The American College of Obstetricians and Gynecologists has loosened up its recommendations regarding women who've previously given birth via ceserean section but want to deliver vaginally the next time around.

As the WSJ reports, now women who have already had two C-sections and those who are pregnant with twins following a C-section delivery are candidates for so-called VBACs, so long as their operations included a low-on-the-abdomen, horizontal incision.

While ACOG still recommends that women attempt vaginal delivery only if they're in a facility that has "staff immediately available to provide emergency care," the group says that if those resources aren't available the woman should "be allowed to accept increased levels of risk" if they are informed about the potential dangers and availability of facilities and staff. There are risks associated with all variations of childbirth, including vaginal birth and C-section.

Will the guidelines do anything to budge the C-section rate, which stood at more than 31% in 2007, according to ACOG? After the last set of guidelines were released, that same "immediately available" language led some hospitals to refuse to allow women with a history of C-section to make an attempt at delivering vaginally by allowing labor to progress.

William Grobman, a co-author of the guidelines and an associate professor of obstetrics and gynecology at Northwestern University's medical school, says that's the wrong question to ask. "We are culturally very focused on outcomes -- the C-section rate, the VBAC rate," he tells the Health Blog. "But we aren't trying to achieve arbitrary rates. There's as much focus on process as there is on outcomes," he says, which is why the guidelines emphasize "autonomy, shared decisionmaking and the provision of information."

If there were a metric to track, says Grobman, it would be the percentage of medical charts that show "there was a clear discussion about the risks and benefits" of an attempt at labor by women with a history of C-section.

He says it's not clear how many women have wanted a VBAC but have been unable to get it due to hospital or physician policy, but that there were enough people speaking out at a recent NIH consensus conference on the topic to suggest "it's a problem of some importance."

Grobman says the new clinical guidelines won't be "the start and finish" of a shift in physician behavior and hospital policies, since those things are also shaped by personal experience and professional liability concerns. "That being said, there's no doubt the guidelines are an important foundation," he says.

Perhaps you've heard stories in the media about mix-ups at fertility clinics where the identities of the parents of embryos become uncertain due to mislabeling of sperm, eggs, or resulting embryos. Statistically, these mishaps are rare, but you can imagine what a nightmare it is for the patients as well as the medical practitioners when mistakes do happen.

A new software technology is helping to reduce the risk of laboratory errors in infertility treatment, by electronically identifying the sperm, eggs, resulting embryos and other materials used in in vitro fertilization (IVF) treatment cycles. Non-invasive Radio Frequency Identification (RFID) can track a patient's sperm, eggs and embryos during the course of treatment. If the wrong material is introduced in the lab environment, RFID alerts the staff, via visual and audible signals, to help prevent mislabeling of any materials.

RFID tags contain a microchip that acts as a unique digital fingerprint, safely identifies samples at the outset and tracks them through the fertilization process. Each patient is given an RFID identity card, with a unique identification, that are used with all sample materials for that patient, including Petri dishes and test tubes used in a patient's treatment cycle. The entire system is electronically managed. By creating an automated system to minimize the chance for mix up, RFID safeguards the infertility treatment process and gives patients peace of mind.

Some fertility practices in the US and UK have already installed RFID. Since launching this new technology last year, over 20,000 infertility treatment cycles have employed RFID to ensure the safety and security of patients' genetic material.

The American Society for Reproductive Medicine (ASRM) recently pledged to work with patient groups, policy makers and other stakeholders to develop systems to reduce the risk of errors.

Childbirth is an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may be doing more harm than good.

As the number one cause of hospital admissions, childbirth accounts for more than $79 billion in hospital charges alone. Pregnancy is the most expensive condition for both private insurers and Medicaid.

The financial toll of maternity care on private insurers (employers) and Medicaid (taxpayers) is huge. Maternity care therefore plays a considerable role in escalating healthcare costs, which increasingly threaten the financial stability of families, employers, and federal and state budgets.

Cesareans Out of Control

The cesarean rate in the U.S. is higher than in most other developed nations. And in spite of a standing government goal of reducing such deliveries, the U.S. has set a new record every year for more than a decade. Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.

Among privately insured patients, uncomplicated cesareans run about $13,000. nearly twice as much as a comparable vaginal birth. Cesareans account for a disproportionate amount (45%) of delivery costs.

The problem, experts say, is that the cesarean -- delivery via uterine incision -- exposes a woman to the risk of infection, blood clots and other serious problems. Cesareans also have been shown to increase premature births and the need for intensive care for newborns.The typical American newborn is delivered at 39 weeks, down from the full 40. Even without such complications, cesareans result in longer hospital stays.

Oxytocin Induction Adds Risk

Inducing childbirth -- bringing on or hastening labor with the drug oxytocin, also raises the risk of complications that lead to cesareans. Experts say miscalculations often result in the delivery of infants who are too young to breathe on their own.

Despite of or perhaps because of all this intervention, childbirth in the U.S. doesn't measure up. The U.S. lags behind other developed nations on key performance indicators including infant mortality and birth weight. More intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions

Informed Mothers must Fight the System

If an expectant mother has had a cesarean with her first baby, she will have a difficult time holding out for a vaginal birth with her second one. With a toddler underfoot, most mom's would opt for vaginal delivery if for no other reason than faster recovery. But finding a physician to deliver her second child by vaginal delivery will be difficult.

Most U.S. physicians discourage vaginal deliveries after a cesarean because of some widely publicized cases several years ago in which the uterus split disastrously along the prior incision. The modern C-section in the United States is the low transverse, an incision in the bottom part of the uterus, from side to side. Those heal better. All the studies say, in those types of incisions, the risk is less than 1%, probably a half percent that it will open during labor. Doctor's will insist on a C-section again for the second birth because of a 1% chance of a uterine rupture.

Over time, Cesarean births have become a profit center in many hospitals, There's a wide variation in cesarean rates among hospitals: cesareans range from 16% to 62% of births. There's no justification for that kind of variation. That means a lot of women are getting unnecessary cesareans.

Back in February 2007, I wrote that the state of Texas was mandating that all 6th grade girls be vaccinated with Gardasil, the Merck HPV vaccine, that promises to reduce the incidence of cervical cancer in Texas by 70% within a generation. I applauded Gov. Rick Perry for getting out ahead of the curve with his bold public health policy mandate.

In short order, the press questioned Perry's motivation when it disclosed that Merck (who manufactures Gardasil) had donated a total of $10,000 to Perry and eight Texas lawmakers. Then a groundswell of complaints were raised by concerned parents. Some resented the mandated HPV vaccine treatment as contrary to their religious beliefs. Others voiced fears that their daughters might become promiscuous if the fear of cervical cancer was removed. The volume of complaints was surprising even after Perry explained that parents already had the option to opt out of the mandate on an individual basis if they wished.

At the end of April, the Texas legislature approved a bill that prevents mandatory vaccination for school girls for 4 years. Perry can veto, but the legislature would likely override his veto due to the overwhelming numbers in favor of the delay.

In next 4 years, over 6,000 new cases of cervical cancer will be diagnosed in Texas and over 1,500 Texas women will die of the disease.

Bladder infections infect women 400% more often than men. E. coli bacteria causes virtually all urinary tract infections in the bladder. It's a pesky infection to get rid of. More often than not, the infection returns after antibiotic treatment. Repeated antibiotic use is expensive, can cause liver and kidney damage, and could lead to antibiotic-resistant bacteria, so a successful treatment would be welcomed.

Researchers* at Duke University found that some bacteria hide in tiny niches in the baldder lining, where the antibiotics can't get at them. They come out again and multipy a few weeks after antibiotic treatment. But forskolin, an extract of the coleus plant, flushes out the imbedeed E-Coli colonies from their hiding places and into the urine, where the antibiotic kills them. Forskolin has been used for centuries to treat a wide variety of symptoms including urination pain. Forskolin, a common herbal treatment, is available in health food stores.

* Soman Abraham, Ph.D. a microbiologist at Duke University published the results April 8, 2007, in the Journal Nature Medicine.

At least 25 percent of women suffer from uterine fibroids and as many as 77 percent of women may actually have the condition but be unaware of it, according to the U.S. National Institutes of Health. Although the tumors are benign, there are several uncomfortable and often very painful symptoms such as heavy bleeding, frequent urination, cramping and painful periods. Traditionally, treatment options have included some rather expensive hormonal treatments or even invasive surgical procedures like hysterectomies and myomectomies.

The MRI Imaging of Georgia is a medical center that now offers a non invasive outpatient treatment option for the ablatement or the breakdown of uterine fibroids. The procedure itself is performed with a Magnetic Resonance guided Focused Ultrasound device designed specifically for treating uterine fibroids. The procedure offers significant improvement in quality of life for patients as it preserves the uterus and the cervix. Menstrual bleeding and urinary dysfunction are also greatly improved.
Using a magnetic resonance (MR) scanner, the device enables the physician to determine the level of heating and further to track the progress of treatment both during and after the treatment. In addition it allows the doctor to distinguish between treated and untreated tissue and to recognize the three-dimensional boundaries of the fibroid itself and the surrounding organs with exact precision.

During the procedure, the ultrasound waves break the tumor down while the patient lies inside the scanner, which precisely targets the affected tissue. The heat of the ultrasound waves ablates the tumor and the process can be repeated as many times as is needed until the fibroid is completely broken down. As part of a natural process the patient’s body eliminates the unwanted tissue.

On average the treatment is found to last approximately 3-4 hours depending on the size of the tumor. Typically patients are able to return to normal activities within one to two days and report relief from symptoms within 3 months, depending on the size of the original tumor.

A high level of vitamin D in the blood can reduce breast cancer risk by half. Edward Gorham, a professor of family and preventive medicine at the Moores UCSD Cancer Center, and colleagues analyzed data from two previous studies on the response to vitamin D among 1,760 people. The researchers divided participants into five groups based on vitamin D levels. The study found that participants with the lowest vitamin D levels had the highest incidence of breast cancer, while breast cancer incidence among participants who took 2,000 international units of vitamin D daily decreased by half.

The researchers recommend that people take 2,000 IUs of vitamin D daily.

Vitamin D and breast cancer, Journal of Steroid Biochemistry and Molecular Biology

Despite FDA's recent approval (November 2006) of silicone breast implants, there still are considerable risks that women must consider before walking into the operating room. The FDA approval stipulates that the manufacturers inform women that the implants are not lifetime devices and that most recipients will need at least one additional surgery to replace or remove their implants. In addition, women also will need to receive magnetic resonance imaging every two to three years to ensure the implants are not leaking.

The medical community does not have a clear picture of how many women have become sick due to a leaking implant. Silicone that leaks into the lymph nodes poses greater risks than leaking saline. Requiring silicone manufacturers to conduct a study on the implants long-term effects after the approval is the greatest indicator that the FDA has proceeded too quickly. Women considering the implants need to be fully aware of the lack of data showing these implants are safe.

Texas Gov. Rick Perry (R) signed an executive order mandating that girls entering the sixth grade receive a human papillomavirus vaccine beginning in September 2008. Merck's HPV vaccine Gardasil and GlaxoSmithKline's HPV vaccine Cervarix in clinical trials have been shown to be 100% effective in preventing infection with HPV strains 16 and 18, which together cause about 70% of cervical cancer cases.

Perry said that parents who do not want their daughters to receive an HPV vaccine "for reasons of conscience, including religious beliefs," will be able to opt out of the requirement. Last year, 1,169 new cervical cancer cases were reported and about 400 women in Texas died from the disease.

Study after study has confirmed that regular exercise, combined with modest weight loss and a healthy diet, can lower type 2 diabetes risk and improve outcomes once people have the disease. In one of the most persuasive, researchers from the Diabetes Prevention Program Research Group concluded that diet and regular exercise were more effective than one of the most widely prescribed drug treatments for preventing type 2 diabetes

Yet, only 39% of surveyed adults with diabetes engaged in regular physical activity, compared with 58% of adults who did not have the disease, according to a report in the February issue of Diabetes Care. And activity levels declined as risk factors for type 2 diabetes increased.

It's not surprising to find that those with diabetes were more sedentary than the general public, but it's particularly troubling to see so few at-risk people were physically active. It's difficult to be optimistic about addressing the twin epidemics of obesity and diabetes. The best way to prevent type 2 diabetes is to prevent obesity, but it is really hard to exercise once you are obese.

Cervical cancer could be virtually eliminated if all females used the vaccine against the sexually transmitted Human Papillomavirus (HPV), the virus that causes cervical cancer. In June 2006 the FDA gave the go ahead to use the vaccine in females aged 9 to 26. Another HPV vaccine is due to come before the FDA for approval this year.

The types of HPV that the vaccines protect against account for 70 per cent of cervical cancer cases, so it is still important to push for screening to catch the other 30 per cent. Also, screening will be important for those women who may already have been exposed to the HPV types target by the vaccines, and for women who for whatever reason do not get vaccinated.

HPV is the most common sexually transmitted disease in America, where 6 million cases are diagnosed annually. The number of women in 2006 that will have been diagnosed with cervical cancer is estimated by the American Cancer Society (ACS) to reach 9,710, and 3,700 will have died of it.

A study in Norway examined delivery records over a six-month period. According to the study, 5.2% of infants delivered by planned vaginal deliveries were transferred to neonatal intensive care units, compared with 9.8% of infants delivered by planned c-section. About 0.8% of the infants in the vaginal delivery group experienced lung disorders, compared with 1.6% in the c-section group.

"For the child, the stress of vaginal delivery seems superior to elective caesarean delivery in many situations," the researchers write, adding, "Therefore, we emphasize the importance of limiting planned caesarean deliveries to cases with proven benefit for the mother and/or child".

American Journal of Obstetrics and Gynecology, 16 Jan 2007

It can't be that easy. Can it? Pregnant women should take a multivitamin.

A study published in the Journal of Obstetrics and Gynaecology of Canada finds that pregnant women who take a daily multivitamin reduce the risks of having an infant born with birth defects. The researchers also found that taking a daily multivitamin reduced the chance of a fetus developing cardiovascular defects by 39%, cleft palates by 58%, brain-damaging hydrocephalus by 63%, limb deformities by 47%, neural-tube defects by 48%, and urinary-tract defects by 52%. It is unclear which vitamins and minerals are linked to the reduction in certain birth defects.

Come on ladies, take your daily multivitamin. You've got nothing to loose and everything to gain.

OB Gyn doctors, who's religious beliefs sometimes conflict with patients who demand certain services, are joining "Natural Family Planning" (NFP) centers, which "tailor" the type of care provided with the religious beliefs of the physicians. At NFP clinics, physicians teach NFP techniques -- including monitoring a woman's temperature and other signals to time intercourse to control pregnancy timing -- while "shunning" birth control, emergency contraception, intrauterine devices, sterilization, in vitro fertilization and abortion.

Advocates, say that the NFP approach provides an alternative to commonly used medicines and devices that some physicians believe can negatively effect a patient's personal life. The American College of Obstetricians and Gynecologists does not have a formal position on NFP. "If women know before selecting [NFP centers], then it's quite a legitimate thing to do and might meet the needs of many women and doctors," Anita Nelson of the University of California-Los Angeles and ACOG spokesperson, said, adding, "But if you hang out your shingle that says 'All-purpose ob-gyn' and don't offer certain services, that's false advertising." Nearly 500 physicians have registered on an Ohio-based Web site to practice NFP. However the actual number of practices that offer only NFP is unknown, according to the Post (Stein, Washington Post, 8/31). View the full Washington Post article.