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Am J Obstet Gynecol 2001 Apr;184(5):881-8; discussion 888-90.

Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women.

Signorello LB, Harlow BL, Chekos AK, Repke JT.

Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Abstract

OBJECTIVE: Our goal was to evaluate the relationship between obstetric perineal trauma and postpartum sexual functioning.

STUDY DESIGN: Our study was carried out with a retrospective cohort design in 3 groups of primiparous women after vaginal birth: Group 1 (n = 211) had an intact perineum or first-degree perineal tear; group 2 (n = 336) had second-degree perineal trauma; group 3 (n = 68) had third- or fourth-degree perineal trauma. These sample sizes reflect a 70% response rate. Outcomes were time to resuming sexual intercourse, dyspareunia, sexual satisfaction, sexual sensation, and likelihood of achieving orgasm.

RESULTS: At 6 months post partum about one quarter of all primiparous women reported lessened sexual sensation, worsened sexual satisfaction, and less ability to achieve orgasm, as compared with these parameters before they gave birth. At 3 and 6 months post partum 41% and 22%, respectively, reported dyspareunia. Relative to women with an intact perineum, women with second-degree perineal trauma were 80% more likely (95% confidence interval, 1.2--2.8) and those with third- or fourth-degree perineal trauma were 270% more likely (95% confidence interval, 1.7--7.7) to report dyspareunia at 3 months post partum. At 6 months post partum, the use of vacuum extraction or forceps was significantly associated with dyspareunia (odds ratio, 2.5; 95% confidence interval, 1.3--4.8), and women who breast-fed were > or = 4 times as likely to report dyspareunia as those who did not breast-feed (odds ratio, 4.4; 95% confidence interval, 2.7--7.0). Episiotomy conferred the same profile of sexual outcomes as did spontaneous perineal lacerations.

CONCLUSIONS: Women whose infants were delivered over an intact perineum reported the best outcomes overall, whereas perineal trauma and the use of obstetric instrumentation were factors related to the frequency or severity of postpartum dyspareunia, indicating that it is important to minimize the extent of perineal damage incurred during childbirth.

PMID: 11303195 [PubMed - indexed for MEDLINE]

 

Midwifery. 2007 Dec;23(4):392-403. Epub 2006 Dec 29.

The prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma.

Williams A, Herron-Marx S, Carolyn H.

Princess of Wales Maternity Unit, Heart of England NHS Foundation Trust, Bordesley Green, Birmingham, B9 5SS, UK. Mandy.williams209@talktalk.net

Abstract

OBJECTIVE: to investigate the prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma.

DESIGN: a retrospective cross-sectional community survey of postnatal women.

PARTICIPANTS AND SETTING: a total population sample of 2100 women were surveyed from two maternity units within Birmingham. Women were identified from the Trust's computerised Maternity Information System (MIS).

METHODS: Women were surveyed using a self-administered postal questionnaire 12 months after birth. The questionnaire included self-assessment of perineal pain, perineal healing, urinary incontinence, flatus incontinence, faecal incontinence, sexual morbidity and dyspareunia.

FINDINGS: a response rate of 23.3% was achieved (n=482). A high level of perineal morbidity was reported (53.8% stress urinary incontinence, 36.6% urge urinary incontinence, 9.9% liquid faecal incontinence, 54.5% with at least one index of sexual morbidity). Women with perineal trauma reported significantly more morbidity (sexual morbidity, dyspareunia, stress and urge urinary incontinence) than women with an intact perineum. Women with perineal trauma also resumed sexual intercourse later than women with an intact perineum. Women with a first- or second-degree tear reported significantly more perineal morbidity (stress incontinence, sexual morbidity) than women with an intact perineum, and resumed sexual intercourse later. However, a high percentage of women with an intact perineum also reported new-onset perineal morbidity: stress urinary incontinence (34.8%); urge urinary incontinence (19.5%); flatus incontinence (13.8%); and dyspareunia (25.3%), highlighting that enduring perineal morbidity can occur irrespective of perineal trauma.

CONCLUSION: enduring postnatal perineal morbidity is common in women with all types and grades of perineal trauma and intact perineum after childbirth. This highlights the need for further debate and research into the prevalence and experience of postnatal morbidity.

 

Am J Perinatol. 2010 Oct;27(9):675-83. Epub 2010 Mar 16.

Maternal outcomes associated with planned vaginal versus planned primary cesarean delivery.

Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG.

University of North Carolina at Chapel Hill, Department of Obstetrics and Gynecology, CB #7570, Chapel Hill, NC 27599-7570, USA. egeller@med.unc.edu

Abstract

We compared maternal morbidity between planned vaginal and planned cesarean delivery. A university hospital's database was queried for delivery outcomes. Between 1995 and 2005, 26,356 deliveries occurred. Subjects were divided into two groups: planned vaginal and planned cesarean delivery. This was based on intent to deliver vaginally or by cesarean, despite actual route of delivery. Planned vaginal delivery included successful vaginal delivery and labored cesarean delivery intended for vaginal delivery. Planned cesarean delivery included unlabored and labored cesarean delivery and vaginal delivery intended for cesarean. Chart abstraction confirmed the delivery plan. Primary outcomes were chorioamnionitis, postpartum hemorrhage, and transfusion. Secondary outcomes were also measured. A subanalysis compared actual vaginal delivery, labored cesarean delivery, and unlabored cesarean delivery. There were 3868 planned vaginal deliveries and 180 planned cesarean deliveries. Planned cesarean delivery had less chorioamnionitis (2.2% versus 17.2%), postpartum hemorrhage (1.1% versus 6.0%), uterine atony (0.6% versus 6.4%), and prolonged rupture of membranes (2.2% versus 17.5%) but a longer hospital stay (3.2 versus 2.6 days). There were no differences in transfusion rates. For healthy primiparous women, planned cesarean delivery decreases certain morbidities. Labored cesarean delivery had increased risks compared with both vaginal delivery and unlabored cesarean delivery.

© Thieme Medical Publishers.

PMID: 20235001 [PubMed - indexed for MEDLINE]

 

Obstet Gynecol. 2006 Aug;108(2):286-94.

Maternal morbidity associated with cesarean delivery without labor compared with induction of labor at term.

Allen VM, O'Connell CM, Baskett TF.

Department of Obstetrics and Gynaecology, and Perinatal Epidemiology Research Unit, Dalhousie University, Halifax, Nova Scotia, Canada. victoria.allen@dal.ca

Abstract

OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with induction of labor at term.

METHODS: A 15-year population-based cohort study (1988-2002) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women delivering by cesarean delivery without labor and nulliparous women at term undergoing induction of labor for planned vaginal delivery with singleton, cephalic presentation.

RESULTS: A total of 5,779 pregnancies satisfied inclusion and exclusion criteria, 879 of which were cesarean deliveries without labor. There were no maternal deaths. There was no difference in wound infection, puerperal febrile morbidity, blood transfusion or intraoperative trauma. After controlling for potential confounders, women undergoing cesarean delivery without labor were less likely to have complications of early postpartum hemorrhage (relative risk 0.61, 95% confidence interval 0.42-0.88, number needed to treat 32) and composite maternal morbidity (relative risk 0.71, 95% confidence interval 0.52-0.95, number needed to treat 34) compared with women undergoing induction of labor. Subgroup analyses of maternal outcomes after induction of labor in women by method of delivery were also performed and demonstrated additional risks of traumatic morbidity after induction of labor. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups.

CONCLUSION: Early postpartum hemorrhage and composite maternal morbidity were decreased in cesarean delivery without labor compared with induction of labor. Hemorrhagic and traumatic morbidities with labor induction are increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.

PMID: 16880297 [PubMed - indexed for MEDLINE]

 

Arch Dis Child Fetal Neonatal Ed. 2008 May;93(3):F176-82. Epub 2007 Oct 17.

Neonatal outcomes with caesarean delivery at term.

Liston FA, Allen VM, O'Connell CM, Jangaard KA.

Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.

Comment in:

Abstract

OBJECTIVE: To estimate the impact of caesarean delivery on the incidence of selected neonatal outcomes. Patients and methods: A 15-year, population-based, cohort study (1988-2002) using the Nova Scotia Atlee Perinatal Database compared neonatal outcomes in term newborns born by spontaneous and assisted vaginal delivery, with newborns born by caesarean delivery, with and without labour, using multiple logistic regression.

RESULTS: From a total of 142 929 deliveries, there were 27 263 caesarean deliveries, 61% of which were performed in labour. Relative risks were adjusted for year of birth, maternal age, parity, smoking, maternal weight at delivery, hypertensive diseases, diabetes, previous caesarean delivery, use of regional anaesthesia, induction of labour, gestational age at delivery and large and small for gestational age, where significant. Caesarean delivery in labour, but not caesarean delivery without labour, had increased risks for depression at birth and neonatal respiratory conditions compared with spontaneous or assisted vaginal delivery. Compared with spontaneous vaginal delivery and assisted vaginal delivery, the risk of major neonatal birth trauma was decreased for infants after caesarean delivery with labour (odds ratio (OR) = 0.34, 95% CI 0.21 to 0.56 and OR = 0.07, 95% CI 0.04 to 0.11, respectively) and caesarean delivery without labour (OR = 0.20, 95% CI 0.08 to 0.52 and OR = 0.04, 95% CI 0.02 to 0.10, respectively).

CONCLUSION: Caesarean delivery in labour, compared with vaginal delivery, is more likely to be associated with an increased risk for respiratory conditions and depression at birth than caesarean delivery without labour. Caesarean delivery appears protective against neonatal birth trauma, especially when performed without labour.

PMID: 17942582 [PubMed - indexed for MEDLINE]

 

Eur J Obstet Gynecol Reprod Biol. 2007 Nov;135(1):35-40. Epub 2006 Nov 28.

Short-term maternal and neonatal outcomes by mode of delivery. A case-controlled study.

Benedetto C, Marozio L, Prandi G, Roccia A, Blefari S, Fabris C.

Department of Obstetrics and Gynecology, University of Torino, Italy. chbened@tin.it

Abstract

OBJECTIVE: Side-by-side comparisons of short-term maternal and neonatal outcomes for spontaneous vaginal delivery, instrumental vaginal delivery, planned caesarean section and caesarean section during labor in patients matched for clinical condition, age, and week of gestation are lacking. This case-controlled study was undertaken to evaluate short-term maternal and neonatal complications in a healthy population at term by mode of delivery.

STUDY DESIGN: Four groups of healthy women, with antenatally normal singleton pregnancies at term, who underwent instrumental vaginal delivery (no. 201), spontaneous delivery (no. 402), planned caesarean section without labor (no. 402) and caesarean section in labor (no. 402) have been retrospectively selected. Outcome measures were maternal and neonatal short-term complications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS: Maternal complications were mostly associated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 6.9; 95% CI: 2.9-16.4 and OR 3.0; 95% CI 1.1-8.8, respectively, versus spontaneous deliveries). No significant differences in overall complications were observed between spontaneous vaginal deliveries and caesarean sections, whether planned or in labor. By comparison with caesarean sections in labor, instrumental deliveries significantly increased the risk of complications (OR: 3.2; 95% CI: 1.6-6.5). Neonatal complications were also mostly correlated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 3.5; 95% CI: 1.9-6.7 and OR 3.8; 95% CI 2.0-7.4, respectively, versus spontaneous deliveries). By comparison with caesarean sections in labor, instrumental vaginal deliveries significantly increased the risk of complications (OR: 4.2; 95% CI: 2.4-7.4).

CONCLUSIONS: In healthy women with antenatally normal singleton pregnancies at term, instrumental deliveries are associated with the highest rate of short-term maternal and neonatal complications.

PMID: 17126475 [PubMed - indexed for MEDLINE]

 

BJOG. 2007 Oct;114(10):1266-72.

Risk factors for anal sphincter tears: the importance of maternal position at birth.

Gottvall K, Allebeck P, Ekéus C.

Department of Women and Child Health, Division of Reproductive and Perinatal Health, Karolinska Institutet, Stockholm, Sweden. karin.gottvall@ki.se

Abstract

OBJECTIVE: To assess the role of birth position in the occurrence of anal sphincter tears (AST).

DESIGN: Observational cohort study.

SETTING: South Hospital in Stockholm, a teaching hospital with around 5700 births per year.

POPULATION: Among all 19,151 women who gave birth at the South Hospital during the study period 2002-05, 12,782 women met the inclusion criteria of noninstrumental, vaginal deliveries.

METHODS: Data on birth position and other obstetric factors were analysed in relation to occurrence of AST.

MAIN OUTCOME MEASURE: Third- and fourth-degree AST.

RESULTS: AST occurred in 449 women (3.5%). The trauma was more frequent in primiparous (5.8%) than in multiparous women (1.7%). The highest proportion of AST was found among women who gave birth in lithotomy position (6.9%), followed by squatting position (6.4%). Logistic regression analyses showed that lithotomy (adjusted OR 2.02, 95% CI 1.58-2.59) and squatting positions (adjusted OR 2.05, 95% CI 1.09-3.82) were associated with a significantly increased risk for AST. Other major risk factors for anal sphincter trauma were primiparity (adjusted OR 3.29, 95% CI 2.55-4.25), prolonged second stage of labour >1 hour (adjusted OR 1.52, 95% CI 1.11-2.10), infant birthweight more than 4 kg (adjusted OR 2.12, 95% CI 1.64-2.72) and large infant head circumference (adjusted OR 1.57, 95% CI 1.23-1.99).

CONCLUSION: Lithotomy and squatting position at birth were associated with an increased risk for AST also after control for other risk factors.

PMID: 17877679 [PubMed - indexed for MEDLINE]

 

J Minim Invasive Gynecol. 2006 Sep-Oct;13(5):457-62.

A randomized comparison of suturing techniques for episiotomy and laceration repair after spontaneous vaginal birth.

Morano S, Mistrangelo E, Pastorino D, Lijoi D, Costantini S, Ragni N.

Department of Obstetrics and Gynaecology, San Martino Hospital and University of Genova, Genova, Italy.

Abstract

STUDY OBJECTIVE: To compare the continuous knotless technique of perineal repair with the interrupted method after spontaneous vaginal birth

DESIGN: A randomized controlled trial. DESIGN CLASSIFICATION: Canadian Task Force Classification I.

SETTING: This study was undertaken in a university hospital with more than 2200 deliveries per year. The static population of this district includes a wide range of socioeconomic classes and is predominately white.

PATIENTS: From May 1 to November 19, 2003, 214 primiparous women with a second-degree perineal tear or episiotomy were randomly allocated to either the continuous knotless technique (CKT; n=107) or the interrupted technique (IT; n=107) suturing method.

INTERVENTIONS: The interrupted technique (IT) involves placing 3 layers of sutures whereas the continuous knotless technique (CKT) involves reapproximating vaginal trauma, perineal muscles, and skin with a loose, continuous, nonlocking technique.

MEASUREMENTS AND MAIN RESULTS: The primary outcomes of the study were perineal pain (evaluated by visual analogue scale) at 48 hours and day 10 and dyspareunia 3 months after delivery. Secondary outcomes included suture removal, wound dehiscence, analgesia use up to 48 hours, and satisfaction with repair established at 3 and 12 months after childbirth. At day 10, 19 women had dropped out of the study. Significantly fewer women reported pain at 10 days with the CKT than with the IT (32.3% vs 60.4%; p<.001). Analgesia use up to 48 hours postpartum was less in the CKT group than in the IT group (33.6% vs 54.2%; p<.05). No difference was found in superficial dyspareunia at 3 months for the CKT versus the IT group.

CONCLUSION: The use of a continuous knotless technique for perineal repair is associated with less short-term pain than techniques with interrupted sutures.

PMID: 16962532 [PubMed - indexed for MEDLINE]

 

BJOG. 2008 Mar;115(4):472-9.

Postpartum perineal repair performed by midwives: a randomised trial comparing two suture techniques leaving the skin unsutured.

Kindberg S, Stehouwer M, Hvidman L, Henriksen TB.

Perinatal Epidemiology Research Unit, Aarhus University Hospital, Skejby, Aarhus, Denmark.

Abstract

OBJECTIVE: To compare a continuous suture technique with interrupted stitches using inverted knots for postpartum perineal repair of second-degree lacerations and episiotomies.

DESIGN: A double-blind randomised controlled trial.

SETTING: A Danish university hospital with more than 4800 deliveries annually.

POPULATION: A total of 400 healthy primiparous women with a vaginal delivery at term. METHOD Randomisation was computer-controlled. Structured interviews and systematic assessment of perineal healing were performed by research midwives blinded to treatment allocation at 24-48 hours, 10 days and 6 months postpartum. Pain was evaluated using a visual analogue scale and the McGill Pain Questionnaire. Wound healing was evaluated using the REEDA scale and by assessment of gaping wounds >0.5 cm. Analysis complied with the intention-to-treat principle.

MAIN OUTCOME MEASURES: The primary outcome was perineal pain 10 days after delivery. Secondary outcomes were wound healing, patient satisfaction, dyspareunia, need for resuturing, time elapsed during repair and amount of suture material used.

RESULTS: A total of 400 women were randomised; 5 women withdrew their consent, leaving 395 for follow up. The follow-up rate was 98% for all assessments after delivery. No difference was seen in perineal pain 10 days after delivery. No difference was seen in wound healing, patient satisfaction, dyspareunia or need for resuturing. The continuous suture technique was significantly faster (15 versus 17 minutes, P = 0.03) and less suture material was used (one versus two packets, P < 0.01).

CONCLUSION: Interrupted, inverted stitches for perineal repair leaving the skin unsutured appear to be equivalent to the continuous suture technique in relation to perineal pain, wound healing, patient satisfaction, dyspareunia and need for resuturing. The continuous technique, however, is faster and requires less suture material, thus leaving it the more cost-effective of the two techniques evaluated.

PMID: 18271883 [PubMed - indexed for MEDLINE]

 

BJOG. 2009 Mar;116(4):569-76. Epub 2008 Dec 19.

Ear acupuncture or local anaesthetics as pain relief during postpartum surgical repair: a randomised controlled trial.

Kindberg S, Klünder L, Strøm J, Henriksen TB.

Department of Research and Medical Education, Sønderborg Hospital, Denmark. sara.fevre.kindberg@ki.au.dk

Abstract

OBJECTIVE: To evaluate two methods of pain relief during postpartum surgical repair in regard to effectiveness, wound healing and patient evaluation.

DESIGN: A randomised controlled trial testing a pragmatic set-up of brief training of clinicians.

SETTING: Delivery ward at a Danish district hospital with approximately 1600 annual deliveries.

POPULATION: Primiparous women with a vaginal delivery at term who needed surgical repair of lacerations to the labia or the vagina, perineal lacerations of first or second degree or mediolateral episiotomies.

METHODS: The trial was set up to evaluate the effect of a brief 2-hour hands-on training in the use of ear acupuncture. All midwives (n = 36) in the department had previous experience in using acupuncture for obstetric pain relief. Pain and wound healing were evaluated using validated scores. Data collection was performed by research assistants blinded towards treatment allocation. Randomisation was computer assisted. A total of 207 women were randomised to receive ear acupuncture (105) and local anaesthetics (102), respectively.

MAIN OUTCOME MEASURES: The primary outcome was pain during surgical repair. Secondary outcomes were wound healing at 24-48 hours and 14 days postpartum, participant satisfaction, revision of wound or dyspareunia reported 6 months postpartum.

RESULTS: Pain during surgical repair was more frequently reported by participants allocated to ear acupuncture compared with participants receiving local anaesthetics (89 versus 54%, P < 0.01). Pain intensity during surgical repair was also reported higher (Visual Analogue Scale score 3.5 versus 1.5, P < 0.01). The ear acupuncture group received more additional pain relief during repair (53 versus 19%, P < 0.01). No difference was observed in wound healing at 24-48 hours or 14 days postpartum. Revision of wounds was rare, and no difference occurred in this trial. Comparable proportions of participants reported dyspareunia at 6 months. Patient satisfaction with the allocated pain-relief method was lower in the ear acupuncture group (69 versus 91%, P < 0.01) and fewer women would recommend the method to a friend (74 versus 91%, P < 0.01).

CONCLUSIONS: Ear acupuncture as used in this trial was less effective for pain relief compared with a local anaesthetic. No difference was observed in wound healing, need for revision of wound or dyspareunia. Patient satisfaction with allocated pain-relief method was lower in the ear acupuncture group.

PMID: 19120322 [PubMed - indexed for MEDLINE]

 

Cochrane Database Syst Rev.2005 Apr 18;(2):CD004223.

Topically applied anaesthetics for treating perineal pain after childbirth.

Hedayati H, Parsons J, Crowther CA.

Department of Public Health, University of Adelaide, Level 6 Bice Building, Royal Adelaide Hospital, Adelaide, Australia, 5005. hedyeh.hedayati@adelaide.edu.au

Abstract

BACKGROUND: Perineal trauma is a major problem affecting millions of women around the world each year. The degree of perineal pain and discomfort associated with perineal trauma is often underestimated. Pain often interferes with basic daily activities for the woman such as walking, sitting and passing urine and also negatively impacts on motherhood experiences.

OBJECTIVES: To assess the effects of topically applied anaesthetics for relief of perineal pain following childbirth whilst in hospital and following discharge.

SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (February 2004), CINAHL (1982 to December 2002) and MIDIRS (last searched February 2003). We checked reference lists of trials and review articles.

SELECTION CRITERIA: Randomised controlled trials comparing topically applied anaesthetic with no treatment, placebo or alternative treatment.

DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial eligibility and quality and double-entered the data. We contacted study authors for additional information.

MAIN RESULTS: Eight trials made up of 976 women were included in the review. Five of these trials measured pain experienced up to 24 hours after birth but different methods to assess pain were used in each of the studies. All five trials showed no difference in pain relief when the topical anaesthetic was compared with placebo. One of these studies looked at topical anaesthetics compared with indomethacin vaginal suppositories but there was no significant difference in mean pain scores. All trials reported only short-term follow up (up to four days). Two trials looked at additional analgesia taken for perineal pain, with one trial finding that less additional analgesia was required with epifoam use in comparison with placebo (relative risk (RR) 0.58, 95% confidence interval (CI) 0.40 to 0.84, one trial, 97 women). However, lignocaine/lidocaine showed no difference with regard to additional analgesia use. Adverse effects were not formally measured in the studies; however, some studies commented that there were no side-effects severe enough to discontinue treatment. One study found that the women in the treatment group were more satisfied than the placebo group (RR 0.09, 95% CI 0.01 to 0.65, one trial, 103 women).

AUTHORS' CONCLUSIONS: Evidence for the effectiveness of topically applied local anaesthetics for treating perineal pain is not compelling. There has been no evaluation for the long-term effects of topically applied local anaesthetics.

PMID: 15846702 [PubMed - indexed for MEDLINE]

 ------------------------------------------------------------------------------------------------------------------

These were obstetrical pictures taken at the Misericordia Hospital in Edmonton, Alberta.

Covenant Health apologizes to patients and takes action after patient images go missing

March 14, 2011

Toll free number set up to respond to patient concerns

Edmonton, Canada

Covenant Health has taken steps to change how it handles patient images after an unencrypted back-up hard drive containing digital images went missing.

“We apologize for the emotional distress the loss of this hard drive may cause our patients,” says Patrick Dumelie, Covenant Health President and CEO. “I also want to reassure anyone who comes to our facilities for care; changes have been made and we are working with staff and the Office of the Information and Privacy Commissioner to prevent this from happening again.”

The images were not stored according to Covenant Health’s policies on the protection of information. All the originals of the missing images are now uploaded to a secure server meeting privacy and information technology standards and Covenant Health is reviewing its practices and providing staff education and training around secure image storage.

This weekend a team of highly trained staff was contacting the 233 impacted patients. The missing photos and two videos are back-ups of images taken at the Misericordia from 2002 to 2010.

“We are doing all we can to ensure our patients are informed appropriately and in a respectful manner,” says Dumelie. “We recognize when patients enter our facilities, they are in vulnerable situations that require great care and compassion.”

147 of the 233 patients impacted have been contacted by Covenant Health. If people had an image taken or suffered a late term pregnancy loss while they were a patient at the Misericordia Community Hospital between 2002 and 2010 and have concerns, they are asked to call 1.855. 735. 9900. The line will be staffed from 3:00 p.m. until 8:00 p.m. Monday to Friday until March 25, 2011.

Background

• There are 233 patient folders containing approximately 3,600 photos and two videos on the missing unencrypted hard drive

• The missing images are back-ups of images taken at the Misericordia Community Hospital between 2002 and 2010

• The missing hard drive did not contain any original images – all original images are secure

• The folders and file names included the patient’s name and hospital number. They did not contain the Alberta Health Care number or any other personal identification, with the exception of four files. There was no financial information in  any of the files

The folders containing patient images were from the following areas:

• Hyperbaric Oxygen Chamber
• Infant bereavement
• Laboratory specimen
• Clinical and wound documentation
• Surgery
• Reconstructive surgery (two videos)

Timeline
• Unencrypted hard drive was last seen January 17, 2011 – it was placed under a desk while other equipment in the office was being moved to a new location
• Noticed missing January 28, 2011
• Office of the Information and Privacy Commissioner Informed February 3, 2011 – report was filed and work with OIPC is ongoing
• Incident investigated by Covenant Health Protective Services – concluded no sign of break-in or indication of a theft
• Thorough search of the hospital conducted – no sign of misplaced hard drive
• Phoning blitz March 11, 12 and 13, 2011 - done during the weekend in an effort to contact the maximum number of patients at home.

-30-
Contact:

Rayne Kuntz, Media Relations Senior Advisor
Covenant Health
E rayne.kuntz@covenanthealth.ca
W 780.735.9930 C 780.246.2523

Covenant Health is Canada's largest Catholic health care organization with over 14,000 physicians,
employees and volunteers serving in 11 communities across Alberta. A major provider in Alberta's
integrated health system, Covenant Health works with Alberta Health Services and community partners to
positively influence the health of Albertans through a broad range of programs and services.

 

Heart Failure - Miscarriage of Justice

by Michael Greger, MD and United Progressive Alumni

http://www.upalumni.org/medschool/ob-gyn.html

 


IV. OBSTETRICS AND GYNECOLOGY - February 16-March 27

Miscarriage of Justice

Back in the hole. First day and furious at the garbage they're teaching. "All postmenopausal women must be on hormone replacement. It's imperative. They're crazy if they're not." What a coincidence, lunch brought to us by Premarin*. Grand rounds or infomercial?

* Premarin is a brand name of "hormone replacement therapy." It is now one of the most commonly prescribed drugs in the U.S. Premarin is inhumanely derived from the urine of confined and catheterized pregnant mares.

Appendix 48 documents some of the industry's hormone marketing tactics.

"Anesthetized women look so vulnerable."[119]

I am all gloved up, fifth in line. At Tufts, medical students - particularly male students - practice pelvic exams on anesthetized women without their consent and without their knowledge. Women come in for surgery and, once they're asleep, we all gather around; line forms to the left.

In the medical ethics literature this practice has been called, "an outrageous assault upon the dignity and autonomy of the patient...."[120] "The practice shows a lack of respect for these patients as persons, revealing a moral insensitivity and a misuse of power."[121] "It is just another example of the way in which physicians abuse their power and have shown themselves unwilling to police themselves in matters of ethics, especially with regard to female patients."[122]

We learn more than examination skills. Taking advantage of the woman's vulnerability - as she lay naked on a table unconscious - we learn that patients are tools to exploit for our education.

It all started on the first day when the clerkship director described that we were to gain valuable experience doing pelvic exams on women in the operating room. I asked him if the women knew what we were doing. Are the women asked permission? "No," he said. And not only no, he described that he was, "ethically comfortable with that." I did some reading.

Massachusetts state law reads: "Every patient... has the right... to refuse to be examined... by students... and to refuse any care or examination when the primary purpose is educational or informational rather than therapeutic."[123] Yes, the right to refuse, but what if the patient doesn't even know? Was the director's attitude what-she-doesn't-know-can't-hurt-her? The confrontation continued.

He countered, "These women sign off that right to refuse on their surgical consent form." Having long learned a healthy skepticism about the pronouncements of authority, I got a copy of the form. The only mention of students reads as follows: "I am aware that occasionally there may be visiting surgeons/ healthcare professionals/ students observing techniques." Observing? We were going to be doing a lot more than observing. I went back to talk to him.

"Women are smart," he told me. "They know that when it says a student observes, that the student will be participating in the procedures." My eyes widened. And anyway, I was told, "Most women wouldn't mind." My jaw dropped. And, "Why are you so sensitive?"

I was just stunned, a stranger in a strange land. I was reminded of the summer I spent in Louisiana, where I had a debate with an orthopedic surgeon over whether or not the abolishment of slavery was really a good thing. "Now just think about it," I was admonished. What do you even say? How do you even respond?

So if the patients already secretly know and wouldn't mind regardless, then surely the course director wouldn't mind me wasting my breath to ask the women permission. (For that matter, he shouldn't mind a quick letter to the Boston Globe either.) No, I was told initially, I am not to ask women permission to use them - their bodies - for our education. I shouldn't let them know. Why? "We would just confuse the patients," he said. "You don't ask permission for male genital exams, do you?" I was asked. "We don't get them to sign permission for every little detail?"

John M. Smith, in Women and Doctors writes, "Many doctors regularly abuse women as a result of underlying prejudice and self-deception."[124] The whole situation reminds me of a famous James Thurber cartoon. A male doctor is leering over the headboard of a hospital bed at a female patient. Caption: "You're not my patient, you're my meat."[125]

"It is grossly unjust to exploit the vulnerable."[126]

Maybe the women wouldn't mind not being asked. After all, he is a doctor. I went back to the library. Sixty-nine women were asked in a British survey whether they thought permission should be specifically sought for students doing pelvic exams in the operating room. One hundred percent said yes; they all thought that specific permission should be sought.[127] A Swedish study found that 90% of gynecologic patients "would feel aggrieved if they discovered that they had participated in [any kind of] clinical training without first having been informed or given the opportunity of declining."[128] And of course, "Express consent does not mean a signature on a piece of paper... [it means] the patient must understand the general nature of the procedure - that is, that she is being used for teaching."[129]

I brought this to the director's attention. I gave him a copy of the British study. He dismissed it; how could I possibly extrapolate data from a British low income clinic to our population? Again, speechless. Even if the data were two orders of magnitude off and only one out of a hundred would mind not being asked, shouldn't that be enough?

The practice may even put the school and hospital in legal jeopardy - battery, professional misconduct, perhaps even aggravated sexual assault. Maybe I should just walk out of the OR and call the police. As written in a British Sunday Times article, "There is nothing to stop a woman bringing a legal action of assault. The only reason no one has done it is because they don't know what's going on."[130] The attending assured me they had thought of that too. "It's been past the risk analysis committee," he told me as he patted my shoulder, "there's nothing to worry about." At that point I gave up.

Appendix 49 offers some perspective on this outrageous practice.

It is often easier to fight for principles than to live up to them.
- Adlai Stevenson

The patient is a Cantonese speaking woman. No English and no interpreter. In the OR an epidural catheter is placed in her back with a big needle. They bark orders at her, but she doesn't understand. When she's under I am all gloved up, fifth in line, with another medstudent behind me.

Medical students and unethical conduct - Appendix 50

From the book Humanization and Dehumanization of Health Care:

The literature stresses structural rather than psychological causes of helplessness in depersonalizing institutions. People appear to be crushed by hierarchies of power, often arbitrary in application, and rendered impotent by bureaucratic inertia that frustrates attempts to change 'evil' norms, behaviors and values.[131]

From another commentary:

Students often react with a policy of silence when they observe or take part in ethically suspect actions. This is not surprising given the pressures to conform, the fear of punishment or prejudice, the complex nature of moral judgments and the power imbalance between student and teacher.... Placing students in morally untenable situations or failing to support their concerns that they voice represents a failure [of the medical education system]....

It will be weeks before I regain consciousness from the sleep deprivation. How much longer to regain conscience-ness? Instead of a suspension of disbelief, third year is a suspension of belief - in one's ethics, one's integrity, in one's sense of self. "How unhappy is he who cannot forgive himself" - Publilius Syrus.

Medical school is particularly difficult on activists. See Appendix 51a

Morning lecture. We are told of the guild system that medicine education used to be, where apprentices were evidently sold to masters. And so if it feels like slavery....

The dean gives us a booklet she wrote on getting into residency. In the interview, she advises, "Questions regarding days off... are 'no-no's.'" Of course they are.

Friday afternoon lecture. "Ultrasound works best through water." Accompanying slide? Bikini Clad Woman. Of course. From the "Passing Through Third Year" guide: "On Ob/Gyn, you can carry anything you want, but avoid being seen carrying Ms. Magazine."[132] The slide show ends with the perfunctory naked woman painting. The afternoon taught me more than I expected. Mark Twain: "I have never let my schooling interfere with my education."

One needs look no further than Ob/Gyn textbooks for the specialty's views on women. Appendix 52a.

Having to plan a fourth year schedule forces me to see a picture larger than tomorrow, overwhelming through the denial. On the outside I walk slower than I used to, days in a daze.

Back to the squeaky smell of the OR floor wax. With 14 hour days you can't have an existence outside the hospital. I live days within myself.

Writing a letter, I start using medical short hand. "c" for with. I'm just on a different circuit.

A male gynecologist is like an auto mechanic who has never owned a car.
- Carrie Snow

A week on outpatient. I look at the list of appointments - 3:00, 3:10, 3:20 - ten minutes each. Robotic. Write, write, write - patient tells doctor newborn infant has inoperable brain tumor; doctor looks up, "That must be difficult," - write, write - "when was your last menstrual period?" It's an assembly line. Insert breast self exam schpiel here. "Not diagnosing breast cancer is the number one cause of malpractice," she tells me. "So that's why you should tell them, and document it in the chart. But don't ever run behind."

Florence Haseltine, co-author of Woman Doctor and a doctor herself:

Many patients are angry that we're not better than men. We're callous. We hurt them when we examine them. A lot of people have been very disappointed. I don't know what they expected of women doctors. If they expect us to say, 'Yes, you've been horribly treated, and the males did everything wrong, and now women are going to do everything right,' they're not going to get that, because we're trained the same way.[133]

"Give her... [this drug] to cover," shouts the doctor. But I realized it's not to cover the patient, it's to cover himself, from liability.

The chief resident is a zombie from sleep deprivation. He tells me he can't think; he can't remember phone numbers. And he did seven hours of surgery that day. He walks around hugging himself.

"My empathy went asleep," I heard the Ob/Gyn Fellow say when confronted over an ethical impropriety. "If it was before midnight I would of felt bad."

More on the loss of empathy in Appendix 53a

My intern on being an intern: "You're deprived of being good to yourself."

Are we going to become them? I ask a peer. He jokes that after medical school we'll all need to see an exorcist. "Resilience," he says, "may not be enough."

A lecture from the oldest faculty member in the department. He sees my Ad Hoc Committee button, "Patients Not Profits." "I like your altruism," he said, "but you're going to lose it. Doctors need incentives."

A nurse reads the button and comments, "Oh, he's a radical." Only in America.

My text has a section called Financial Aspects of Practice:

If you allow the patient to leave without paying, then the first and second billing notices that are sent to the patient for payment will increase your overhead expenses. You should educate the patient as to how these charges are arrived at, so that she will in turn recognize that when she fails to keep her appointment without notifying you, she eliminates a block of time in which you could have received income by seeing another patient.[134],[135]

I am asked by someone with a clipboard why the hell the patient was just under observation. "She should be admitted," she said, "it's $1500 versus $600."

One of the residents tells me she wants to practice in the South. "Doctors get more respect." I wonder what she means. Another wants New York City. "They make money. And they don't pretend," she tells me. "They want to make money."

Conservatism in medicine, Appendix 54

I believe the power to make money is a gift from God - John D. Rockefeller

Plummet, fell and shrank. "Between 1993 and 1995 radiologists watched their inflation-adjusted pay plummet... to $244,400. Anesthesiologists' salaries fell... to $215,000; and general surgeons' shrank... to $269,400."

I hear a doctor complain about the regional physician glut. "In Boston you can't really make more than 135." Echoes from the literature: "I totally agree that most physicians are paid much less than they are worth," one physician writes to Pharos. "Society seems to choke when hearing that the 'average' physician earns over $100,000 per year...."[136] From a letter published in the New England Journal: "It is ethical to be paid reasonably, and in a manner that is commensurate with the value of the product. Last time I looked, a patient's life was deemed precious."[137]

Doctors and money, Appendix 55

The chief resident asks if I want to draw blood. If it looks like an easy stick, yes. "Well we don't want it to look like we're practicing on her," he replies.

Pelvic exenteration, where they basically take out the whole pelvis. "This is going to be exciting," the resident says, eyes wide.

"I want to keep her in here [on the service] so we can learn off her," she says.

Patients as teaching material, Appendix 56

"Are we going to mismanage her?" The intern asks. "Maybe; I'm not confident."

I daydream of soaking beans to make hommus with dill from the garden, dipping carrots - unscraped - and whole wheat pita toast. Bare feet in warm grass, cool earth. Reading, in the shade, shooing cats. Susan my pillow. I wake to bloody scissors, standing my seventh hour retracting organs. And still years to go.

They laughed at a patient today for not knowing the difference between endometrium and endometriosis. While we're at it, let's make fun of the older woman's vaginal prolapse! From Women and Doctors: "It is common and acceptable among practicing gynecologists to speak about their patients and their patients' bodies, sexual behavior, or medical problems indiscriminately, in terms that are demeaning and reflect a lack of simple kindness and respect."[138]

From my Ob/Gyn text: Girls with "confusing" family dynamics, "may fall in with a disenchanted crowd of teenagers...." Further, "these girls do not compete well."[139]

Anorexia nervosa is defined in part as 15% below expected body weight. Where do "ideal" weights come from? The text I'm using hints at the irony:

The ideal weight for an average 5 ft 4 in woman in 1943 was approximately 130 lb.; in 1980 charts, it was under 120 lb.... These revisions have not been based on morbidity or mortality statistics, but on measurements of the heights and weights of 25-year-old graduate students... [reflecting] the upper-class emphasis on fashion model thinness as a standard of beauty.[140]

It's still so difficult to stand residents without semblances of basic decency. No hello, good morning, thank you, please. Is eye contact too much to ask?

We are taught how to present infants at rounds. "Baby boy Smith is a 2000 gram product of a 40 week gestation." The mother is cut out too.

One commentator writes, "A friend of mine who was in the final, yowling, human-cannon-ball/get-the-net stages of labor at 11:45 p.m. was quietly reminded by her obstetrician that if she could just hold off until midnight she'd get another day in the hospital."[141]

Sitting at the nurse's station I see a pricing guide on the wall. I look down the Patient Price column. Vaginal Delivery, $1211. Epidural [thrown in for another] $303.

A patient wants a tubal ligation with her C-section, but she has no insurance. I ask the doctors why they just don't do it anyway. They look at me like I'm from another planet. "If we do it we won't get paid."

According to a recent story in Kenya's largest newspaper The Nation, a Nairobi physician who had just removed a bean from a young girl's ear, "jammed it back in when her parents came up short on cash for the $6 procedure."[142]

CASH ON DELIVERY

Dad sent me a clipping from the LA Times describing a similar practice in California. Evidently, a Ms. Chavez - deep in the throes of labor - told her doctor to begin the epidural for the pain. The nurse came in and said, "That will be $400," to which the patient said, "Sure, no problem." "No, you don't understand," the nurse replied, "I need $400 now."

"Her asthma kicking in," the article reports, "hardly able to breathe, Chavez asked her husband to write a check." But the anesthesiologist refused to accept it. The anesthesiologist also refused her credit cards. So Chavez had her mother wire cash in from England, but the anesthesiologist wouldn't accept the confirmation number from Western Union as proof that the money was on the way. The nurse noted in the chart, "Pt. unable to pay cash."

Chavez had Medi-Cal, California's version of Medicaid, which reimburses doctors $57 for the initial insertion of the epidural, and about a dollar a minute after that. The anesthesiologist's attorney described this amount as, "so nominal it's nothing." Not to let suffering get in the way of making more money, "some doctors suggested that anesthesiologists should refuse to accept Medi-Cal recipients as patients - even if it means leaving them in pain on the delivery table."[143] Which is exactly what happened.

It took me a minute to realize that when the anesthesiologist was describing how risky certain procedures were on pregnant women, he meant for him, in terms of malpractice, not her. As reported in a recent book Enemies of Patients, "A few years ago newspapers reported that all obstetricians in a large region of Georgia came to an agreement that they would no longer provide obstetrical services to women who were lawyers, married to lawyers, or worked in any capacity in a law firm." The author describes this as evidence of a desire to put one's self-interest above the interests of patients.[144]

Today I left and walked in the sun. (Home to get my forgotten beeper.) The birds sang.

ON PLAYING THE GAME OF THIRD YEAR

Third Year is about dis-integration.

Third Year is about frat-house mentality hazing rites of passage.

Third Year is about teaching by humiliation; teacher as enemy.

Third Year is about always feeling one needs an alibi - "But he said I could go get lunch."

Third Year is about hurry up and wait

Third Year is about habituating to fear.

Third Year is about having sufficiently low expectations for life.

The gynecology-oncology attending stops outside the patient's room to tell the residents, "Let's make this quick." She tells the woman inside that she has a particularly bad form of invasive cancer and will need radical surgery and maybe chemo and radiation. The doctor continues to speak right through her sobs, talking about nodes and spinals. And then leaves while the patient is still crying. The secretary gives her some handouts on the way out.

This type of treatment is all too common - Appendix 57

Sometimes the patient's aren't told at all. One cancer patient's account:

Being fed 'tailored' truth and outright lies was psychological torment - I felt continually humiliated, manipulated, out of control.... Smiles deceived, reassurances deluded, suspicions were not shared. But misplaced kindness became brutality as the bad news broke. And the deceit hurt.[145]

With his crown and raised scepter, this morning's Dogbert exclaimed "I need a job where my immense ego seems normal." Next frame: "I've decided to be a doctor. I will determine who lives and who dies." Then, patient on table clutching stomach, "What? I can't die from an ulcer!" And Dogbert, "Maybe not, but I enjoy the challenge."

"The doctor says there is no hope, and since he does the killing he ought to know" - Gaspar Zavala y Zamora.

Doc as God - Appendix 58

I pick up the Herald.

A doctor and Boston University medical professor, who was the subject of 13 stinging complaints [including sexual assaults over a period of 18 years] but never disciplined by the state's medical board, has been indicted for raping one patient and molesting three others.... [The doctor] touched their breasts or made them remove their underwear even though he was examining them for simple hand or knee injuries. 'Shocked, I immediately began to cry,' one distraught woman wrote the Board in 1997. 'Dr. Ramos continued to touch my breasts as I cried uncontrollably.'[146]

This example is far from isolated. See Appendix 59a

I compliment an intern on her bedside manner. She tells me how one can use relations with patients to deal with the brutality of internship.

I got my surgery grades back today. I just pass. I flip to the comments and am incredulous at the irony. "Social skills were described as awkward." I, "sometimes displayed a lack of empathy." And from surgeons! "Reviewers commented that he had questionable professional conduct and he seemed to exhibit a 'political agenda'"

"If a man really knew himself he would utterly despise the ignorant notions others might form on a subject in which he had such matchless opportunities for observation" - George Santayana. Or as the button Holly gave me yesterday says, "Gandhi Would Have Smacked You in the Head."

Lightening rounds through the ICU. A patient waves to me with her foot. I go to her. "I'm being held prisoner," she says in desperation. All I feel I can do is apologize - for everyone else, but especially for me. I leave her to catch up with rest of the team.

From a doctor's personal account published in the Western Journal of Medicine:

I read Dalton Trumbo's 1939 antiwar novel, Johnny Got His Gun, as a teenager: The plot remained buried in my memory until I started working with comatose, nonresponsive, postoperative or intensive care unit (ICU) patients as a medical student and later as a resident. After one particularly difficult case, the memory of 'Johnny' - blind, deaf, dumb, a multiple amputee, sustained in a hospital bed, struggling to communicate with the outside world - began returning to me. The parallels with ICU patients - intubated, lined (with central line, oxygen, feeding tubes), paralyzed - became apparent to me.[147]

No man who is in a hurry is quite civilized - Will Durant

From an article in JAMA:

Although most patients may perceive a 2-minute encounter with a physician seated at the bedside as more reassuring then a 2-minute chat with him standing at the doorjamb, 2 minutes is still only 2 minutes; patients placated enough to comply (or not complain), still may not feel connected to their physicians in any meaningful sense.... The healing touch in major medical centers rarely lingers. Patients suffer - and so too do those who desire to be healers....

A student or house officer may wonder, 'would it be right for me, a temporary stranger, who just wandered into these patient's lives, to engage them on an intimate level when I only spend 8 hours on call with them? Wouldn't that be the emotional or therapeutic equivalent of a one-night stand?' We believe that too many students and residents incur long-term personal damage by engaging in transient relationships with strangers.[148]

A patient swears her three year old gave her the black eye. The head of the department tells the resident just to document it. "As long as it's in the chart we're safe."

Medicine's treatment of domestic violence has been less than ideal. See Appendix 60

One study found that 37% of obstetric patients - across class, race, and educational lines - were physically abused during pregnancy. One enlightened obstetrician reminds me how rampant domestic violence is in this patient population. I ask him if he asks patients about it, screens for it. He laughs. "With the way we see patients?" Eighteen patients in three hours.

So why don't doctors just see fewer patients? Because they'd make less money. As Dr. Zarren - one of the few docs I've ever met deserving of the title "doctor" - told me, "If you're willing to make a low enough salary, you can do anything you want in medicine."

According to an article in Medical Economics, family practitioners who make more than $250,000 a year do so because they see an average of 164 patients a week.[149] If you see 150 patients per weeks, you average $178,000 a year. And if you see 50 a week, you net only $146,000.[150]

I explained to a surgeon that at Gesundheit*, initial interviews will go on for hours. "You are a lousy doctor if you spend three hours with a patient," he replied. "You should only need 5 minutes."

* The Gesundheit Institute is Patch Adams' dream of a hospital utopia designed to spark the conscience and imagination of the world.

Four a.m. breakfasts at the hospital. I sit by the window and watch people. I hope to never take outside for granted again.

The bitter stale taste of ghosts of coffees past. "The damp of the night drives deeper into my soul" - Walt Whitman.

Dizzy-sick tired, I suck on ice to stay awake, humming, "Show me the way to go home (bum, bum, bum) I'm tired and I want to go to bed."

Coming home I trip on steps, my body screaming for sleep. I cringe like a vampire from the morning sun.

"It is rather incredible that things as important as human lives are being taken care of by people who are dead tired" [151] See Appendix 61

Thoreau: "We must learn to reawaken and keep ourselves awake, not by mechanical aids, but by an infinite expectation of the dawn.... To be awake is to be alive." Shut up Henry.

I tighten the hood over my face in the cold rain. I can only see a circle around my feet. Though I cannot see ahead, I just keep walking.

I was much further out than you thought
And not waving but drowning
- Stevie Smith

I continue to get stares as the only one washing my hands.

One of the many ways doctors kill patients, Appendix 62a

Two residents have red surgical clogs. They run around like smurfs in their bright blue scrubs.

I find myself harder. Notices of meetings, lectures, protests go straight into the recycling. I can't even stand to read them. Throwing my life away. One hesitates to become unidimensional in fear of becoming undimensional. I'm embarrassed to walk by the Food Not Bombs table. Just another shirt and tie. Susan sums third year up in a word, disconnection.

FOOD NOT BOMBS

Ram Dass: "At one point I asked him how I could become enlightened. Maharaji said, 'Serve everyone'.... At the next opportunity I tried a different tack and asked him how I could know God. He replied, 'Feed everyone.'"

An article about Tufts called "Medicine as a Vehicle for Social Change"? Yes, a 1967 rural Mississippi health center where prescriptions were written for food.[152] There is nothing like the face of a mother to whose child you just gave a cup of hot soup.

STEREOTYPEWRITTEN

The hospital just issued little ink stamps to all the residents to clarify their illegible signatures. Results from a 1997 study of doctor's handwriting: Twenty out of 176 of the medication orders and 78% of the signatures of 36 different physicians were totally illegible or legible only after consultation with one or more nurses or use of references.

Medical students may actually, "gain advantage from illegibility," one doctor notes. "A school report once read: 'Alas, the dawn of legibility in his handwriting only reveals his utter inability to spell.'"[153]

Illegible handwriting may also, however, be used as an unconscious symbol of superiority: "My time is more valuable than yours," it says. "You can take the time to decipher what I write."[154]

Preparing to put in epidurals, doctors ferry the husbands out of the room for the same reason they do the moms on pediatrics for spinal taps - it's just too obvious that patients are unwillingly practiced upon.

An intern tells us of her medschool experience in New York City. "Indigent medicine is wild medicine. You learn a ton."

Doctor Sims, the father of American gynecology, learned a ton that way too. See Appendix 63

On postpartum days we are equivocably told to do breast exams. Shouldn't we ask permission? "No, that's weird," proclaimed my intern. Of course, student exams are only for the uninsured. The paying patients aren't woken up, questioned or fondled by the students. The medical students see the "service patients."

Studying for the exam at the end, there is too much to learn - risking spontaneous rupture of my-brains.

"We're going to 'section her," I hear a doctor say.

"Of all the 36 countries I have visited to observe maternity facilities," writes Doris Haire, past president of the International Childbirth Education Association. "I am absolutely convinced that the United States has to be the most bizarre on earth in its management of obstetrics."

A woman describes her midwifery experience:

When I attended home births I carried no pain medications; I told the women they would have to go to the hospital if they needed such.... An angry obstetrician confronted me once at a meeting in New Jersey, where, shouting across a table which separated us, he asked, 'But... what do you do when a woman is in pain?' He was shaking his fist, accusing me of cruelty and inhumanity. 'When a woman is in pain, I put my arms around her and I hold her,' I said.[155]

Midwives have been viciously persecuted through the centuries - Appendix 64

Many find it troubling that Ob/Gyns, whose training is primarily surgical, are entrusted with so much of women's healthcare[156]. One commentator asks, "Why are surgeons prescribing birth control pills?"[157]

A REAL PILL

Examples of the surgical frame of mind:

Nobel Laureate and former medical school dean Frederick Robbins:

The dangers of overpopulation are so great that we may have to use certain techniques of conception control that may entail considerable risk to the individual woman.

From the Textbook of Contraceptive Practice:

Contraception is not merely a medical procedure; it is also a social convenience, and if a technique carried a mortality several hundred times greater than that now believed to be associated with the Pill, its use might still be justified on social if not medical grounds.[158]

I am twenty-five years old. Wow. Emerson: "The days come and go like muffled and veiled figures sent from a distant friendly party, but they say nothing, and if we do not use the gifts they bring, they carry them silently away."

STERILE TECHNIQUE

A doctor from Texas spoke of tubal ligations being done, not for the benefit of the patient but for the doctors in training. He said, "Sure, they push them all the time here, from third year medical students to residents. If an intern got them to sign he'd get to do it, so they'll do anything even beg them... for the practice. Yes, they would ask them during labor."[159]

Doctors sterilized people for other reasons too. See Appendix 65a

I sent an Email out to everyone in my class in preparing a talk for the class of 2000 on how to survive third year. I see my classmates are in pain too. One woman reminds me to tell next year's class, "They [the doctors] always have more power. [Tell the students] don't let your independence get in the way. Yes it's ridiculous, but you got to bow and scrape like a servant.... Suck it up." Inspiration from another classmate, "[Tell them] the year ends; Time marches on."

Days later, on the panel with other classmates, I mostly just sit and shake my head. I see them changing. Amidst the have-fun's and be-enthusiastic's, one pediatrics bound panelist complains about mothers who don't want medical students involved in their child's care. Her advice to the audience is, "Just tell the mom that the resident is busy." Another fourth year advises lying to the doctors too. "Whatever rotation you're in, tell the doctors that's what you want your specialty to be."

Last day. Out of the dark and into the light. Na na. Nana na na. Hey hey hey. Good-bye.

I look back at the month's entries. Where's the miracle of life? The precious moments/baby holding/hand holding? The joy, celebration, congratulation? Good question.

The day of the test I unearth my clashiest violet pants, neon shirt and sherbet yellow tie-die. I'm colorful because I'm happy; I'm happy because I'm free. "I am here to live out loud" - Emile Zola.

I want a button with the three words a dear friend ended an Email with: "Defiantly Still Smiling." 

[119] Harrison, M. A Woman in Residence New York: Random House, 1982:234.

[120] Tishelman, R. Letter. Hastings Center Report 1994(July-August):45.

[121] Dwyer, J. Letter. Hastings Center Report 1994(July-August):45.

[122] Tishelman, R. Letter. Hastings Center Report 1994(July-August):45.

[123] Chapter 111, Section 70E.

[124] Smith, JM. Women and Doctors New York: Atlantic Monthly Press, 1992.

[125] Shem, S. Mount Misery New York : Ivy Books, Jan. 1998:486.

[126] Sukol, RB. "Teaching Ethical Thinking and Behavior to Medical Students." Journal of the American Medical Association 273(1995):1388-1389.

[127] Lawton, FG and DM Luesley. "Patient Consent for Gynaecological Examination." British Journal of Hospital Medicine 44(1991):326.

[128] Lynoe, N, et al. "Informed Consent in Clinical Training - Patient Experiences and Motives for Participating." Medical Education 32(1998):465-471.

[129] Bewley, S. "The Law, Medical Students and Assault." British Medical Journal 304(1992):1551.

[130] Rogers, L. "Anaesthetised Women Suffer Unauthorized Medical Probes." Sunday Times 21 May 1995.

[131] Humanization and Dehumanization of Health Care:57.

[132] Ricks, AE. "Passing Through Third Year." New Physician 31(1982):16-19.

[133] Osborne, D. "My Wife, the Doctor." Mother Jones 1983(January):21-25, 42-44.

[134] Fundamentals of Gynecology & Obstetrics Philadelphia: Lippincott-Raven, 1992:346.

[135] I do not endorse any of the textbooks I used - they just happened to be what the library had to lend.

[136] Lanard, MS. Letter. The Pharos 1997(Winter):39.

[137] Zwelling-Aamot, ML. Letter. New England Journal of Medicine 339(1998):1326.

[138] Smith, JM. Women and Doctors New York: Atlantic Monthly Press, 1992.

[139] Fundamentals of Gynecology & Obstetrics Philadelphia: Lippincott-Raven, 1992:346.

[140] Goldman, HH. Review of General Psychiatry Stamford: Appleton & Lange, 1991.

[141] Dusen, LV. "This Business Called Medicine." Canadian Medical Association Journal 157(1997):1724.

[142] News of the Weird (1998).

[143] Bernstein, S. "Childbirth Anesthesia Refusals Spur Probe."LA Times 14 June 1998:A26.

[144] Macklin, R. Enemies of Patients New York: Oxford University Press, 1993.

[145] Tattersall, M and P Ellis. "Communication is a Vital Part of Care." British Medical Journal 316(1998):1891.

[146] Estes, A. "BU Doc Indicted of Rape, Molesting of Patients." Boston Herald 19 Feb. 1999:1,26.

[147] Dyer, KA. "A Cry From Within." Western Journal of Medicine 169(1998):251.

[148] Christakis, DA and C Feudtner. "Temporary Matters." Journal of the American Medical Association 278(1997):739-743.

[149] Guglielmo, WJ. Medical Economics 23 November 1998:146-155.

[150] "Income Rises in Busier Practices and With Time Invested" Medical Economics 9/7/98:181.

[151] Harvard researcher Lucian Leape in Duncan, DE. Residents: The Perils and Promise of Educating Young Doctors. New York, NY: Scribner, 1996:107.

[152] Rogers, DA. "Medicine as Vehicle for Social Change." New Physician 1970(Nov.):917-918.

[153] Kandela, P. "Doctor's Handwriting." The Lancet 353(1999):1109.

[154] Winslow, EH, et al. "Legibility and Completeness of Physicians' Handwritten Medication Orders." Heart and Lung 26(1997):158-163.

[155] Harrison, M. A Woman in Residence New York: Random House, 1982:76.

[156] Fugh-Berman, A. "Training Doctors to Care for Women." Technology Review 97(1994):34.

[157] Ibid.

[158] Robbins, J. Reclaiming Our Health Tiburon, CA: HJ Kramer, 1996.

[159] Stevens, W. "Doctors Should Have Their Tongues Tied." Off Our Backs 7(1977):24. 

Reader's Comments

At the age of 41 I had a hysterectomy. In the two and a half years since, I have lost all faith in the medical community. My body has been turned inside out and my once vital self has become a person who is looking at having to work only part time because I have no energy any more. And I have seen more than ten doctors in the meantime; every one of them until the last two has insisted that all of my symptoms have nothing to do with the hysterectomy. Why do doctors believe that ripping out one complete endocrine system will have no impact on a woman's body and general health? My gynecologist assured me that I'd be better than new; instead I aged thirty years overnight. He never even said the word "hormones" to me before the surgery; now my quest for the right balance of hormones rules my life. This is America in the new millenium?

-- Polly Elledge, April 23, 2000

Thanks to Dr. Greger for these candid insights.

I want to express to any and all med school students, that hysterectomy, is most often NOT a surgery or procedure that a woman feels *great* afterwards, life is better than ever, sex is better than ever, etc., despite what you will hear. Yes, you will hear it, and for a select number of women, this seems to be true.

For many other women, this is very far from the case.

I know, I hear from them everyday, and have been hearing from them for the last four years. I am also one of them.

I had all my female organs removed 4 years ago, at the age of 36, due to endometriosis, painful adhesions, recurrent painful ovarian cysts, and chronic pelvic pain.

I was at peace with the decision of tah/bso, all other treatments to eradicate pain and slow the disease had failed, my quality of life was seriously suffering.

I was not prepared for the multitude of complex endocrine related changes that would take place within my body, and the endocrine related health problems that would follow. The aftermath of ovarian removal has been as devastating to my health as the endometriosis was. I would not have changed my decision to have a tah/bso, even if I had known of the possible consequences of ovarian removal, but it sure would have been nice to know! No one even hinted at what would follow.

Organ removal (ovaries) is serious and permanent. Once the ovaries are removed and your body no longer can produce it's own natural hormones, there can be serious consequences to health and finding effective, low side effect hormone replacement can be extremely challenging, at best. even though I am free of the endo pain,I have ended up with health problems and challenges that have been equally as difficult and painful as the endo was (severe hormone loss when the ovaries are removed at a younger age, fibromyalgia, weight gain, low sex drive, severe fatigue, joint pain,etc.)

Women suffer in many ways after removal of their female organs, some do fine, some develop many problems it is not in their head, it is a true physiological response to hormone loss and sometimes even hormone disruptions, hormones produced in the body of both women and men affect every cell in the body. Women go back to doctors after hysterectomy with and without removal of the ovaries presenting with clear hormone loss/disruption symptoms and health problems, only to often be told it is in their head, or given anti depressants, or the ever popular synthetic hormones which are often not effective and come along with many negative side effects of their own, it is truly a disgrace in this age of medical advancement. That is the reason I have spent every single day of the last four years answering emails and working to raise awareness, perhaps when men speak up and out about the negative effects that this often life changing surgery has had on their partners and family, perhaps then those in a position to effect change will listen.

Respectfully, Jeannah McElroy Hysterectomy Awareness http://www.hysterectomyawareness.com

-- Jeannah McElroy, August 21, 2001

 

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