Midterm 2 Material Flashcards
Explain how culture determines our worldview:
Culture determines what we are exposed to, which builds our associative memory and determines our intuitive valuations.
It also shapes our implicit model of the world subconsciously
and our explicit model of the world, consciously and subconsciously
Explain systems 1 and 2 and how what we are exposed to influences their interplay:
System 1 is a fast acting intuitive system that creates connections based on associations and emotions
System 2 is a consciously operated system that takes in information from system 1 and makes corrections based on logical reasoning.
EX: what do cows drink?
- System 1 retrieves milk based on associations to drinks and cows
- System 2 corrects the error and uses logical reasoning to determine that the correct answer is water
Evidence is really important for system 2’s functioning, that’s why what we’re exposed to influences our worldviews
- EX: childbirth in media is seen to be extremely stressful. System 1 picks up on those associations and system 2 can cite plenty of examples where it is seen to be
Explain availability heuristic and how it interacts with system 2? Also explain what Processing fluency is I don’t want this to be it’s own card
The more examples of something that can be recalled, the more frequently system 2 believes said example exists in the world.
Processing Fluency: The subjective ease at which we process information. Can influence judgements.
If something is easy to process, it is easier to recall it as having happened.
What are some problems with availability heuristics?
they can be misleading when our associative memory is biased
this is an issue when many things such as culture, expectations and desires influence availability heuristics
Explain how heuristics play a role in our interpretations of danger? Why is this important for this course?
in events where the odds of dying are less than 1/100, people usually consider this too small to be true. In this range of danger, judgements are often determined through cultural influences and emotional associations
The odds of dying when being born or giving birth are extremely low (roughly 1/1000 and 1/10,000 respectively).
How does the Council of International Organizations of Medical Sciences describe the odds of dying when being born or giving birth?
Rare and Very Rare, respectively
What are our judgements about what is safe or dangerous based/influenced by?
- Not based on statistical probabilities
- Culturally influenced
- Based on associative memory and heuristics
What is culturally motivated reasoning? What is not included in culturally dominant views of CB?
We are motivated to attribute positive outcomes to dominant cultural values and negative outcomes to non-dominant cultural values
intervention during CB is a culturally dominant value
Culturally dominant views of CB tend to avoid the biological reality of it, the dependency of newborns on their mothers and the emotionality of it.
Explain the two types of explanation motives:
Accuracy Motives:
- Priority on accurate, thorough explanations
- Leads to deeper information processing, more cognitive effort and the use of more complex thinking strategies
Directional Motives:
- Particular, directional explanations
- Leads us to try to justify a conclusion in a rational, convincing manner, undertake a biased memory search for particular beliefs and rules and access only a subset of our relevant knowledge.
Explain the graph showing the length of human pregnancy:
Very shallow increases in non-elective delivery probability until about 270 days, in which an exponential increase begins to happen. This is also where the two paths for multiparous and nulliparous women diverge, with the probability of delivery for multiparous women being slightly higher in less days. The paths for both graphs shows a plateau at around 290 days.
Define “due date”, “term pregnancy” and “pre/post-term”:
Due Date:
- 280 days, or 40 weeks from the first day of the last menstrual period.
Term Pregnancy:
- Between 37 and 42 weeks of pregnancy
Pre: before 37 weeks
Post: after 42 weeks
Explain membrane sweeping, as well as its pros and cons:
The goal of membrane sweeping is cause the release of endogenous prostaglandins from the adjacent membranes and cervix.
Offered at 38-41 weeks
(prostaglandins are hormone-like lipid compounds that are known
to play a partial role in the initiation of labor)
PROS:
- may decrease the length of pregnancy by 1-4 days on average
- May reduce the rate of formal induction
* !/8 membrane sweeps avoid formal induction*
CONS;
- Can be very painful (7/10)
- Can cause bleeding or irregular contractions
- 1/10 chance of rupturing the amniotic sac, which then leads to formal induction
- Sometimes done without consent during exams at the end of pregnancy
How many women have their labor induced manually?
Around 20-30%
Explain Formal Induction and it’s most common methods:
It is offered at 41+0 to 42+0 weeks because present evidence shows a decrease in perinatal mortality with induction.
- Performed at 41 weeks + 3 days of pregnancy if labor hasn’t started on it’s own
- Artificial Oxytocin (Pitocin), IV drip is the most common and currently recommended practice
- Continuous administration throughout and after delivery
Prostaglandins (vaginal misoprostol) are more effective in bringing about V. delivery within 24 hours, but is more likely to cause uterine hyperstimulation
Mechanical methods such as balloon catheters and amniotomy have a reduced likelihood of uterine hyperstimulation compared to prostaglandins, but have a higher chance of maternal and neonatal infections compared to prostaglandins and artificial oxytocin
Explain how the risk of induction after 41 weeks is overestimated:
The risk of still birth starting at week 36 is very small and increases every week slightly (0.36% at week 36, 2.5% at week 42)
around 500 unnecessary inductions are performed to avoid one stillbirth.
Explain the precautionary and anti-cautionary principles and the prevalence of the anti-cautionary principle:
Pre-Cautionary: Assumed unsafe until proven otherwise
Anti-Cautionary: Assumed safe until proven otherwise
- linked to medical reversals and is not linked to medicine and obstetrics
What is the purpose of the placenta?
Stays connected to the baby and continues to provide blood and oxygen.
enables the gradual transition into breathing
What is the importance of Wharton’s jelly?
protects and insulates blood vessels
provides a physiological clamping effect, slowing the flow of blood
contains stem cells and may have yet unknown benefits
Can be used to create adult stem cells, including neural cells in rats
Treat brain damage in mice effectively
Explain the history of early cord clamping:
First records date from the late 1600’s
Early explanations for the practice include…
- to avoid blood loss before physiological closure of umbilical vessels
- to spare the bed linen from being soiled by placental blood leaking from the cut end of the cord
“the common method of tying and cutting the navel string in the instant the child is born… has nothing to plead in its favor but custom”
-1773, Charles white
Why was cord clamping important during the use of chloroform?
Chloroform would get into the blood stream and to the baby, which could cause profound respiratory depression.
cord clamping was done to prevent the baby from receiving any more chloroform
Explain the Standard of Care:
Defined as those acts performed by a reasonably prudent practitioner
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
influenced by the Clinical Practice Guidelines issued by each Country’s professional society
What are the triad of interventions involved in the active management of the third stage of labor?
- Administration of a prophylactic uterotonic drug (Pitocin)
- inducing contractility of the uterus and making the placenta separate from the uterine wall quicker - early cord clamping and cutting
- controlled traction of the umbilical cord
- pulling on the cord while applying counter pressure to help deliver the placenta
The goal is to limit postpartum hemorrhage
What is the statistical evidence surrounding the triage of interventions?
Immediate cord clamping does not decrease post partum hemorrhage and cord traction may not be important
uterotonics might be the only worthwhile intervention for reducing PPH, but the evidence is generally low and more research is needed
What are the benefits of delayed cord clamping vs immediate cord clamping? (4)
- Increase in blood volume
- Increase in RBC volume
- higher birth weight (average of 101g)
- Fewer infants are iron deficient
What are 2 dangers associated with immediate cord clamping?
- iron deficiency
- in premature infants, it can lead to intraventricular hemorrhage
What is the relationship between delayed cord cutting and rates of jaundice?
It doesn’t increase the rates of jaundice, but it does increase the number of children who need phototherapy for it (2.74% - 4.36%)
What is the difference between medical and scientific knowledge?
Medical knowledge is mostly procedural while scientific knowledge is mostly semantic
Medical knowledge explains why certain practices are adopted and why some are not
Scientific knowledge prescribes what we should do to update and improve the semantic knowledge
What is the evidence-practice gap?
It takes a long time for science to influence medical practice and only does so partially
the percentage of medical reversal among articles testing standard of care was 40%
medical articles are more likely to look at new possible practices than already existing standards of care
What is the difference between semantic and procedural knowledge?
Semantic knowledge forms and changes based on evidence (could be biased or faulty)
Procedural knowledge forms and changes based on what we do and the systems of incentives and disincentives that are part of our environment
Why is Archie Cochrane important?
advocated for the use of randomized control trials to make medicine more effective and efficient
laid the foundation for evidence based medicine
Lead to the development of the Cochrane library database of systematic reviews
What is the main thing you have to know about the levels of evidence image?
Systematic reviews at the top, expert opinion at the bottom
What are the system of incentives and disincentives that influence the practice of obstetrics?
Personal
professional
- Duty of care
- Financial
- Medicolegal
- Litigation processes
- Insurance policies
What is the primary allegation for legal obstetric cases?
Neurologically impaired infants, making up 29% of all cases
How do lawsuits in obstetrics tend to play out?
most lawsuits are either settled out of court or are dismissed
Oh those that DO go to court, 75% end up in the obstetrician’s favor
risk of losing a case as an obstetrician is about 5%
How do lawsuits/the idea of a lawsuit impact obstetricians?
Over half of Ob/Gyns say their thinking and actions are continuously affected by the threats of lawsuits
more than half of them describe being sued as an extremely negative experience
more than a third agreed that they do not trust patients, that they treat them differently and have sometimes lost trust in colleagues and organizations
How are fetuses treated legaly?
Fetus is not a legal person until it is born and separated from the mother
The law may recognize that its existence began before birth for certain limited purposes, such as attracting a duty of care in negligence during delivery
Pregnant women and their unborn children are usually seen as two separate patients, of which a duty of care is both owed to
What are some problems with regarding the fetus as a second patient?
Can resort to court orders to force invasive procedures on pregnant women for the perceived benefit of the fetus
May be unconstitutional, can discriminate against people on the basis of gender.
What happened in the Georgia case?
Mother believed that whatever happened to the baby was the lord’s will
seen to have had complete placental previa, which has a 99% chance of killing the baby and a 50% chance of killing her
Mother appealed the order to have a C-section
Courts found that the baby has a right to live, so the appeal was denied
Mother ended up giving birth just fine
ultrasound showed that the placental previa has gone away, which should be impossible
What happened in the Pennsylvania case?
Baby was estimated to be 13lbs, deemed too large for a safe natural birth
parents didn’t care, looked for another hospital
The original one sought out legal guardianship of the child and were allowed to force her into surgery if she returned
She gives birth to the kid just fine, didn’t realize that the original hospital had done this.
What is EFM? What are some problems surrounding it?
Electronic Fetal Monitoring
- Promised to reduce cases of
- Cerebral Palsy
- Intellectual disability
- Peri-natal mortality
- by 50%
using it increases C-section rates, without improving outcomes for babies
interpretations of fetal heart tracings are highly subjective
False positives of fetal distresses are a given
very little agreement among experts as to the interpretation of “non-reassuring” findings
How are EFM records used in brain injury litigation?
they are used by expert witnesses who testify as to when the baby sustained irreversible neurological injury
is heavily relied upon to support counterfactual claims that a poor outcome could have been avoided
What is counterfactual reasoning and hindsight bias?
COUNTERFACTUAL REASONING:
- reasoning about “what might have been”
- Relies on mental representations of alternatives to the past, often activated automatically in response to negative affect
EX: if you’d been paying attention, you wouldn’t have gotten hurt”
the basis of giving blame for positive outcomes or giving credit for positive outcomes
can be problematic because of hindsight bias…
HINDSIGHT BIAS:
- the “knew it all along” effect
- knowing that an event has occurred increases its perceived predictability
- linked to the availability heuristic
- situations that lend themselves to straightforward causal explanations evoke greater hindsight bias than situations that are more ambiguous
- accompanied with overconfidence in the certainty of one’s judgements
