Lecture 16

Question 1

What does the non-heartbeat related belt measure in EFM?how does it work?

Answer 1

This indicates the pressure that the contracting uterus is putting on the device sitting on top of the uterus. When the uterus contracts it also expands and this expansion puts pressure on the device.

Question 2

LOOK AT DIAGRAM ON SLIDE 4

Question 3

How do you determine whether there is something of concern relating to the heartbeat in EFM? How about the pressure?

Answer 3

whether there is something of concern relating to the heartbeat depends on when the peak is. As a practitioner you have to make a judgement call about hich of these 3 categories the heartbeat falls into.

she just wants us to understand how subjective these judgement calls are

contractions affect the baby’s heartbeat as well. May make the heartbeat slow down

Question 4

What is acceleration in EFM?

Answer 4

an abrupt increse in heartrate from baseline. can occur any time during labour

Reassuring sign of fetal well-being

Question 5

What is variable deacceleration in EFM?

Answer 5

an abrupt decrease in heartrate from baseline

onset varies with contractions

extremely common , present in 83% of labours

Question 6

What is late deacceleration in EFM?

Answer 6

gradual, symmetrical decrease in heart rate

HR returns to baseline after contraction ends
onset occurs at the peak of contractions

may indicate fetal distress if repetitive or severe.

Question 7

What are the downsides to using EFM as a fetal surveillance technology?

Answer 7

interpretations of fetal heart tracings are highly subjective

there is very little agreement among experts as to the interpretation of “non-reassuring” tracings

“false-positive” predictions of fetal distress are a given (>99%)

using it increases C-section rates, without improving outcomes for babies

the big danger with relying on this is that babies move a lot and the movement will require someone to go and adjust the belt and if the baby is moving a lot then it will look like there’s more dacceleration because the baby is moving. So a judgement call you have ot make is the deacceleration due to the pick up of due to the baby’s actually heartbeat.

Question 8

What is EFM a good tool for detecting? What is it not good at detecting?

Answer 8

this tool is really reliable to detect wellbeing but it is a very bad tool to detect fetal distress. When you are trying to interpret the non-reassuring signas, this is where the huge variability in judgement occurs

Question 9

Why was EFM originally introduced? Did this turn out to be true?

Answer 9

people introduced this promising that it would reduce the rates of cerebral paulsy but this was a hollow promise. the c section rates have increased but the cerebral paulsy rates are unchanged.

Question 10

What are EFM records usually used for?

Answer 10

brain injury litigation

used by expert witnesses who testify as to when (the exact moment, based on the tracings) the baby sustained irreversible neurological injury (this is the main way of assigning blame to the person who is being attacked)

it is the main tool of blame

is heavily relied upon to support counterfactual claims that a poor outcome (e.g., brain injury) could have been avoided

The counterfactual claims are supported by the EFM

in addition to people becoming worried about false c sections, the litigation lead to c sections going up and up.

Question 11

What is counterfactual reasoning? What is it the basis of?

Answer 11

• reasoning about “what might have been”
  AKA if you did do a c section, then the baby might not have had brain damage
• relies on counterfactuals: mental representations of alternatives to the past, often activated automatically in response to negative affect
• the basis for assigning blame for harmful outcomes or giving credit for beneficial out comes

Question 12

What form does counterfactual reasonign often take?

Answer 12

• often takes the form of if/then statements or questions

e.g.:“If you had been paying attention, you wouldn’t have gotten hurt.”

“If Alice had not been treated with the experimental drug, would she have survived?”

Question 12

is counterfactual reasoning deliberate?

Answer 12

you can reason counterfactual deliberately but a lot of counterfactual is reasoned automatically. AKA if I had only walked to school instead of boiked, I wouldn;t have been in the hospital right now.

Question 13

Why can counterfactual reasoning be highly problematic?

Answer 13

• could be highly problematic because of hindsight bias

Question 14

What is hindsight bias? what is hindsight bias linked to? What is it accompanied by? is it easy to ignore?

Answer 14

• the “knew-it-all-along” effect

THis is a false perception of how much we would have known, or should have known. in the past

• knowing that an event (outcome) has occurred increases its perceived predictability (or perceived likelihood)

meaning this is hard to ignore

knowing that you got into a car accident you may say, I should have knoen that was a bus rooute. This incKnowing that something happened increases the perceived predictabillity of that event.

• linked to the availability heuristic
• accompanied with over-confidence in the certainty of one’s judgements: people are unaware of the effect that outcome knowledge has on their perceptions of predictability

Question 15

What kind of explanations evoke greater hindsight bias?

Answer 15

• simple causal explanations evoke greater hindsight bias than complex causal explanations and causal ambiguity

When we have some kind of explanation with a simple causal nature like this happened which made this happened, it evokes greater hindsight bias than causal explanations because its harder to argue what someone should have done if we know that we don’t really know.

Question 16

What is the Myth of cerebral Palsy? (8 things)

Answer 16

• Rarely due to “birth asphyxia” (estimated ~ 2% of CP cases)
• Most acute severe hypoxia follow intrapartum hypoxic events (e.g., cord prolapse, uterine rupture, placental abruption)
• CP’s causes are not well understood but most are thought to precede labour and birth (genetic, inflammatory, preterm)
• Medico-legal climate encourages blame of the insured

(20% of UK maternity budget is spent on litigation; $300+ million in settlements/year in Australia)

• Major cause of caesarean escalation
• No association of elective or emergency caesarean with CP outcomes
• CP incidence the same in western and resource-poor settings (e.g., India)

Question 17

does c section do anything to help cerebral palsy rates?

Answer 17

C section doesn’t do anything to help cerebral paulsy rates

Question 18

How is the c section rate connected to the myth of cerebral palsy?

Answer 18

One of the reasons that the c sectiosn are goign on is because of that myth. Parents have to spend a lot of money to take care of these kids with cerebral paulsy. Lawyers will often go after the person that is insured so the blame is placed on he health care providers because it helps the fmaily get money.

Question 19

Why does the cerebral palsy myth exist in the legal system?

Answer 19

THe reason the myth exists is because the legal profession is even slower to accept science than the medical profession

Question 20

What do we consider child mortality?

Answer 20

child mortality is the nnumber of deaths occuring in children under 5 years old divided by all the children in that country.

Question 21

Why is the answer that you give to the question “why” so important? Give an example.

Answer 21

when you ask why, the answer you give is really important because it has a lot of financial implications and determines where funding goes.

Places like Unicef focus our attention on the time period around birth to tell us that is where the biggest danger is. They say the day of birth is really dangerous and the first week is really dangerous too. Spoiler alert, one of the things the UN has to do is to raise money and this is bascially what they’re trying to do. A lot of the countries they are trying to get money from don’t want to give money away so they have to elicit some empathy and concern in order to get some funding.

Question 22

Look at the graph on slide 15

What is the embrella term that encompasses stillbirth and neonatal mortality?

Answer 22

perinatal mortality

Question 23

what is intrapartum mortality?

Answer 23

the number of babies dying during labour or birth

Question 24

What does perinatal mean?

Answer 24

aroudn the time of birth

Question 25

how de we define neonatal mortality?

Answer 25

neonatal mortality is the first month of birth. This means it could be related to somehting that happens after childbirth

Question 26

The idea that we can reduce neonatal mortality in developing countries by providing better medical care around the time of birth is
a) strongly supported by the scientific evidence
b) not based on scientific evidence
a) Yes
c) contradicted by the scientific evidence

Answer 26

B

Question 27

Is there a difference in neonatal mortality for home vs hospital births in the following countries?

Pakistan
Malawi and Zambia
Indonesia
Tnazania
Bangladesh
Vietnam

Answer 27

Pakistan no difference
Malawi and Zambia no difference
Indonesia Higher in hospital
Tnazania No difference
Bangladesh higher in hospital
Vietnam higher at home

Question 28

What do we know about fund raising for improving medical care with the hopes of improving neonatal mortality?

Answer 28

money that has been raised for improving medical care is helping to reduce child mortality but neonatal mortality is staying prety stable

Question 29

What percentage of neonatal deaths do small newborn babies account for?

Answer 29

Small newborn babies account for >80% of neonatal deaths

Question 30

What might small size at birth be due to? How might mother nutrition factor into this?

Answer 30

Small size at birth may be due to being * born preterm (<37 weeks)
* small-for-gestational age
* both of the above

mother nutrition and stress may be an indicator of neonatal mortality. The causes may preceed what you’re trying to do.

Question 31

What is an example of a simple model for understanding how to reduce neonatal mortality?

Answer 31

A simple model with a simple solution
- complications of pre-term birth infections, hypoxia,
- is the cause of babies who die during birth
- solution: provide medical care

Question 32

What does proximal mean?

Answer 32

\proximal means close in time and close in causality to what you’re trying to avoid.

Question 33

Look at the schematic on slide 18

Question 34

What are the societal factors that lead to neonatal mortality? complications during birth? Result?

Why is it important to look beyond the proximal cause of complications?

Answer 34

Societal:
- status of women
- conflict (war)
- dictatorships
- famine

Individual Factors:
- Malnutrition
- birth spacing
-poverty
- physical wellbeing
- psychological well-being
-education

complications:
- preterm birth
- infections
-hypoxia

Result:
cause babies to die during birth

important to look beyond proximal causes because we may be able to create solutions to prevent the larger issue contributing to the proximal cause.