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PSYC 207 > 2-Medical interventions, medicolegal stuff and yah > Flashcards

2-Medical interventions, medicolegal stuff and yah Flashcards

1
Q

from when is gestational age calculated?

A

the first day of your last period

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2
Q

by the due date, the majority of people has ___ given birth spontaneously

A

NOT!!!

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3
Q

multiparous

A

HAS birthed before
gives birth faster

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4
Q

nulliparous

A

has NEVER birthed before
gives birth slower

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5
Q

due date

A

280 days (40 weeks) from the first day of the last menstrual period
10 lunar months

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6
Q

term pregnancy

A

between 37-42 weeks (“window”)

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7
Q

pre-term

A

before full 37 weeks of pregnancy

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8
Q

post-term

A

after 42 weeks of pregnancy

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9
Q

when is membrane sweeping offered?

A

commencing at 38 to 41 weeks
medical guideline

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10
Q

when is induction offered and why?

A

41+0 to 42+0 weeks
medical guidelines
done because present evidence reveals a decrease in perinatal mortality with induction

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11
Q

in practice, when is formal induction performed?

A

41 weeks + 3 days of preganancy if labour hasn’t started yet on its own

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12
Q

membrane sweeping

A

AKA “membrane stripping”, “stretch and sweep”

  • rationale: presumed to cause the release of ENDOGENOUS PROSTAGLANDINS from the adjacent membranes and cervix
  • invasive procedure
  • risk because touching the baby’s head
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13
Q

prostaglandins

A

hormone-like lipid compounds that are known to play a partial role in the initiation of labour

related to membrane sweeping

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14
Q

do we actually know what causes labour?

A

nope

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15
Q

pros of membrane sweeping

A
  • may decrease the length of pregnancy (1-4 days on average)
  • may reduce the rate of formal medical induction…. BUT to avoid one formal, sweeping of membranes must be performed in 8 women
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16
Q

cons of membrane sweeping

A
  • can be very painful (7 on a scale of 1 to 10)
  • can cause BLEEDING or IRREGULAR contractions
  • in 1/10 women leads to rupture of the amniotic sac (“water breaking”) which then leads to formal induction within 24 hours according to current medical guidelines
  • sometimes done WITHOUT CONSENT, during a vaginal/cervical exam at the end of pregnancy
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17
Q

effectivity of routine sweeping

A

routine sweeping from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits

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18
Q

most common methods for induction of labour

A
  • artificial oxytocin (Pitocin), IV drip
  • prostaglandins (and vaginal misoprostol)
  • mechanical methods (balloon catheters, amniotomy, etc.)
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19
Q

artificial oxytocin

A
  • type of induction of labour
  • Pitocin, IV drip
  • currently recommended and most commonly used method
  • involves continuous oxytocin administration throughout labour and after delivery
  • but… doesn’t always work
  • causes stronger contractions!!
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20
Q

prostaglandins (and vaginal misoprostol)

A
  • type of induction of labour
  • gel in vaginal opening and cervix
  • more effective than oxytocin in bringing about vaginal delivery within 24 hours
  • but… more likely than oxytocin to cause UTERINE HYPERSTIMULATION
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21
Q

uterine hyperstimulation and why it can be dangerous

A
  • uterus contracting TOO STRONGLY
  • is dangerous for previous C-sections since it can cause the scar to OPEN UP
  • prostaglandins can cause this
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22
Q

mechanical methods of induction of labour

A
  • balloons catheters, amniotomy, etc.
  • reduced uterine hyper stimulation compared to prostaglandins
  • increased maternal and neonatal infectious compared to prostaglandins and artificial oxytocin
  • more rare compared to the others
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23
Q

what is the rationale for performing induction after 41 weeks?

A

increased risk of STILLBIRTH compared to 40 weeks
there’s an increase of 30%
but… remember the BACKGROUND RISK: the probability of stillbirth in general
(you just need to know the general idea of this)

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24
Q

base rate

A

the general, UNCONDITIONED probability of something (prior probability)

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25
Q

base rate neglect

A

when present with specific info (conditional probabilities, specific risks) we tend to ignore the relevant general information (unconditioned probabilities, background risks)

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26
Q

The representativeness heuristic

A

The heuristic is based on automatic attribute substitution: representativeness = likelihood of occurrence
(i.e., more representative = more likely to occur)
- It can result in neglect of relevant base rates
- a prototype or mental model is activated by the representative individual or event
- alternative mental models are not activated or are suppressed

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27
Q

Representative outcomes that serve as prototypes of events during childbirth:

A

lack of modern medical intervention leads to a dead baby/mother
- modern medical interventions lead to a healthy baby being born to a healthy mother

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28
Q

The representativeness heuristic leads us to:

A
  • overestimate the risk of not intervening
  • underestimate the risk of intervening
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29
Q

Precautionary

A

Assumed unsafe until proven otherwise

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30
Q

Anti-cautionary

A

Assumed safe until proven otherwise

31
Q

Prevalence of anti-cautionary principle

A

Not unique to obstetrics
- often applies to new medical technologies and interventions in medicine as a whole
Not unique to medicine
- often applies to new technologies in society as a whole
Within medicine, it is linked to medical reversals

32
Q

Some medical reversals from modern obstetrics

A
  • routine X-rays for pregnant women (found to cause cancer)
  • Thalidomide for pregnancy nausea (found to cause severe birth defects)
  • routine pubic area shaving (found to cause infection rather than prevent it)
  • routine episiotomy (found to cause tearing rather than prevent it)
33
Q

Childbirth circa 1960

A
  • Heavy sedation
  • Routine enema & shave prep
  • “Sterile” environment
  • “Prophylactic” forceps
  • Routine episiotomy
  • Delivery in operating room
  • Litothomy position (supine, legs in stirrups)
34
Q

augmentation of labour meaning

A

when labour has happened SPONTANEOUSLY… but you’re not dilating fast enough

35
Q

benefits of not clamping the umbilical cord immediately?

A
  • baby stays connected to the placenta
  • continues to receive blood and oxygen
  • enables the gradual transition to breathing bc your lungs are squished when you’re first born
36
Q

Representativeness

A

the degree to which:
- an individual matches the prototype of a category/group
- an event matches the prototype of the kind of events a process tends to generate

37
Q

when does the biggest transformation in the umbilical cord happen?

A

in the first few minutes right after the birth

38
Q

Wharton’s Jelly

A

a gelatinous substance within the umbilical cord (also present in vitreous humor of the eyeball)

39
Q

umbilical cord

A
  • protects and insulates umbilical blood vessels
  • Changes its structure with cooler temperature (compared to body)
  • Provides a physiological clamping action, slowing the flow of blood
  • Contains stem cells and may have yet unknown benefits
40
Q

how can stem cells in the umbilical cord be used

A
  • create adult stem cells including neural cells in rats (Mitchell et al., 2003)
  • treat brain damage in mice effectively (Cheng et al., 2015)
41
Q

Delayed cord clamping (1-3 minutes) vs immediate (<60 sec):

A
  • increase in blood volume of the newborn (20-30%)
  • increase in red cell volume (50%)
  • higher birth weight (mean increase 101 grams)
  • fewer infants iron deficient (at 3-6 months, 50% decrease)
42
Q

Placental transfusion

A

Not passive or influenced by gravity: even when baby is held above placenta, transfusion still occurs

43
Q

historically, what would midwives do regarding the umbilical cord?

A

Historically, midwives would wait until the cord stops pulsating until they do anything to it

Aristotle and Hippocrates wrote approvingly of midwives’ practice of waiting until the cord stops pulsating

44
Q

when do the first records for immediate cord clamping date back to?

A

late 1600s (probably don’t need to know the date tbh)

45
Q

early explanations for the practice of cord clamping

A
  • to avoid blood loss from the baby before physiological closure of the umbilical vessels
  • to “spare the bed linen” from being soiled by placental blood leaking from the cut end of the cord

but… ’[the] common method of tying and cutting the navel string in the instant the child is born… has nothing to plead in its favour but custom”

46
Q

Erasmus Darwin opinion about early cord clamping

A

1800s!
“a very injurious thing”
left babies “much weaker than [they] ought to be”

47
Q

use of chloroform during childbirth

A
  • early 20th century interventions in childgirth
  • general anesthesia with chloroform during childbirth (Stage 2)
  • chloroform passed through the umbilical cord to the baby, with the potential to cause profound respiratory depression
  • cord immediately clamped and cut to prevent the baby from receiving any more of the chloroform
48
Q

cord clamping

A

1960s: Became “the standard of care” in obstetrics
Promoted as a tool to prevent postpartum hemorrhage

49
Q

The standard of care

A
  • a person practicing obstetrics is charged with the responsibility of practicing within the standard of care
  • failing to do so may establish the basis of litigation
  • defined as those acts performed by a reasonably prudent practitioner
  • influenced by the Clinical Practice Guidelines issued by each country’s professional society (e.g., The Society of Obstetricians and Gynecologists of Canada)
50
Q

active management of the third stage of labour

A
  • as opposed to watching and waiting to see what happens… you do this REGARDLESS
  • is an interventionist package of care
  • described it as the “cornerstone” of obstetric and midwifery practice
  • goal is to LIMIT POSTPARTUM HEMORRHAGE
51
Q

triad of interventions during active management of the third stage of labour

A
  1. administration of a PROPHYLACTIC UTEROTONIC DRUG (Pitocin)
    - induce contractility of the uterus
    - make the placenta separate from he uterine wall quicker
  2. early cord clamping and cutting
  3. controlled traction of the umbilical cord
    - pulling on the cord while applying counter pressure to help deliver the placenta
    - helps it come out sooner!!
    - can cause postpartum hemorrhage…
    - capillaries are likely to be fractured
52
Q

statistic evidence on the triad of interventions during active management of the third stage of labour

A
  • immediate cord clamping DOES NOT decrease postpartum hemorrhage rates
  • cord traction may not be important
  • giving uterotonic might be the only intervention in the active management of stage 3 that is associated with reduced hemorrhage but:
    - the quality of the evidence is generally low
    - more data/research are needed
53
Q

effects of early cord cutting on baby

A
  • can lead to iron deficiency anemia in babies
  • in premature infants, can lead to intraventricular hemorrhage… Bleeding in brain!!
54
Q

WHO, UK, and Canadian guidelines for umbilical cord clamping

A

WHO Recommendation
- Delay of umbilical cord clamping for 1–3 minutes
UK Guidelines
- Delay clamping the umbilical cord earlier than necessary
- (unless exigent circumstances such as heavy maternal blood loss or the need for immediate neonatal resuscitation take priority)
Canadian Guidelines
- The risk of jaundice is weighed against the physiological benefits of delayed cord clamping.

55
Q

Delayed cord clamping (1-3 minutes) vs immediate (<60 sec) on clinical jaundice

A

doesn’t increase the risk of clinical jaundice, but increases the percentage of infants who need phototherapy (simulating the sunlight) for it
(from 2.74% to 4.36%)

56
Q

clinical jaundice

A

Infant jaundice is yellow discoloration of a newborn baby’s skin and eyes.

57
Q

Biases in how medical practice (standards of care) change

A
  • Easier to change in the direction of doing (makes reversals common)
  • Harder to change in the direction of not doing
  • Clinical articles are much more likely to examine new possible medical practices than an already existing standard of care
  • The percentage of reversal among articles testing standard of care was 40%
58
Q

Medical knowledge

A
  • mostly procedural
  • some semantic
  • semantic knowledge serves the procedural knowledge
    - explains why certain practices are adopted and others are not
59
Q

scientific knowledge

A
  • mostly semantic (our models of the world)
  • some procedural
  • procedural knowledge serves the semantic knowledge
    - prescribes what we should do to update and improve the semantic knowledge
60
Q

evidence-practice gap

A

It takes a long time for science to influence medical practice and it only does so partially

61
Q

Archie Cochrane


A
  • scottish doctor
  • criticized the lack of reliable evidence behind many of the commonly accepted healthcare interventions
  • advocated for the use of randomized control trials to make medicine more effective and efficient
  • led to the development of the Cochrane Library database of systematic reviews
  • helped lay the foundation for evidence-based medicine
62
Q

conclusions from Cochrane Systematic Review about interventions

A

conclude that there is insufficient evidence to endorse the interventions they examine

63
Q

Semantic (declarative) knowledge

A
  • Forms and changes based on the ‘evidence’ we are exposed to (the evidence could be biased or faulty)
64
Q

Procedural knowledge

A

Forms and changes based on
- what we frequently do (habits)
- the system of incentives and disincentives (rewards and punishments) that are part of our environment

65
Q

Systems of incentives and disincentives

that influence the practice of obstetrics

A
  • Personal
  • Professional
    - duty of care
    - financial (procedure = $$$)
    - medico-legal
66
Q

duty of care

A
  • an obligation to benefit one’s patients medically
  • hippocratic oath!
67
Q

medico-legal systems of incentives and disincentives

A

litigation pressures
- fears of getting sued

insurance policies
- dictates what gets done during childbirth

68
Q

The odds of lawsuits and their outcomes

A
  • Most lawsuits don’t go to trial. Only a fraction do. The rest are settled out of court or dismissed.
  • Of those lawsuits that do go to trial, an overwhelming majority are resolved in the Ob/Gyn’s favour.
  • Overall, the risk of ‘losing’ the lawsuit are very small for the physician
69
Q

Negative impacts of lawsuits on Ob/Gyns

A
  • More than half of Ob/Gyns say that their thinking and actions are continuously affected by the threat of lawsuits
  • More than half describe being sued as an extremely negative experience
  • More than a third agreed that “I no longer trust patients, I treat them different” and in some cases also lost trust in their colleagues and organizations
70
Q

when do we do studies on practices?

A
  • only after they have been widely adopted… this is a problem
  • even when studies are conducted early one, what they actually measure can only be PART of the problem… surrogate outcomes, rather than end points because its simpler and faster
71
Q

Why does the evidence for a certain medical practice change–and continue to change–over time?

A

○ Diseases can change over time

72
Q

past medical education vs the focus that is needed?

A

past (and kinda present) is mostly just MEMORIZATION!!

  • Teaching critical thinking has become central to the curriculum for doctors and other health professionals
  • Much greater focus on the need for evidence-based practice
73
Q

effect of C-section on the baby

A

In a C-section the baby has little warning that its peaceful world is going to change
Without the preparation of labour, birth is abrupt

74
Q

when is it most difficult for the birthing person during a C-section?

A
  • after the baby has been delivered
  • no longer anticipation to see the baby born

PSYC 207 (9 decks)

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