (Cesarean or C-Sections)
Describe C-Sections and Inductions
What’s the problem with C Sections?
What fraction of deliveries are C-sections?
What is the evidence that too many C Sections are done?
What is being done about this?
Why do many obstetricians feel that the rate of C Sections is NOT too high?
6. New approaches to deliveries
What is a laborist?
Has the use of laborists had any effect on obstetrical outcomes?
How widespread is their use?
Briefly discuss pros and cons in the literature
b. What is a Nurse Midwife?
what training is required?
How widespread is their use?
What outcome data is available concerning delivery outcomes by Nurse Midwives?
Group Assignments 2/2
7. Autism/ADHD because of early (induced or C-Section) delivery. You don’t have to use all the references– they are presented as
possible resources.
a. Describe induced deliveries (“Inductions”)
b. Are there benefits of inductions?
https://www.washingtonpost.com/news/to-your-health/wp/2018/08/08/inducing-labor-at-39-weeks-for-healthy-pregnancies-may
-improve-outcomes-for-moms-and-babies-study-suggests/?utm_term=.0a2fe53bfefb
c. Summarize the evidence both for and against Autism and ADHD being due to inductions How compelling is the evidence?
1. Schendel D and Bhasin TK. (2008) Birth weight and gestational age characteristics of children with autism, including a comparison with other developmental disabilities. Pediatrics, 121: 1155-1164.
2. Johnson S, Hollis C, Kochhar P, Hennessy E, Wolke D and Marlow N (2010) Psychiatric disorders in extremely preterm children: longitudinal finding at age 11 years in the EPICure Study. Journal of the American Academy of
Child and Adolecent Psychiatry, 49: 453-463.
3. Johnson S, Hollis C, Kochhar P, Hennessy E, Wolke D and Marlow N (2010) Autism spectrum disorders in extremely preterm children. Journal of Pediatrics, 156: 525-531,
4. Indredavid MS, Torstein V, Evensen KAI, Skranes J,Taradsen G and Brubakk A-M (2010) Perinatal risk and psychiatric outcome in adolescents born preterm with very low birth weight or term small for gestational age. Journal
of Developmental and Behavioral Pediatrics, 31: 286-294.
5. Karmel BZ, Gardner JM, Meade LS, Cohen IL, London E, Flory MJ, Lennon EM, Miroshnicknko I, Rabinowitz S, Parab S, Barone A and Harin A (2010) Early medical and Behavioral Characteristics of NICU infants later classified
with ASD. Pediatrics, 126: 457-
6. Ann Epidemiol. 2014 Apr;24(4):260-6. doi: 10.1016/j.annepidem.2013.12.014. Epub 2014 Jan 15.
7. Report of a presentation at Neuroscience 2015: https://www.autismspeaks.org/science/science-news/study-provides-new-insights-link-between-prematurity-and-autism

d. What other problems have been reported due to inductions?

https://www.nytimes.com/2003/01/14/health/as-cases-of-induced-labor-rise-so-do-experts-concerns.html
 
 

8. prenatal care and preventable birth defects

http://www.pharmacy.arizona.edu/news/2011/ua-experts-list-top-preventable-birth-defects
What are the 5 most common preventable birth defects?
What is being done to prevent them?
What are the challenges in instituting these preventative measures?
How successful has this been in reducing preventable birth defects?
Group 5. Surgical obstetrical deliveries
(Cesarean or C-Sections)

How has the length of human gestation changed in the past 25 years?
Describe C-Sections and Inductions
What’s the problem with C Sections?
What fraction of deliveries are C-sections?
What is the evidence that too many C Sections are done?
What is being done about this?
Why do many obstetricians feel that the rate of C Sections is NOT too high?
So, Was Julius Caesar Born by
Caesarian Section?
• No. It was used, but only after a mother had died
• Caesar’s mother lived a long time after his birth
• Oxford English Dictionary says he was
• Where did it come from?
• Pliny the Elder said that one of Caesar’s ancestors was so born, but…
• Popularized in the Renaissance by Mac Duff’s claiming Macbeth’s
immunity from “any man born of woman” is invalidated:
“You can forget about your charm. The evil spirit you serve can tell you that I was
not born. They cut me out of my mother's womb before she could bear me
naturally.”
• Macbeth Act V scene VIII
 • Fetal problems
• head is too big
• feet first (breech)
Objective •
•
shoulder first (shoulder dystocia)

Reasons to
placenta issues (previa/abruption)
• fetal distress (?)

do a • Maternal problems
• genital herpes
surgical •
•
HELLP (‘pre-eclampsia’) – hemolysis/liver/platelets
severe high blood pressure
delivery • cardiomyopathy
• previous cesarean delivery
• failure to progress
 • Prematurity if <39 weeks
• RDS
Risks of • Surgical injury to organs (ureters, liver, bowel)

surgical • Longer recovery time

• Infection
delivery in • Bleeding
• Emboli
excess of • Increased risks for future pregnancies
vaginal • All future deliveries will be surgical
• Injury to the child during surgery
deliveries • Later problems: adhesions, hernias
 • Increased risk of fatal uterine rupture (rare)

Vaginal • requires continuous physical attendance and standby

surgical team

Births • Confusing data

• 30% of all surgical deliveries are because of
After prior surgical delivery

C-sections • Trend in all developed countries is downward

despite initial enthusiasm
• Intermittently a feminist issue
Subjective • Fear of labor
reasons • Unwillingness to be out of control
• Unwillingness to be awake
patients • Predictability

request a • Ability to schedule

• Efficiency
surgical • Sense that it is safer

delivery
 • Fear of accusation of negligence
• Hard to argue when you have done too much
• Easy to argue (in retrospect) when things go wrong
(Largely) • “career-ending events”

subjective • Sense of control

• Dread of unpredictability; feeling of helplessness

reasons • Satisfaction in using expertise

• “Miracles of medicine” culture
physicians • False positives in fetal monitoring

do C- • Nursing pressure
• Watching slow labor creates anxiety
sections • Doing surgery is satisfying and keeps everyone busy
• Convenience
• Financial reward (decreasing)
 • History of Medicine is eloquent
Beware of • <100 BCE: Faith-based deism
• -1900: Common sense/first principles
bandwago • 1900-2000: Expert opinion
ns • 2000-present: Increasingly evidence based
• Emerging: Faith-based “science”
Changing Human Biology

15
“Men occasionally stumble on
the truth, but most of them
pick themselves up and hurry
off as if nothing had
happened”

- Winston Churchill

16
 • Apnea >20 seconds and SIDS*
• Respiratory distress syndrome
• Intraventricular hemorrhage
Known • Patent ductus arteriosus

risks of •
•
Necrotizing enterocolitis
Retinopathy of prematurity 
prematurit • Jaundice
y • Anemia

*SIDS = Sudden Infant Death Syndrome

 •
Probable •
Cerebral palsy
Impaired learning
long-term • Vision problems
risks of • Hearing problems

prematurit •
•
Dental problems
Behavioral and psychological problems
y
Group 7. Autism/ADHD because of early (induced or C-
Section) delivery

a. Describe induced deliveries (“Inductions”)

b. Are there benefits of inductions?
https://www.washingtonpost.com/news/to-your-health/wp/2018/08/08/inducing-labor-at-39-weeks-for-healthy-pregnancies-may-improve-outcomes-for-moms-and-babies-study-
suggests/?utm_term=.0a2fe53bfefb

c. Summarize the evidence both for and against Autism and ADHD being due to inductions
How compelling is the evidence?
1. Schendel D and Bhasin TK. (2008) Birth weight and gestational age characteristics of children with autism, including a comparison with other developmental
disabilities. Pediatrics, 121: 1155-1164.
2. Johnson S, Hollis C, Kochhar P, Hennessy E, Wolke D and Marlow N (2010) Psychiatric disorders in extremely preterm children: longitudinal finding at age 11 years in the EPICure
Study. Journal of the American Academy of Child and Adolecent Psychiatry, 49: 453-463.
3. Johnson S, Hollis C, Kochhar P, Hennessy E, Wolke D and Marlow N (2010) Autism spectrum disorders in extremely preterm children. Journal of Pediatrics, 156: 525-531,
4. Indredavid MS, Torstein V, Evensen KAI, Skranes J,Taradsen G and Brubakk A-M (2010) Perinatal risk and psychiatric outcome in adolescents born preterm with very low birth
weight or term small for gestational age. Journal of Developmental and Behavioral Pediatrics, 31: 286-294.
5. Karmel BZ, Gardner JM, Meade LS, Cohen IL, London E, Flory MJ, Lennon EM, Miroshnicknko I, Rabinowitz S, Parab S, Barone A and Harin A (2010) Early medical and Behavioral
Characteristics of NICU infants later classified with ASD. Pediatrics, 126: 457-
6. Ann Epidemiol. 2014 Apr;24(4):260-6. doi: 10.1016/j.annepidem.2013.12.014. Epub 2014 Jan 15.
7. Report of a presentation at Neuroscience 2015: https://www.autismspeaks.org/science/science-news/study-provides-new-insights-link-between-prematurity-and-autism

d. What other problems have been reported due to inductions?

https://www.nytimes.com/2003/01/14/health/as-cases-of-induced-labor-rise-so-do-experts-concerns.html
 Outcomes vs Gestational Age

per 1000
70
60
50 Cerebral Palsy

40 Hearing impairment

30 Mental Retardation

20 Autism

10
0
24-28 29-32 33-36 >37

Gestational Age (weeks)

2011 © Copyright American Academy of Pediatrics. All

rights reserved.
American Academy of Pediatrics, 141 Northwest Point 20
Blvd., Elk Grove Village, IL,
Group 6. New approaches to
deliveries
What is a laborist?
Has the use of laborists had any effect on obstetrical outcomes?
How widespread is their use?
Briefly discuss pros and cons in the literature
b. What is a Nurse Midwife?
what training is required?
How widespread is their use?
What outcome data is available concerning delivery outcomes by Nurse
Midwives?
Group 8. prenatal care and preventable birth defects

http://www.pharmacy.arizona.edu/news/2011/ua-experts-list-top-prev
entable-birth-defects
What are the 5 most common preventable birth defects?
What is being done to prevent them?
What are the challenges in instituting these preventative measures?
How successful has this been in reducing preventable birth defects?
 ITTK
1. C-Sections
• More control of timing and events; may avert problems if specific medical conditions are present
• Size issues (head size), certain fetal conditions (breech), specific maternal health issues (prior C-section)
• Many surgical risks (infection/bleeding) + possible fetal risks; longer recovery
2. Induced Labor
• Risks: prematurity, more C-Sections, postpartum bleeding
3. Risks of prematurity
• Birth defects (vision, cardiac)
• Immature lungs/IRDS, jaundice, SIDS
• Behavioral problems
4. Measures known to reduce birth defects
• No Smoking, vitamins (especially folic acid), reduce of stop drug use (prescription when feasible as well as
nonprescription)
5. Breast feeding – clear outcome data is difficult to find
• Possibly better immunity and mother/baby bonding
• Risk of malnutrition if inflexible policies
6. Laborists and midwives
• Proven to decrease C-Section and induction rates
 Reading Assignment (18 pages)
(Plan Ahead: the following week is 27 pages)

1. General screening considerations (11 pages)

A basic review of screening with some surprising points: few tests help;
prevalence of disease determines accuracy; effectiveness of treatment affects
screening recommendations. Read this one closely and take notes.
https://www.wsj.com/articles/SB100014241278873239494045783144232566
94276
2. Screening older people (7 pages)
More surprises in screening in older people. An intelligent discussion of net
benefit and risk. Also discusses the forces pushing so much screening.
https://www.washingtonpost.com/national/health-science/doing-more-harm-t
han-good-epidemic-of-screening-burdens-nations-older-patients/2017/12/20/
b46d0564-e56e-11e7-927a-e72eac1e73b6_story.html?noredirect=on&utm_te
 Reading Assignments for 2 weeks from now
*** NOT NEXT WEEK***
(27 pages)

1. The Use of Medical Evidence in Practice (15 pages)

https://www.theatlantic.com/health/archive/2017/02/when-evidence-says-no-but-
doctors-say-
yes/517368/?utm_source=nl-atlantic-daily-022217
2. Are patients to blame? (4 pages)
https
://www.theatlantic.com/magazine/archive/2019/07/american-health-care-spending
/590623/

 3. Overkill (8 pages)

https://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
Group Assignments 1/4
1. Risks and benefits in screening
a. What cancer screening tests are currently recommended for the general
population? What is the compliance with them in the general population?
b. Why aren’t screening tests for the most lethal cancers (pancreas, stomach,
kidney, esophagus, ovary melanoma) recommended in the general population?
Present the evidence of benefit vs risk – be as quantitatively specific as possible
Be sure you have enough evidence to defend each recommendation, or state
why you disagree with a recommendation. It will help to have some knowledge
of current controversies
https://health.usnews.com/health-news/managing-your-healthcare/slideshows
/11-screening-tests-you-should-or-shouldnt-consider?slide=12
 
 
 Group Assignments 2/4
2. The value of a screening test
Assume the following:
-Early intervention in people having heart attacks (Mis) saves about 35% of the lives that would have been
lost if no or late intervention took place.
-Early intervention also has a 4% mortality.
-The general adult population has a 1/100,000 chance of having a heart attack (MI) at any given time
-A person with chest pain that is “typical” for an MI has a 20% chance of having one
-A blood test (troponin) is 100% sensitive for an MI (it never misses one) and 95% specific (5% of the positive
tests will be in people without MIs)
a. What are the chances that a patient with typical chest pain and a positive troponin has an MI and what are
the chances that he doesn’t?
b. What are the chances that a person with no symptoms and a positive troponin has an MI and doesn’t have
one?
c. How many lives would be saved in the general population (no symptoms) group?
How many lives would the screening cost in this general population?
d. would you recommend screening the population to take advantage of the early intervention benefit?
 Group Assignments 3/4
3. Screening strategies
a. What is the current recommendation status of PSA for prostate cancer
screening? Trace the recommendation status for the past 15 years. Would you
recommend an at-risk male be screened?
b. Assume the following:
A screening chest x-ray in patients in the general population over 45:
-Has a 1 in a million chance of causing a cancer
-Has a 40% sensitivity (it will find 40% of cancers) and assume the cure rate will be
50%
-Has a 10% false positive rate (it will find cancers in 10% of patients who don’t have
them) which will generally trigger a surgical procedure that has a 2% mortality
-0.06% of the population has lung cancer
c. how many lives would general population chest x-ray screening save?
d. What is the mortality of chest x-ray screening?
e. how many patients will die of screening for each one saved?
Group Assignments 4/4
4. Childhood immunizations
a. Report the childhood immunization schedule for California from birth to age 6
b. What are the major objections to this schedule?
If 85% of the population is immunized:
c. How much will getting the immunizations reduce the chances that a child will
contract one of the diseases included in the immunizations?
d. What are the odds that an individual patient will benefit (not suffer serious
adverse effects of the immunizations) from not having the immunizations?
e. Recalculate the above for 95% of the population being immunized.
f. If you were solely concerned with the welfare of your child, what would lead you
to not get them immunized?