28 April 2003
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
Dr. Warren
-I
Dear I: The following information about Vacuum Extraction comes from Scott: Danforth's Obstetrics & Gynecology, 7th ed., Copyright © 1994, Lippincott-Raven Publishers
Berkus and his colleagues compared vacuum extraction with the use of forceps and found that significantly less maternal trauma occurred among patients delivered by vacuum extraction. Other studies have indicated a moderate increase in risk with vacuum extraction compared with the use of forceps. These complications include an increased risk for cephalhematoma and an increased risk for neonatal jaundice. There is some concern about the long-term neurobehavioral outcome in relation to an increase in retinal hemorrhage after vacuum extraction, but the clinical significance of retinal hemorrhage is uncertain.Assuming the delivery you are speaking about was a low vacuum extraction rather than a midvacuum extraction, the risk of injury to the newborn should be lower with the vacuum extraction than a c-section. Since I am not privy to details involved in the decision, I cannot say whether or not a c-section should have been performed. It is not unusual for the vacuum to turn the skin purple. The suction acts the same as the suction when people give each other hickeys. If the swelling you saw was thicker than 2 cm (which is almost an inch) as described above, the baby may have a cephalohematoma. Cephalohematomas are common birth injuries even in spontaneous vaginal deliveries. The presence of a cephalohematoma does not indicate any internal injury to the head or brain.In a 1991 randomized, prospective study, Williams and colleagues compared 48 attempted polyethylene vacuum cup extractions to 51 attempted forceps deliveries and found that 83% of the attempted vacuum and 78% of the attempted forceps deliveries were successful. Facial injuries, usually limited to forceps marks, were more common in the cohort delivered by forceps. Retinal hemorrhage occurred with greater frequency (16% versus 8%) and severity among the group delivered with vacuum extraction that those delivered with forceps. No significant differences were found for serum bilirubin levels between the two groups. The previously described study by Seidman and colleagues did not find a significant difference in IQ among 17-year-old adolescents who were delivered by vacuum extraction compared with forceps, cesarean, or spontaneous vaginal deliveries. Among those delivered by vacuum extraction, there were no significant vision, retinal examination, or strabismus findings.
In 1990, Robertson and colleagues compared midforceps, midvacuum, low forceps, and low vacuum operative deliveries with delivery by cesarean section. They found significantly increased birth trauma (i.e., primarily bruising) among the midvacuum group. There was a significantly increased need for neonatal resuscitation among the midvacuum group compared with the cesarean group; in contrast, significantly fewer subjects in the low vacuum group required resuscitation, compared with neonates delivered by cesarean. The investigators concluded that low forceps and low vacuum operative vaginal birth offer marked maternal advantages, with little or no effect on neonatal outcome parameters.
Interpreting the data available in the literature broadly, there appears to be little difference in outcome for patients for whom forceps or vacuum extraction delivery is indicated. The choice of either modality is based on the experience and competence of the obstetrician and his or her institutional setting.
Vacuum extractors create a sharply demarcated circular edema that may be as thick as 2 cm; it disappears more slowly than naturally occurring edema.
I am not familiar with any statistics on the frequency of any particular delivery procedure. If the delivery was at a teaching hospital, then there is a requirement for supervision. If the delivery was at any other hospital, it would have had to be attended by a physician on staff at the hospital. In order to be on staff and have privileges to do procedures, the physician has to have credentials showing adequate training in the procedures he obtains privileges for.
Sincerely,
Dr. Warren
I have obtained an excellent expert ob-gyn to testify as to the specifics in the lack of due care. We also had an expert pediatrician for causation, but for reasons unrelated to my case, has recently become unable to testify. Now, as we approach the 11th hour, we will require expert testimony as to causation.
Because of your experience and the impressive scope of knowledge which you possess, I believe you to be a very credible witness. My question to you, Dr. Warren, is: would you be willing to speak to my attorney regarding possible testimony? Should you be willing to aid us, you will be adequately compensated for your valuable time and effort.
Thank you for your consideration.
-SM
Dear SM: I take it as a compliment that you would consider me a "credible witness." Nonetheless, I don't consider myself an expert in these matters. I give my answers by e-mail due consideration and research my answers when necessary. On a witness chair, to be an expert witness, I would have to provide credentials and demonstrate knowledge at my fingertips. You need the expertise of a neonatologist or perhaps a pediatric neurologist.
In addition, in spite of any information I gave you which may clarify the situation for you, don't forget that my position was that you will never know how much or if the Rh sensitization contributed to or caused your son's neurological problems. That is hardly the position you want your expert to take on the witness stand.
I do wish you luck in your pursuit of justice. Unfortunately, I don't think I can help. I feel qualified to provide information, insight, and explanations to my readers, but if you've read a number of my columns, you will note that I don't claim to be an expert or in possession of greater knowledge or skills than the average pediatrician.
Sincerely,
Dr. Warren
-TB
Dear TB: A pink area on the eye with a bump in the middle could be a phlyctenular conjunctivitis. It is not serious, but does require the attention of an ophthalmologist.
Sincerely,
Dr. Warren
-VM
Dear VM: You are describing a tic. Tics can sometimes be habits or a response to stress, but for the most part they are compulsive movements. They are under voluntary control, but they usually occur without the person being fully aware of the movements. Conscious efforts to stop the tic can result in tension because the tics are compulsive behaviors. Most tics of childhood are best ignored; however, if a child has frequent, gross (large movements), or disruptive tics, or the degree of tic is increasing, or there are any vocal tics associated with it, then the child should be evaluated by a pediatric neurologist.
Sincerely,
Dr. Warren
-RN
Dear RN: Diarrhea generally does not prevent absorption of nutrients from the intestines unless it is quite severe. The fact that your daughter gained weight indicates that she is not only absorbing nutrients, but also is consuming enough fluids to balance her fluid losses and keep her well hydrated. As long as that continues, your daughter is not at risk from this illness. If your daughter should become sicker, with vomiting, poor intake, lethargy, or fever, then she requires reevaluation.
You didn't say what formula you are feeding your baby. Some babies lose their ability to digest complex sugars after a prolonged bout of gastroenteritis (intestinal virus). Continuing on a regular formula may aggravate the diarrhea. If your baby is taking a milk based formula, she may need to switch temporarily to a lactose free formula like Lactofree.
Lotrimin is fine for treating a yeast infection. There is no relationship between that and diarrhea, but persistent diarrhea can certainly result in a raw diaper rash.
Sincerely,
Dr. Warren
Thank you in advance!
-MA
Dear MA: Fatigue can be a symptom in apparently healthy children for a variety of reasons. I use the word apparently, because the fatigue may be the only sign of a chronic condition, therefore, I have to recommend that your son have a complete physical.
Fatigue may be the only symptom in a child who has had an inapparent bout of mononucleosis. Fatigue may also be a result of disturbed sleep even if a child goes to bed at a reasonable hour. Sleep apnea associated with large tonsils may be evident as severe snoring punctuated by sorts and stops with daytime somnolence. Even with what appears to be a reasonable amount of sleep, some children may experience fatigue in response to a demanding schedule. Boredom and an overheated classroom might also result in a child falling asleep in class.
Sincerely,
Dr. Warren
Best Regards
-NG
Dear NG: I understand the problem a person faces in deciding whether or not to seek medical treatment when he has no insurance and no money; however, delayed treatment can sometimes result in serious consequences, or at least higher medical bills. Your daughter's symptoms may be the result of influenza. If she is better by the time you receive my response, nothing more needs to be done. Coughing, vomiting, and symptoms of generally feeling ill can also be caused by pneumonia, so if your daughter is not better, I urge you to seek medical treatment.
Sincerely,
Dr. Warren
-SC
Dear SC: Most childhood leg pains are muscle spasms that occur in response to high levels of activity. As a result, the pains occur when the child is at rest, often in bed. These are not serious and generally respond to heat and massage. It may also help for the child to do some stretching exercises like toe touchers before activity and massage the muscles in a warm bath before bed.
These types of pains do not occur while a child is active. They do not cause a limp or interfere with activity. If a child has a limp or has pain which interferes with activity, then the child needs evaluation by a pediatrician or orthopedist.
Sincerely,
Dr. Warren
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