Commentary

How did you pick your field?

Neurology, for me, was a combination of personal likes and dislikes. I found it interesting, but also learned I didn’t enjoy most other branches of medicine.

Like other medical students, I went through a series of rotations, gradually crossing things off my list. Eventually, I found that internal medicine fit my personality best, but I didn’t like having to know something about everything. Neurology was a good fit for the way my mind and temperament work. Now, after 16 years in practice, I have no regrets. I still like the job, in spite of having to deal with insurance companies, excessive paperwork, and hospital administrators.

I’m not an adrenaline junkie, living to run in and save lives at the drop of a hat. Nor am I someone who enjoys procedures. I’m the thinking type, and happy to spend my days sitting behind a desk and trying to look smart. I’d have to say I nailed it, my atypical wardrobe notwithstanding.

Medical fields, like cars and music, are incredibly diverse. There’s something out there for every personality type. And that’s excluding all the subspecialties a field gets further broken down to. (In my world there’s movement disorder docs, epileptologists, and stroke-ologists, to name a few.)

When I was in training, an adviser told me that one’s choice of field is as much success as failure. By becoming a neurologist, I’m admitting that I’ve failed to understand pretty much everything else in medicine. On the opposite side, an internist has conceded failure to understand any given organ system in depth.

Most importantly, you don’t care that you’ve failed the rest. This frees you to focus only on what you enjoy and what interests you, and to not worry about anything else.

Using this argument, the best care is from someone who failed everything else. Or, in a better light, who only does one thing, but does it well. No matter how you play it, it’s what works out best for all involved – especially our patients.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How did you pick your field?

Neurology, for me, was a combination of personal likes and dislikes. I found it interesting, but also learned I didn’t enjoy most other branches of medicine.

Like other medical students, I went through a series of rotations, gradually crossing things off my list. Eventually, I found that internal medicine fit my personality best, but I didn’t like having to know something about everything. Neurology was a good fit for the way my mind and temperament work. Now, after 16 years in practice, I have no regrets. I still like the job, in spite of having to deal with insurance companies, excessive paperwork, and hospital administrators.

I’m not an adrenaline junkie, living to run in and save lives at the drop of a hat. Nor am I someone who enjoys procedures. I’m the thinking type, and happy to spend my days sitting behind a desk and trying to look smart. I’d have to say I nailed it, my atypical wardrobe notwithstanding.

Medical fields, like cars and music, are incredibly diverse. There’s something out there for every personality type. And that’s excluding all the subspecialties a field gets further broken down to. (In my world there’s movement disorder docs, epileptologists, and stroke-ologists, to name a few.)

When I was in training, an adviser told me that one’s choice of field is as much success as failure. By becoming a neurologist, I’m admitting that I’ve failed to understand pretty much everything else in medicine. On the opposite side, an internist has conceded failure to understand any given organ system in depth.

Most importantly, you don’t care that you’ve failed the rest. This frees you to focus only on what you enjoy and what interests you, and to not worry about anything else.

Using this argument, the best care is from someone who failed everything else. Or, in a better light, who only does one thing, but does it well. No matter how you play it, it’s what works out best for all involved – especially our patients.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How did you pick your field?

Neurology, for me, was a combination of personal likes and dislikes. I found it interesting, but also learned I didn’t enjoy most other branches of medicine.

Like other medical students, I went through a series of rotations, gradually crossing things off my list. Eventually, I found that internal medicine fit my personality best, but I didn’t like having to know something about everything. Neurology was a good fit for the way my mind and temperament work. Now, after 16 years in practice, I have no regrets. I still like the job, in spite of having to deal with insurance companies, excessive paperwork, and hospital administrators.

I’m not an adrenaline junkie, living to run in and save lives at the drop of a hat. Nor am I someone who enjoys procedures. I’m the thinking type, and happy to spend my days sitting behind a desk and trying to look smart. I’d have to say I nailed it, my atypical wardrobe notwithstanding.

Medical fields, like cars and music, are incredibly diverse. There’s something out there for every personality type. And that’s excluding all the subspecialties a field gets further broken down to. (In my world there’s movement disorder docs, epileptologists, and stroke-ologists, to name a few.)

When I was in training, an adviser told me that one’s choice of field is as much success as failure. By becoming a neurologist, I’m admitting that I’ve failed to understand pretty much everything else in medicine. On the opposite side, an internist has conceded failure to understand any given organ system in depth.

Most importantly, you don’t care that you’ve failed the rest. This frees you to focus only on what you enjoy and what interests you, and to not worry about anything else.

Using this argument, the best care is from someone who failed everything else. Or, in a better light, who only does one thing, but does it well. No matter how you play it, it’s what works out best for all involved – especially our patients.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I read about Dr. Siedhof’s decision analysis with interest, because I fear that the Food and Drug Administration may have overreached again. Based on a few, small, retrospective studies, the FDA has published a position statement discouraging the use of power morcellation for laparoscopic hysterectomy for fibroids. This has caused an uproar in the ob.gyn. community, particularly with the recent popularity of minimally invasive laparoscopic surgical (MIS) approaches. I realize the FDA has the safety of the American populace at heart, but I think that FDA officials really do not understand the power they hold in such announcements.

Based on this and other similar statements, our legal colleagues turn the full force of the product liability teams on the “problem,” beginning to advertise and sign up class action lawsuit cases. Because the bulk of the legal profession concentrates on only one side of the issue (potential injuries), this in turn results in one-sided media coverage. The public begins to be bombarded with negative opinions, and through repetition, public opinion is typically swayed. Product manufacturers and physician groups circle the wagons as the number of complaints and lawsuits explodes. As the complaint numbers increase, the FDA has no choice but to issue a “boxed warning.” We have seen this pattern repeat itself with silicone breast implants, and, more recently, vaginal mesh. Already we have seen hospitals ban the use of morcellators, and at least one manufacturer has pulled its instruments off the market.

I must emphasize that the FDA safety alert about morcellators is not a boxed warning. Nothing about the position statement suggests that the morcellator itself malfunctions, risks patient injury, or performs in any way other than the way it was designed. The issue is whether women are being counseled that morcellation could lead to the very rare possibility of disseminating a leiomyosarcoma. Seeing that the underlying risk of leiomyosarcoma has not been well established (with the range of incidence being 1/350 to 1/7,400), it is difficult to know how much to emphasize the risks of leiomyosarcoma to each patient, and, thus, the risk of distant spread or up-staging as a result of morcellation during laparoscopic hysterectomy.

I believe Dr. Siedhof’s team used the best published data available, made conservative assumptions, and tried to take into account the 5-year survival and quality-adjusted life-years (QALY) data for those patients who ultimately were determined to have leiomyosarcoma, regardless of hysterectomy route. Their major findings showed very similar results whether the hysterectomy was performed abdominally or laparoscopically with morcellation. If reliable screening tests or predictive factors were available, then those at higher risk could be guided away from MIS and morcellation. But because symptoms and ultrasound findings are nonspecific, and endometrial sampling that is less than 50% effective is establishing the diagnosis, we are back to square one.

While I cautiously applaud Dr. Siedhof’s team for performing much needed research in an area where we desperately need information, I urge my colleagues to temper their reactions to the position statement before changing their practice patterns. Certainly, we can emphasize the possibility of disseminating a rare leiomyosarcoma in 1/1,000 cases, if a power morcellator is used. But we need to balance out the overwhelmingly bad information being propagated by legal professionals and the media with a good dose of common sense.

Patrick J. Woodman, D.O., is associate director of the female pelvic medicine and reconstructive surgery fellowship at Indiana University, Indianapolis.

I read about Dr. Siedhof’s decision analysis with interest, because I fear that the Food and Drug Administration may have overreached again. Based on a few, small, retrospective studies, the FDA has published a position statement discouraging the use of power morcellation for laparoscopic hysterectomy for fibroids. This has caused an uproar in the ob.gyn. community, particularly with the recent popularity of minimally invasive laparoscopic surgical (MIS) approaches. I realize the FDA has the safety of the American populace at heart, but I think that FDA officials really do not understand the power they hold in such announcements.

Based on this and other similar statements, our legal colleagues turn the full force of the product liability teams on the “problem,” beginning to advertise and sign up class action lawsuit cases. Because the bulk of the legal profession concentrates on only one side of the issue (potential injuries), this in turn results in one-sided media coverage. The public begins to be bombarded with negative opinions, and through repetition, public opinion is typically swayed. Product manufacturers and physician groups circle the wagons as the number of complaints and lawsuits explodes. As the complaint numbers increase, the FDA has no choice but to issue a “boxed warning.” We have seen this pattern repeat itself with silicone breast implants, and, more recently, vaginal mesh. Already we have seen hospitals ban the use of morcellators, and at least one manufacturer has pulled its instruments off the market.

I must emphasize that the FDA safety alert about morcellators is not a boxed warning. Nothing about the position statement suggests that the morcellator itself malfunctions, risks patient injury, or performs in any way other than the way it was designed. The issue is whether women are being counseled that morcellation could lead to the very rare possibility of disseminating a leiomyosarcoma. Seeing that the underlying risk of leiomyosarcoma has not been well established (with the range of incidence being 1/350 to 1/7,400), it is difficult to know how much to emphasize the risks of leiomyosarcoma to each patient, and, thus, the risk of distant spread or up-staging as a result of morcellation during laparoscopic hysterectomy.

I believe Dr. Siedhof’s team used the best published data available, made conservative assumptions, and tried to take into account the 5-year survival and quality-adjusted life-years (QALY) data for those patients who ultimately were determined to have leiomyosarcoma, regardless of hysterectomy route. Their major findings showed very similar results whether the hysterectomy was performed abdominally or laparoscopically with morcellation. If reliable screening tests or predictive factors were available, then those at higher risk could be guided away from MIS and morcellation. But because symptoms and ultrasound findings are nonspecific, and endometrial sampling that is less than 50% effective is establishing the diagnosis, we are back to square one.

While I cautiously applaud Dr. Siedhof’s team for performing much needed research in an area where we desperately need information, I urge my colleagues to temper their reactions to the position statement before changing their practice patterns. Certainly, we can emphasize the possibility of disseminating a rare leiomyosarcoma in 1/1,000 cases, if a power morcellator is used. But we need to balance out the overwhelmingly bad information being propagated by legal professionals and the media with a good dose of common sense.

Patrick J. Woodman, D.O., is associate director of the female pelvic medicine and reconstructive surgery fellowship at Indiana University, Indianapolis.

I read about Dr. Siedhof’s decision analysis with interest, because I fear that the Food and Drug Administration may have overreached again. Based on a few, small, retrospective studies, the FDA has published a position statement discouraging the use of power morcellation for laparoscopic hysterectomy for fibroids. This has caused an uproar in the ob.gyn. community, particularly with the recent popularity of minimally invasive laparoscopic surgical (MIS) approaches. I realize the FDA has the safety of the American populace at heart, but I think that FDA officials really do not understand the power they hold in such announcements.

Based on this and other similar statements, our legal colleagues turn the full force of the product liability teams on the “problem,” beginning to advertise and sign up class action lawsuit cases. Because the bulk of the legal profession concentrates on only one side of the issue (potential injuries), this in turn results in one-sided media coverage. The public begins to be bombarded with negative opinions, and through repetition, public opinion is typically swayed. Product manufacturers and physician groups circle the wagons as the number of complaints and lawsuits explodes. As the complaint numbers increase, the FDA has no choice but to issue a “boxed warning.” We have seen this pattern repeat itself with silicone breast implants, and, more recently, vaginal mesh. Already we have seen hospitals ban the use of morcellators, and at least one manufacturer has pulled its instruments off the market.

I must emphasize that the FDA safety alert about morcellators is not a boxed warning. Nothing about the position statement suggests that the morcellator itself malfunctions, risks patient injury, or performs in any way other than the way it was designed. The issue is whether women are being counseled that morcellation could lead to the very rare possibility of disseminating a leiomyosarcoma. Seeing that the underlying risk of leiomyosarcoma has not been well established (with the range of incidence being 1/350 to 1/7,400), it is difficult to know how much to emphasize the risks of leiomyosarcoma to each patient, and, thus, the risk of distant spread or up-staging as a result of morcellation during laparoscopic hysterectomy.

I believe Dr. Siedhof’s team used the best published data available, made conservative assumptions, and tried to take into account the 5-year survival and quality-adjusted life-years (QALY) data for those patients who ultimately were determined to have leiomyosarcoma, regardless of hysterectomy route. Their major findings showed very similar results whether the hysterectomy was performed abdominally or laparoscopically with morcellation. If reliable screening tests or predictive factors were available, then those at higher risk could be guided away from MIS and morcellation. But because symptoms and ultrasound findings are nonspecific, and endometrial sampling that is less than 50% effective is establishing the diagnosis, we are back to square one.

While I cautiously applaud Dr. Siedhof’s team for performing much needed research in an area where we desperately need information, I urge my colleagues to temper their reactions to the position statement before changing their practice patterns. Certainly, we can emphasize the possibility of disseminating a rare leiomyosarcoma in 1/1,000 cases, if a power morcellator is used. But we need to balance out the overwhelmingly bad information being propagated by legal professionals and the media with a good dose of common sense.

Patrick J. Woodman, D.O., is associate director of the female pelvic medicine and reconstructive surgery fellowship at Indiana University, Indianapolis.

"UPDATE ON MINIMALLY INVASIVE GYNECOLOGY" AMY GARCIA, MD (APRIL 2014)

Mucocele in cesarean scar can cause pain, bladder urgency, dyspareunia
Like Dr. Garcia, I too, have seen many cesarean-scar defects; most were diagnosed prior to surgery by my in-house technicians during vaginal ultrasonography.

I would like to add that, in addition to these defects, some patients who have undergone cesarean delivery also may form a mucocele in the scar that causes pain, bladder urgency, and dyspareunia. These defects also can be seen by ultrasonography, but in some cases may erroneously be labeled “nabothian cysts” by a radiologist. Most mucoceles probably are caused by incorporation of endocervical glands within a very low transverse uterine incision. Discovery and removal of these mucoceles during hysterectomy result in a very satisfied patient whose pain and urinary symptoms are resolved.

David G. Bryan, MD
Monroe, Louisiana

“Q: FOLLOWING CESAREAN DELIVERY, WHAT IS THE OPTIMAL OXYTOCIN INFUSION DURATION TO PREVENT POSTPARTUM BLEEDING?” ROBERT L. BARBIERI, MD (EDITORIAL; APRIL 2014)

Oxytocin protocol decreased postpartum hemorrhage rates
We commend Dr. Barbieri for his April 2014 editorial, “Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding?” because he addresses a critical gap in the evidence regarding oxytocin administration postpartum. Standardized protocols for such administration are lacking at many facilities.

Our multidisciplinary team developed a standardized postpartum oxytocin administration protocol to prevent postpartum hemorrhage (PPH) based on limited evidence from trials in which 10 units to 80 or more units of oxytocin were given (from <1 to 12 hours) postpartum.^1–5 Our protocol is a “middle of the road’’ approach in which a total of oxytocin 60 U is administered intravenously postdelivery, including a bolus of oxytocin 15 U in 250 mL of lactated Ringers solution (LR) at delivery followed by an additional oxytocin 15 U in 250 mL LR over the next hour, then oxytocin 30 U in 500 mL LR at a rate of 125 mL/hr for the following 4 hours. Thus, the total time for oxytocin administration postdelivery is 5 hours, within Dr. Barbieri’s recommendation of 4 to 8 hours 

We have since performed a retrospective quality improvement assessment comparing PPH rates at 6-months preprotocol (n = 1267) with rates at 6-months postprotocol (n = 1440) implementation. PPH was defined as PPH treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all deliveries at greater than 23 weeks’ gestation from April 2012 to March 2013. Patient characteristics for both cohorts were similar for race, age, parity, gestational age, delivery type, and neonatal weight.

The PPH rate decreased 37% after protocol implementation (adjusted relative risk [ARR], 0.63; 95% confidence interval [CI], 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased postprotocol implementation by 36%, 38%, 32%, and 22%, respectively. The PPH rate for women with a vaginal delivery decreased significantly after protocol implementation (5.9% preprotocol vs 3.8% postprotocol; P = .03). The PPH rate for women undergoing cesarean delivery increased, but not significantly, after protocol implementation (6.9% preprotocol vs 8.6% postprotocol; P = .34).

We did not control for some PPH risk factors, including abnormal insertion of placenta, preeclampsia, and multiple gestation. Despite this limitation, our PPH rate for women undergoing cesarean delivery is lower than other published rates.^6,7 These findings are the preliminary step in a larger, more comprehensive 4-year study.

Our team is encouraged by these results and believes our protocol warrants further study. Thank you for your attention to this topic. We hope our experience can offer support for future practice change and research.

Enas Ramih, MD, MPH; Jennifer Doyle, MSN, WHNP; Tiffany Kenny, MSN;
Michele McCarroll, PhD; Vivian von Gruenigen, MD
Summa Health System Akron City Hospital
Women’s Health Services
Akron, Ohio

References

1. Tita AT, Szychowski JM, Rouse DJ, et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012;119(2 pt 1):293–300.

2. Munn MB, Owen J, Vincent R, Wakefield M, Chestnut DH, Hauth JC. Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2001;98(3):386–390.

3. Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section: pilot study. ISRCTN 40302163. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):30–33.

4. King KJ, Douglas MJ, Waldmar U, Wong A, King RAR. Five-unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial. Anesth Analg. 2010;111(6):1460–1466.

5. Gungorduk K, Asicioglu O, Celikkol O, Olgac Y, Ark C. Use of additional oxytocin to reduce blood loss at elective caesarean section: a randomized control trial. Aust N Z J Obstet Gynaecol. 2010;50(1):36–39.

6. Dagraca J, Malladi V, Nunes K, Scavone B. Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period. Int J Obstet Anesth. 2013;22(3):194–199.

7. Sheehan SR, Montgomery AA, Carey M, et al. Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ. 2011;343:d4661. doi:10.1136/bmj.d4661.

Dr. Barbieri responds
I deeply appreciate the very important clinical observation provided by the Summa Health System team. Implementation of a standardized 5-hour protocol of oxytocin administration following delivery resulted in a reduction in the rate of diagnosis of PPH following vaginal delivery, but not cesarean delivery, and a reduction in the use of adjuvant misoprostol, caboprost, and methylergonovine maleate. The quality improvement intervention initiated by the Summa Health System team and their ability to assess before and after outcomes demonstrates how high-quality clinical networks can develop and disseminate best practices, thereby improving the health of all the pregnant women in our care. Thank you for sharing this important clinical observation with our readers.

“FDA, HOSPITALS CAUTION AGAINST LAPAROSCOPIC POWER MORCELLATION DURING HYSTERECTOMY AND MYOMECTOMY”
JANELLE YATES (MAY 2014)

The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!
I'm sorry to say it, but your piece on morcellators is slanted. Many of us believe the FDA is wrong. The incidence of occult sarcoma came from nowhere. In properly selected, evaluated, and surgically managed cases, the use of an open power morcellator is an excellent option and the risks of a bad outcome are extremely small (especially the risk of worsening an occult leiomyosarcoma). Incidentally, we face the same risk of finding and possibly worsening an occult cancer in every gynecologic surgery we do.

Possible spillage, contamination, or outright tumor rupture is possible no matter what route or incision size. Minimally invasive surgeons understand the risk−benefit ratio very well. We use our judgment and patient informed consent in every case and should not be unnecessarily obstructed by government agencies. The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!

The controversy here is reminiscent of the issues brought up about breast implants in the 70s, IUDs in the 80s, estrogen in 2004, vaginal mesh in 2012, and robotics and hysterectomy approach recently. Show me some real data that are convincing against the use of morcellators, or support the physician’s choice in how to care for our patients.

Michael Swor, MD
Sarasota, Florida

Ms. Yates responds
I appreciate Dr. Swor’s response to the article on actions by the FDA and various hospitals to limit the use of power morcellation during hysterectomy and myomectomy. That article was not endorsing those actions, nor was it condemning them—it was simply a report of the latest events in a sea change taking place in minimally invasive gynecologic surgery.

Since the article was published, new data have become available on the likelihood of occult uterine malignancy among women who undergo minimally invasive hysterectomy with electric power morcellation. Wright and colleagues found a rate of uterine cancer of 27 cases per 10,000 women at the time of the procedure.¹ That figure translates into one case of undetected uterine cancer in every 368 women undergoing hysterectomy.¹

In a two-part series on tissue extraction at the time of hysterectomy and myomectomy, Dr. Jason Wright, the author of the study just mentioned, and other expert panelists discuss this issue in more depth.^2,3 They also note, as does Dr. Swor, that spillage, contamination, or outright tumor rupture is possible regardless of the route of hysterectomy.

References

1. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation [published online ahead of print July 22, 2014]. JAMA. doi: 10.1001/jama.2014.9005.

2. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Best practices for an environment in flux. OBG Manage. 2014;26(9):44–51.

3. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Counseling the patient. OBG Manage. 2014;26(10):41–45. 

Share your thoughts on this or other articles! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

"UPDATE ON MINIMALLY INVASIVE GYNECOLOGY" AMY GARCIA, MD (APRIL 2014)

Mucocele in cesarean scar can cause pain, bladder urgency, dyspareunia
Like Dr. Garcia, I too, have seen many cesarean-scar defects; most were diagnosed prior to surgery by my in-house technicians during vaginal ultrasonography.

I would like to add that, in addition to these defects, some patients who have undergone cesarean delivery also may form a mucocele in the scar that causes pain, bladder urgency, and dyspareunia. These defects also can be seen by ultrasonography, but in some cases may erroneously be labeled “nabothian cysts” by a radiologist. Most mucoceles probably are caused by incorporation of endocervical glands within a very low transverse uterine incision. Discovery and removal of these mucoceles during hysterectomy result in a very satisfied patient whose pain and urinary symptoms are resolved.

David G. Bryan, MD
Monroe, Louisiana

“Q: FOLLOWING CESAREAN DELIVERY, WHAT IS THE OPTIMAL OXYTOCIN INFUSION DURATION TO PREVENT POSTPARTUM BLEEDING?” ROBERT L. BARBIERI, MD (EDITORIAL; APRIL 2014)

Oxytocin protocol decreased postpartum hemorrhage rates
We commend Dr. Barbieri for his April 2014 editorial, “Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding?” because he addresses a critical gap in the evidence regarding oxytocin administration postpartum. Standardized protocols for such administration are lacking at many facilities.

Our multidisciplinary team developed a standardized postpartum oxytocin administration protocol to prevent postpartum hemorrhage (PPH) based on limited evidence from trials in which 10 units to 80 or more units of oxytocin were given (from <1 to 12 hours) postpartum.^1–5 Our protocol is a “middle of the road’’ approach in which a total of oxytocin 60 U is administered intravenously postdelivery, including a bolus of oxytocin 15 U in 250 mL of lactated Ringers solution (LR) at delivery followed by an additional oxytocin 15 U in 250 mL LR over the next hour, then oxytocin 30 U in 500 mL LR at a rate of 125 mL/hr for the following 4 hours. Thus, the total time for oxytocin administration postdelivery is 5 hours, within Dr. Barbieri’s recommendation of 4 to 8 hours 

We have since performed a retrospective quality improvement assessment comparing PPH rates at 6-months preprotocol (n = 1267) with rates at 6-months postprotocol (n = 1440) implementation. PPH was defined as PPH treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all deliveries at greater than 23 weeks’ gestation from April 2012 to March 2013. Patient characteristics for both cohorts were similar for race, age, parity, gestational age, delivery type, and neonatal weight.

The PPH rate decreased 37% after protocol implementation (adjusted relative risk [ARR], 0.63; 95% confidence interval [CI], 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased postprotocol implementation by 36%, 38%, 32%, and 22%, respectively. The PPH rate for women with a vaginal delivery decreased significantly after protocol implementation (5.9% preprotocol vs 3.8% postprotocol; P = .03). The PPH rate for women undergoing cesarean delivery increased, but not significantly, after protocol implementation (6.9% preprotocol vs 8.6% postprotocol; P = .34).

We did not control for some PPH risk factors, including abnormal insertion of placenta, preeclampsia, and multiple gestation. Despite this limitation, our PPH rate for women undergoing cesarean delivery is lower than other published rates.^6,7 These findings are the preliminary step in a larger, more comprehensive 4-year study.

Our team is encouraged by these results and believes our protocol warrants further study. Thank you for your attention to this topic. We hope our experience can offer support for future practice change and research.

Enas Ramih, MD, MPH; Jennifer Doyle, MSN, WHNP; Tiffany Kenny, MSN;
Michele McCarroll, PhD; Vivian von Gruenigen, MD
Summa Health System Akron City Hospital
Women’s Health Services
Akron, Ohio

References

1. Tita AT, Szychowski JM, Rouse DJ, et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012;119(2 pt 1):293–300.

2. Munn MB, Owen J, Vincent R, Wakefield M, Chestnut DH, Hauth JC. Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2001;98(3):386–390.

3. Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section: pilot study. ISRCTN 40302163. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):30–33.

4. King KJ, Douglas MJ, Waldmar U, Wong A, King RAR. Five-unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial. Anesth Analg. 2010;111(6):1460–1466.

5. Gungorduk K, Asicioglu O, Celikkol O, Olgac Y, Ark C. Use of additional oxytocin to reduce blood loss at elective caesarean section: a randomized control trial. Aust N Z J Obstet Gynaecol. 2010;50(1):36–39.

6. Dagraca J, Malladi V, Nunes K, Scavone B. Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period. Int J Obstet Anesth. 2013;22(3):194–199.

7. Sheehan SR, Montgomery AA, Carey M, et al. Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ. 2011;343:d4661. doi:10.1136/bmj.d4661.

Dr. Barbieri responds
I deeply appreciate the very important clinical observation provided by the Summa Health System team. Implementation of a standardized 5-hour protocol of oxytocin administration following delivery resulted in a reduction in the rate of diagnosis of PPH following vaginal delivery, but not cesarean delivery, and a reduction in the use of adjuvant misoprostol, caboprost, and methylergonovine maleate. The quality improvement intervention initiated by the Summa Health System team and their ability to assess before and after outcomes demonstrates how high-quality clinical networks can develop and disseminate best practices, thereby improving the health of all the pregnant women in our care. Thank you for sharing this important clinical observation with our readers.

“FDA, HOSPITALS CAUTION AGAINST LAPAROSCOPIC POWER MORCELLATION DURING HYSTERECTOMY AND MYOMECTOMY”
JANELLE YATES (MAY 2014)

The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!
I'm sorry to say it, but your piece on morcellators is slanted. Many of us believe the FDA is wrong. The incidence of occult sarcoma came from nowhere. In properly selected, evaluated, and surgically managed cases, the use of an open power morcellator is an excellent option and the risks of a bad outcome are extremely small (especially the risk of worsening an occult leiomyosarcoma). Incidentally, we face the same risk of finding and possibly worsening an occult cancer in every gynecologic surgery we do.

Possible spillage, contamination, or outright tumor rupture is possible no matter what route or incision size. Minimally invasive surgeons understand the risk−benefit ratio very well. We use our judgment and patient informed consent in every case and should not be unnecessarily obstructed by government agencies. The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!

The controversy here is reminiscent of the issues brought up about breast implants in the 70s, IUDs in the 80s, estrogen in 2004, vaginal mesh in 2012, and robotics and hysterectomy approach recently. Show me some real data that are convincing against the use of morcellators, or support the physician’s choice in how to care for our patients.

Michael Swor, MD
Sarasota, Florida

Ms. Yates responds
I appreciate Dr. Swor’s response to the article on actions by the FDA and various hospitals to limit the use of power morcellation during hysterectomy and myomectomy. That article was not endorsing those actions, nor was it condemning them—it was simply a report of the latest events in a sea change taking place in minimally invasive gynecologic surgery.

Since the article was published, new data have become available on the likelihood of occult uterine malignancy among women who undergo minimally invasive hysterectomy with electric power morcellation. Wright and colleagues found a rate of uterine cancer of 27 cases per 10,000 women at the time of the procedure.¹ That figure translates into one case of undetected uterine cancer in every 368 women undergoing hysterectomy.¹

In a two-part series on tissue extraction at the time of hysterectomy and myomectomy, Dr. Jason Wright, the author of the study just mentioned, and other expert panelists discuss this issue in more depth.^2,3 They also note, as does Dr. Swor, that spillage, contamination, or outright tumor rupture is possible regardless of the route of hysterectomy.

References

1. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation [published online ahead of print July 22, 2014]. JAMA. doi: 10.1001/jama.2014.9005.

2. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Best practices for an environment in flux. OBG Manage. 2014;26(9):44–51.

3. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Counseling the patient. OBG Manage. 2014;26(10):41–45. 

Share your thoughts on this or other articles! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

"UPDATE ON MINIMALLY INVASIVE GYNECOLOGY" AMY GARCIA, MD (APRIL 2014)

Mucocele in cesarean scar can cause pain, bladder urgency, dyspareunia
Like Dr. Garcia, I too, have seen many cesarean-scar defects; most were diagnosed prior to surgery by my in-house technicians during vaginal ultrasonography.

I would like to add that, in addition to these defects, some patients who have undergone cesarean delivery also may form a mucocele in the scar that causes pain, bladder urgency, and dyspareunia. These defects also can be seen by ultrasonography, but in some cases may erroneously be labeled “nabothian cysts” by a radiologist. Most mucoceles probably are caused by incorporation of endocervical glands within a very low transverse uterine incision. Discovery and removal of these mucoceles during hysterectomy result in a very satisfied patient whose pain and urinary symptoms are resolved.

David G. Bryan, MD
Monroe, Louisiana

“Q: FOLLOWING CESAREAN DELIVERY, WHAT IS THE OPTIMAL OXYTOCIN INFUSION DURATION TO PREVENT POSTPARTUM BLEEDING?” ROBERT L. BARBIERI, MD (EDITORIAL; APRIL 2014)

Oxytocin protocol decreased postpartum hemorrhage rates
We commend Dr. Barbieri for his April 2014 editorial, “Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding?” because he addresses a critical gap in the evidence regarding oxytocin administration postpartum. Standardized protocols for such administration are lacking at many facilities.

Our multidisciplinary team developed a standardized postpartum oxytocin administration protocol to prevent postpartum hemorrhage (PPH) based on limited evidence from trials in which 10 units to 80 or more units of oxytocin were given (from <1 to 12 hours) postpartum.^1–5 Our protocol is a “middle of the road’’ approach in which a total of oxytocin 60 U is administered intravenously postdelivery, including a bolus of oxytocin 15 U in 250 mL of lactated Ringers solution (LR) at delivery followed by an additional oxytocin 15 U in 250 mL LR over the next hour, then oxytocin 30 U in 500 mL LR at a rate of 125 mL/hr for the following 4 hours. Thus, the total time for oxytocin administration postdelivery is 5 hours, within Dr. Barbieri’s recommendation of 4 to 8 hours 

We have since performed a retrospective quality improvement assessment comparing PPH rates at 6-months preprotocol (n = 1267) with rates at 6-months postprotocol (n = 1440) implementation. PPH was defined as PPH treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all deliveries at greater than 23 weeks’ gestation from April 2012 to March 2013. Patient characteristics for both cohorts were similar for race, age, parity, gestational age, delivery type, and neonatal weight.

The PPH rate decreased 37% after protocol implementation (adjusted relative risk [ARR], 0.63; 95% confidence interval [CI], 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased postprotocol implementation by 36%, 38%, 32%, and 22%, respectively. The PPH rate for women with a vaginal delivery decreased significantly after protocol implementation (5.9% preprotocol vs 3.8% postprotocol; P = .03). The PPH rate for women undergoing cesarean delivery increased, but not significantly, after protocol implementation (6.9% preprotocol vs 8.6% postprotocol; P = .34).

We did not control for some PPH risk factors, including abnormal insertion of placenta, preeclampsia, and multiple gestation. Despite this limitation, our PPH rate for women undergoing cesarean delivery is lower than other published rates.^6,7 These findings are the preliminary step in a larger, more comprehensive 4-year study.

Our team is encouraged by these results and believes our protocol warrants further study. Thank you for your attention to this topic. We hope our experience can offer support for future practice change and research.

Enas Ramih, MD, MPH; Jennifer Doyle, MSN, WHNP; Tiffany Kenny, MSN;
Michele McCarroll, PhD; Vivian von Gruenigen, MD
Summa Health System Akron City Hospital
Women’s Health Services
Akron, Ohio

References

1. Tita AT, Szychowski JM, Rouse DJ, et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012;119(2 pt 1):293–300.

2. Munn MB, Owen J, Vincent R, Wakefield M, Chestnut DH, Hauth JC. Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2001;98(3):386–390.

3. Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section: pilot study. ISRCTN 40302163. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):30–33.

4. King KJ, Douglas MJ, Waldmar U, Wong A, King RAR. Five-unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial. Anesth Analg. 2010;111(6):1460–1466.

5. Gungorduk K, Asicioglu O, Celikkol O, Olgac Y, Ark C. Use of additional oxytocin to reduce blood loss at elective caesarean section: a randomized control trial. Aust N Z J Obstet Gynaecol. 2010;50(1):36–39.

6. Dagraca J, Malladi V, Nunes K, Scavone B. Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period. Int J Obstet Anesth. 2013;22(3):194–199.

7. Sheehan SR, Montgomery AA, Carey M, et al. Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ. 2011;343:d4661. doi:10.1136/bmj.d4661.

Dr. Barbieri responds
I deeply appreciate the very important clinical observation provided by the Summa Health System team. Implementation of a standardized 5-hour protocol of oxytocin administration following delivery resulted in a reduction in the rate of diagnosis of PPH following vaginal delivery, but not cesarean delivery, and a reduction in the use of adjuvant misoprostol, caboprost, and methylergonovine maleate. The quality improvement intervention initiated by the Summa Health System team and their ability to assess before and after outcomes demonstrates how high-quality clinical networks can develop and disseminate best practices, thereby improving the health of all the pregnant women in our care. Thank you for sharing this important clinical observation with our readers.

“FDA, HOSPITALS CAUTION AGAINST LAPAROSCOPIC POWER MORCELLATION DURING HYSTERECTOMY AND MYOMECTOMY”
JANELLE YATES (MAY 2014)

The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!
I'm sorry to say it, but your piece on morcellators is slanted. Many of us believe the FDA is wrong. The incidence of occult sarcoma came from nowhere. In properly selected, evaluated, and surgically managed cases, the use of an open power morcellator is an excellent option and the risks of a bad outcome are extremely small (especially the risk of worsening an occult leiomyosarcoma). Incidentally, we face the same risk of finding and possibly worsening an occult cancer in every gynecologic surgery we do.

Possible spillage, contamination, or outright tumor rupture is possible no matter what route or incision size. Minimally invasive surgeons understand the risk−benefit ratio very well. We use our judgment and patient informed consent in every case and should not be unnecessarily obstructed by government agencies. The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!

The controversy here is reminiscent of the issues brought up about breast implants in the 70s, IUDs in the 80s, estrogen in 2004, vaginal mesh in 2012, and robotics and hysterectomy approach recently. Show me some real data that are convincing against the use of morcellators, or support the physician’s choice in how to care for our patients.

Michael Swor, MD
Sarasota, Florida

Ms. Yates responds
I appreciate Dr. Swor’s response to the article on actions by the FDA and various hospitals to limit the use of power morcellation during hysterectomy and myomectomy. That article was not endorsing those actions, nor was it condemning them—it was simply a report of the latest events in a sea change taking place in minimally invasive gynecologic surgery.

Since the article was published, new data have become available on the likelihood of occult uterine malignancy among women who undergo minimally invasive hysterectomy with electric power morcellation. Wright and colleagues found a rate of uterine cancer of 27 cases per 10,000 women at the time of the procedure.¹ That figure translates into one case of undetected uterine cancer in every 368 women undergoing hysterectomy.¹

In a two-part series on tissue extraction at the time of hysterectomy and myomectomy, Dr. Jason Wright, the author of the study just mentioned, and other expert panelists discuss this issue in more depth.^2,3 They also note, as does Dr. Swor, that spillage, contamination, or outright tumor rupture is possible regardless of the route of hysterectomy.

References

1. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation [published online ahead of print July 22, 2014]. JAMA. doi: 10.1001/jama.2014.9005.

2. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Best practices for an environment in flux. OBG Manage. 2014;26(9):44–51.

3. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Counseling the patient. OBG Manage. 2014;26(10):41–45. 

Share your thoughts on this or other articles! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Numerous studies on the reproductive safety of selective serotonin reuptake inhibitors (SSRIs) have been published, particularly over the last decade. With the different methodologies used and often disparate results, the extensive data now available in the medical literature can be overwhelming for clinicians and researchers to sort through. Many of the most recently published studies derive from analyses using large administrative databases, from sources such as Medicare, Medicaid, or large HMO databases. Less common are prospective cohort studies, where patients with or without a history of exposure to SSRIs are followed across pregnancy in real time.

Studies over the past 5-10 years have consistently suggested that the risk of major congenital malformations associated with fetal exposure to SSRIs is nonexistent or modest. A major criticism of this literature has been that much of the data are derived from claims databases, which do not adequately account for the potential confounding effect of major depression – so-called “confounding by indication.”

While the consensus is that fetal exposure to SSRIs is not associated with a significant overall risk for major congenital malformations, questions have lingered about whether antidepressant exposure during pregnancy increases risk for cardiac defects. This had been a particular concern with respect to paroxetine, which in 2006 was changed from a pregnancy category C to D because of a purported increase in risk of heart defects associated with first-trimester exposure to this medication.

This issue was addressed again in a large population cohort study published this past June, using Medicaid data from 2000-2007. The study, in which I participated, involved a collaboration of investigators representing epidemiology, teratology, and reproductive psychiatry (N. Engl. J. Med. 2014;370:2397-2407). The study compared the risk of major cardiac defects in babies with and without exposure to antidepressants during the first trimester, providing a risk estimate unadjusted for depression, and an analysis that adjusted for the potential effect of depression and other potential confounders using propensity score adjustment methodology. (Propensity scores are an analytic tool that makes it possible to match groups with the exception of the variable being scrutinized, to minimize confounding.)

Results indicated that the increased risk identified in the unadjusted analysis is attenuated when factoring in depression: Compared with those not exposed to SSRIs, the unadjusted relative risk of any cardiac defect associated with SSRI exposure was 1.25. But with the fully adjusted analysis, the relative risk approached the null, at 1.06, and is not significant. The results are noteworthy because of the large sample size and the effort to control for relevant confounding factors, relevant to many other previously published studies evaluating risk of fetal SSRI exposure.

One would imagine that the increasing number of studies such as this one would be helpful to clinicians. But it can be very challenging for clinicians and even clinical researchers to navigate the growing literature and to attempt to parse out the methodologic strengths and limitations of the various analyses put forth. What makes interpretation of these growing data even more complicated is that reviews of this topic frequently are selective, and reflect what the author chooses to highlight, with resulting conclusions about safety that may be incomplete. The issue is relevant with respect to the medical literature and even the more general media.

An example is the recent publication of an article in the New York Times about whether antidepressants are safe during pregnancy. The article elicited volley after volley of diverse replies, expressing both outrage at the selective reference of studies associating antidepressants with increased fetal risk, as well as criticism of potential cavalier prescribing and use of antidepressants during pregnancy, with their risks still not absolutely quantified. The New York Times public editor also weighed in with a response, writing in a column that “readers – many of them doctors – wrote to complain that the article was inappropriately alarmist, and that the idea behind it was dangerous for pregnant women suffering from depression.”

As my colleagues and I wrote in a response to the article in a blog, whatever the reason for the brevity, a “cursory presentation of the complexity of decisions made around antidepressant use during pregnancy” can potentially be harmful to patients, and at best “is just incomplete; at its worst, it is irresponsible.”

Perhaps of even greater concern than the selective discussion of studies was the implication in the article that the decision to take antidepressants during pregnancy is similar to the decision to give up wine, caffeine, and ripened cheese across such an important time. The decision is certainly not that simple. After more than 2 decades and thousands of consults with women contemplating the decision of whether to take an SSRI during pregnancy or not, I remain impressed with the bind faced by patients with major depression who are trying to make this decision with their doctors and partners, applying their own private calculus to the question of whether to use antidepressants during pregnancy.

What is also ironic is that there is common use of other medications during pregnancy for which there are vastly less available reproductive safety data. These medicines would include, for example, sedative hypnotics or antibiotics; so why the enormous concern about SSRIs? One has to wonder whether the scrutiny about SSRIs is not about using the medication but is related to bias regarding the use of a medicine during pregnancy to treat an illness such as depression, where many people, including clinicians, would discount the devastating effect of depression on women’s lives – as well as the evolving data on the impact of untreated psychiatric illness on fetal well-being, and the well-documented association between psychiatric illness during pregnancy and increased risk for postpartum depression.

Ironically, the availability of more data has not made it easier for the clinician but has brought about a need for greater scrutiny; the conversation about this issue is probably good for the field. Ultimately, decisions about what women choose to do will be made on a case-by-case basis, as individuals make the decision with their doctors and partners using available data in the context of their individual clinical situations, factoring in severity of illness as well as their own individual wishes.

Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information about reproductive mental health at www.womensmentalhealth.org. He is a consultant to manufacturers of antidepressant medications. He was an author of the NEJM study, which was funded by the U.S. Agency for Healthcare Research and Quality and the National Institutes of Health. To comment, e-mail him at [email protected].

Numerous studies on the reproductive safety of selective serotonin reuptake inhibitors (SSRIs) have been published, particularly over the last decade. With the different methodologies used and often disparate results, the extensive data now available in the medical literature can be overwhelming for clinicians and researchers to sort through. Many of the most recently published studies derive from analyses using large administrative databases, from sources such as Medicare, Medicaid, or large HMO databases. Less common are prospective cohort studies, where patients with or without a history of exposure to SSRIs are followed across pregnancy in real time.

Studies over the past 5-10 years have consistently suggested that the risk of major congenital malformations associated with fetal exposure to SSRIs is nonexistent or modest. A major criticism of this literature has been that much of the data are derived from claims databases, which do not adequately account for the potential confounding effect of major depression – so-called “confounding by indication.”

While the consensus is that fetal exposure to SSRIs is not associated with a significant overall risk for major congenital malformations, questions have lingered about whether antidepressant exposure during pregnancy increases risk for cardiac defects. This had been a particular concern with respect to paroxetine, which in 2006 was changed from a pregnancy category C to D because of a purported increase in risk of heart defects associated with first-trimester exposure to this medication.

This issue was addressed again in a large population cohort study published this past June, using Medicaid data from 2000-2007. The study, in which I participated, involved a collaboration of investigators representing epidemiology, teratology, and reproductive psychiatry (N. Engl. J. Med. 2014;370:2397-2407). The study compared the risk of major cardiac defects in babies with and without exposure to antidepressants during the first trimester, providing a risk estimate unadjusted for depression, and an analysis that adjusted for the potential effect of depression and other potential confounders using propensity score adjustment methodology. (Propensity scores are an analytic tool that makes it possible to match groups with the exception of the variable being scrutinized, to minimize confounding.)

Results indicated that the increased risk identified in the unadjusted analysis is attenuated when factoring in depression: Compared with those not exposed to SSRIs, the unadjusted relative risk of any cardiac defect associated with SSRI exposure was 1.25. But with the fully adjusted analysis, the relative risk approached the null, at 1.06, and is not significant. The results are noteworthy because of the large sample size and the effort to control for relevant confounding factors, relevant to many other previously published studies evaluating risk of fetal SSRI exposure.

One would imagine that the increasing number of studies such as this one would be helpful to clinicians. But it can be very challenging for clinicians and even clinical researchers to navigate the growing literature and to attempt to parse out the methodologic strengths and limitations of the various analyses put forth. What makes interpretation of these growing data even more complicated is that reviews of this topic frequently are selective, and reflect what the author chooses to highlight, with resulting conclusions about safety that may be incomplete. The issue is relevant with respect to the medical literature and even the more general media.

An example is the recent publication of an article in the New York Times about whether antidepressants are safe during pregnancy. The article elicited volley after volley of diverse replies, expressing both outrage at the selective reference of studies associating antidepressants with increased fetal risk, as well as criticism of potential cavalier prescribing and use of antidepressants during pregnancy, with their risks still not absolutely quantified. The New York Times public editor also weighed in with a response, writing in a column that “readers – many of them doctors – wrote to complain that the article was inappropriately alarmist, and that the idea behind it was dangerous for pregnant women suffering from depression.”

As my colleagues and I wrote in a response to the article in a blog, whatever the reason for the brevity, a “cursory presentation of the complexity of decisions made around antidepressant use during pregnancy” can potentially be harmful to patients, and at best “is just incomplete; at its worst, it is irresponsible.”

Perhaps of even greater concern than the selective discussion of studies was the implication in the article that the decision to take antidepressants during pregnancy is similar to the decision to give up wine, caffeine, and ripened cheese across such an important time. The decision is certainly not that simple. After more than 2 decades and thousands of consults with women contemplating the decision of whether to take an SSRI during pregnancy or not, I remain impressed with the bind faced by patients with major depression who are trying to make this decision with their doctors and partners, applying their own private calculus to the question of whether to use antidepressants during pregnancy.

What is also ironic is that there is common use of other medications during pregnancy for which there are vastly less available reproductive safety data. These medicines would include, for example, sedative hypnotics or antibiotics; so why the enormous concern about SSRIs? One has to wonder whether the scrutiny about SSRIs is not about using the medication but is related to bias regarding the use of a medicine during pregnancy to treat an illness such as depression, where many people, including clinicians, would discount the devastating effect of depression on women’s lives – as well as the evolving data on the impact of untreated psychiatric illness on fetal well-being, and the well-documented association between psychiatric illness during pregnancy and increased risk for postpartum depression.

Ironically, the availability of more data has not made it easier for the clinician but has brought about a need for greater scrutiny; the conversation about this issue is probably good for the field. Ultimately, decisions about what women choose to do will be made on a case-by-case basis, as individuals make the decision with their doctors and partners using available data in the context of their individual clinical situations, factoring in severity of illness as well as their own individual wishes.

Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information about reproductive mental health at www.womensmentalhealth.org. He is a consultant to manufacturers of antidepressant medications. He was an author of the NEJM study, which was funded by the U.S. Agency for Healthcare Research and Quality and the National Institutes of Health. To comment, e-mail him at [email protected].

Numerous studies on the reproductive safety of selective serotonin reuptake inhibitors (SSRIs) have been published, particularly over the last decade. With the different methodologies used and often disparate results, the extensive data now available in the medical literature can be overwhelming for clinicians and researchers to sort through. Many of the most recently published studies derive from analyses using large administrative databases, from sources such as Medicare, Medicaid, or large HMO databases. Less common are prospective cohort studies, where patients with or without a history of exposure to SSRIs are followed across pregnancy in real time.

Studies over the past 5-10 years have consistently suggested that the risk of major congenital malformations associated with fetal exposure to SSRIs is nonexistent or modest. A major criticism of this literature has been that much of the data are derived from claims databases, which do not adequately account for the potential confounding effect of major depression – so-called “confounding by indication.”

While the consensus is that fetal exposure to SSRIs is not associated with a significant overall risk for major congenital malformations, questions have lingered about whether antidepressant exposure during pregnancy increases risk for cardiac defects. This had been a particular concern with respect to paroxetine, which in 2006 was changed from a pregnancy category C to D because of a purported increase in risk of heart defects associated with first-trimester exposure to this medication.

This issue was addressed again in a large population cohort study published this past June, using Medicaid data from 2000-2007. The study, in which I participated, involved a collaboration of investigators representing epidemiology, teratology, and reproductive psychiatry (N. Engl. J. Med. 2014;370:2397-2407). The study compared the risk of major cardiac defects in babies with and without exposure to antidepressants during the first trimester, providing a risk estimate unadjusted for depression, and an analysis that adjusted for the potential effect of depression and other potential confounders using propensity score adjustment methodology. (Propensity scores are an analytic tool that makes it possible to match groups with the exception of the variable being scrutinized, to minimize confounding.)

Results indicated that the increased risk identified in the unadjusted analysis is attenuated when factoring in depression: Compared with those not exposed to SSRIs, the unadjusted relative risk of any cardiac defect associated with SSRI exposure was 1.25. But with the fully adjusted analysis, the relative risk approached the null, at 1.06, and is not significant. The results are noteworthy because of the large sample size and the effort to control for relevant confounding factors, relevant to many other previously published studies evaluating risk of fetal SSRI exposure.

One would imagine that the increasing number of studies such as this one would be helpful to clinicians. But it can be very challenging for clinicians and even clinical researchers to navigate the growing literature and to attempt to parse out the methodologic strengths and limitations of the various analyses put forth. What makes interpretation of these growing data even more complicated is that reviews of this topic frequently are selective, and reflect what the author chooses to highlight, with resulting conclusions about safety that may be incomplete. The issue is relevant with respect to the medical literature and even the more general media.

An example is the recent publication of an article in the New York Times about whether antidepressants are safe during pregnancy. The article elicited volley after volley of diverse replies, expressing both outrage at the selective reference of studies associating antidepressants with increased fetal risk, as well as criticism of potential cavalier prescribing and use of antidepressants during pregnancy, with their risks still not absolutely quantified. The New York Times public editor also weighed in with a response, writing in a column that “readers – many of them doctors – wrote to complain that the article was inappropriately alarmist, and that the idea behind it was dangerous for pregnant women suffering from depression.”

As my colleagues and I wrote in a response to the article in a blog, whatever the reason for the brevity, a “cursory presentation of the complexity of decisions made around antidepressant use during pregnancy” can potentially be harmful to patients, and at best “is just incomplete; at its worst, it is irresponsible.”

Perhaps of even greater concern than the selective discussion of studies was the implication in the article that the decision to take antidepressants during pregnancy is similar to the decision to give up wine, caffeine, and ripened cheese across such an important time. The decision is certainly not that simple. After more than 2 decades and thousands of consults with women contemplating the decision of whether to take an SSRI during pregnancy or not, I remain impressed with the bind faced by patients with major depression who are trying to make this decision with their doctors and partners, applying their own private calculus to the question of whether to use antidepressants during pregnancy.

What is also ironic is that there is common use of other medications during pregnancy for which there are vastly less available reproductive safety data. These medicines would include, for example, sedative hypnotics or antibiotics; so why the enormous concern about SSRIs? One has to wonder whether the scrutiny about SSRIs is not about using the medication but is related to bias regarding the use of a medicine during pregnancy to treat an illness such as depression, where many people, including clinicians, would discount the devastating effect of depression on women’s lives – as well as the evolving data on the impact of untreated psychiatric illness on fetal well-being, and the well-documented association between psychiatric illness during pregnancy and increased risk for postpartum depression.

Ironically, the availability of more data has not made it easier for the clinician but has brought about a need for greater scrutiny; the conversation about this issue is probably good for the field. Ultimately, decisions about what women choose to do will be made on a case-by-case basis, as individuals make the decision with their doctors and partners using available data in the context of their individual clinical situations, factoring in severity of illness as well as their own individual wishes.

Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information about reproductive mental health at www.womensmentalhealth.org. He is a consultant to manufacturers of antidepressant medications. He was an author of the NEJM study, which was funded by the U.S. Agency for Healthcare Research and Quality and the National Institutes of Health. To comment, e-mail him at [email protected].

Gone are the days when, upon completion of training, the newly minted orthopedic surgeon would return to his or her hometown, raise a shingle, and begin a busy practice. Did these halcyon days ever exist? Who knows?

What I do know is that 75% of our shoulder fellowship graduates (my partner, Frances Cuomo, MD, and I offer an ACGME-accredited fellowship in shoulder surgery at Mount Sinai Beth Israel) in the past 10 years have accepted jobs as
employees of HMOs or hospital systems. They prefer the certainty of regular hours and incentive options offered by these institutions to the potential opportunities of greater (or lesser!) rewards as an entrepreneur in private practice.

I also know my local New York metropolitan orthopedic market, where the recent trend is towards consolidation among large medical centers. In September 2013, Mount Sinai Medical Center merged with the hospital where I work (full disclosure: I have been a full-time employee of my hospital since 1996), Continuum Health Partners, a consortium of 3 academic hospitals in Manhattan (Beth Israel Medical Center, St. Luke’s Roosevelt Hospital, and New York Eye and Ear Infirmary), to form the Mount Sinai Health System, currently the largest health care system in New York City. Other medical centers in the New York metropolitan region are actively recruiting physicians in private practice to join their respective institutions. Among the institutional goals, in addition to improving the scope, coordination, and efficiency of care, is to appoint as many practitioners as possible to increase the
number of patients treated by the particular medical center in certain geographic areas. Hence, the practice landscape in the New York metropolitan region is changing dramatically and reflects similar changes throughout the country.

While many practitioners of a certain generation, like mine, may lament the loss of those good old days as independent private practitioners, where self-reliance and experience dictated orthopedic practice, the reality is that today the business of medicine is the largest sector of our national economy, currently approaching 20% of the gross domestic product (GDP),¹ and that individual practitioners no longer
really control their practices. The number of independent physicians and surgeons is diminishing, and our practice environment is changing drastically. What’s an orthopedic surgeon to do?

Medical reports are abuzz with new terminology: accountable care organizations, population management, value-based care, etc.¹ They all reflect a fundamental shift in health care financing away from our current model of fee for services rendered to that of a global payment for groups of patients in which the outcome of treatment, not the number of procedures or interventions, is compensated. How such a bundled payment that covers the health care requirements for a population will be distributed among the various practitioners is extremely complicated and, to date, not widely embraced. However, these changes are coming.

To succeed in the future health care arena, I believe orthopedic surgeons must have 2 prerequisites. First, there must be reliable data that not only report accurate diagnoses, procedures, and outcomes of treatment (risk-adjusted by medical comorbidities and economic status) but also include the financial costs of treatment. Second, orthopedic surgeons must participate in the decision-making process and the development of treatment algorithms that will be ever-increasing elements of medical practice. Who better than practicing orthopedic surgeons should recommend treatment guidelines based on best practice and prudent
economics?

The new landscape of medical practice isn’t coming—it has already arrived. It behooves us practicing orthopedic surgeons to be involved in the decision-making process that will determine musculoskeletal care and to partner with our hospital and insurance administrators to establish the parameters that will deliver efficient and high-quality care to our patients. ◾

Reference
1. Black EM, Warner JJ. 5 points on value in orthopedic surgery. Am J
Orthop. 2013;42(1):22-25.

Gone are the days when, upon completion of training, the newly minted orthopedic surgeon would return to his or her hometown, raise a shingle, and begin a busy practice. Did these halcyon days ever exist? Who knows?

What I do know is that 75% of our shoulder fellowship graduates (my partner, Frances Cuomo, MD, and I offer an ACGME-accredited fellowship in shoulder surgery at Mount Sinai Beth Israel) in the past 10 years have accepted jobs as
employees of HMOs or hospital systems. They prefer the certainty of regular hours and incentive options offered by these institutions to the potential opportunities of greater (or lesser!) rewards as an entrepreneur in private practice.

I also know my local New York metropolitan orthopedic market, where the recent trend is towards consolidation among large medical centers. In September 2013, Mount Sinai Medical Center merged with the hospital where I work (full disclosure: I have been a full-time employee of my hospital since 1996), Continuum Health Partners, a consortium of 3 academic hospitals in Manhattan (Beth Israel Medical Center, St. Luke’s Roosevelt Hospital, and New York Eye and Ear Infirmary), to form the Mount Sinai Health System, currently the largest health care system in New York City. Other medical centers in the New York metropolitan region are actively recruiting physicians in private practice to join their respective institutions. Among the institutional goals, in addition to improving the scope, coordination, and efficiency of care, is to appoint as many practitioners as possible to increase the
number of patients treated by the particular medical center in certain geographic areas. Hence, the practice landscape in the New York metropolitan region is changing dramatically and reflects similar changes throughout the country.

While many practitioners of a certain generation, like mine, may lament the loss of those good old days as independent private practitioners, where self-reliance and experience dictated orthopedic practice, the reality is that today the business of medicine is the largest sector of our national economy, currently approaching 20% of the gross domestic product (GDP),¹ and that individual practitioners no longer
really control their practices. The number of independent physicians and surgeons is diminishing, and our practice environment is changing drastically. What’s an orthopedic surgeon to do?

Medical reports are abuzz with new terminology: accountable care organizations, population management, value-based care, etc.¹ They all reflect a fundamental shift in health care financing away from our current model of fee for services rendered to that of a global payment for groups of patients in which the outcome of treatment, not the number of procedures or interventions, is compensated. How such a bundled payment that covers the health care requirements for a population will be distributed among the various practitioners is extremely complicated and, to date, not widely embraced. However, these changes are coming.

To succeed in the future health care arena, I believe orthopedic surgeons must have 2 prerequisites. First, there must be reliable data that not only report accurate diagnoses, procedures, and outcomes of treatment (risk-adjusted by medical comorbidities and economic status) but also include the financial costs of treatment. Second, orthopedic surgeons must participate in the decision-making process and the development of treatment algorithms that will be ever-increasing elements of medical practice. Who better than practicing orthopedic surgeons should recommend treatment guidelines based on best practice and prudent
economics?

The new landscape of medical practice isn’t coming—it has already arrived. It behooves us practicing orthopedic surgeons to be involved in the decision-making process that will determine musculoskeletal care and to partner with our hospital and insurance administrators to establish the parameters that will deliver efficient and high-quality care to our patients. ◾

Reference
1. Black EM, Warner JJ. 5 points on value in orthopedic surgery. Am J
Orthop. 2013;42(1):22-25.

Gone are the days when, upon completion of training, the newly minted orthopedic surgeon would return to his or her hometown, raise a shingle, and begin a busy practice. Did these halcyon days ever exist? Who knows?

What I do know is that 75% of our shoulder fellowship graduates (my partner, Frances Cuomo, MD, and I offer an ACGME-accredited fellowship in shoulder surgery at Mount Sinai Beth Israel) in the past 10 years have accepted jobs as
employees of HMOs or hospital systems. They prefer the certainty of regular hours and incentive options offered by these institutions to the potential opportunities of greater (or lesser!) rewards as an entrepreneur in private practice.

I also know my local New York metropolitan orthopedic market, where the recent trend is towards consolidation among large medical centers. In September 2013, Mount Sinai Medical Center merged with the hospital where I work (full disclosure: I have been a full-time employee of my hospital since 1996), Continuum Health Partners, a consortium of 3 academic hospitals in Manhattan (Beth Israel Medical Center, St. Luke’s Roosevelt Hospital, and New York Eye and Ear Infirmary), to form the Mount Sinai Health System, currently the largest health care system in New York City. Other medical centers in the New York metropolitan region are actively recruiting physicians in private practice to join their respective institutions. Among the institutional goals, in addition to improving the scope, coordination, and efficiency of care, is to appoint as many practitioners as possible to increase the
number of patients treated by the particular medical center in certain geographic areas. Hence, the practice landscape in the New York metropolitan region is changing dramatically and reflects similar changes throughout the country.

While many practitioners of a certain generation, like mine, may lament the loss of those good old days as independent private practitioners, where self-reliance and experience dictated orthopedic practice, the reality is that today the business of medicine is the largest sector of our national economy, currently approaching 20% of the gross domestic product (GDP),¹ and that individual practitioners no longer
really control their practices. The number of independent physicians and surgeons is diminishing, and our practice environment is changing drastically. What’s an orthopedic surgeon to do?

Medical reports are abuzz with new terminology: accountable care organizations, population management, value-based care, etc.¹ They all reflect a fundamental shift in health care financing away from our current model of fee for services rendered to that of a global payment for groups of patients in which the outcome of treatment, not the number of procedures or interventions, is compensated. How such a bundled payment that covers the health care requirements for a population will be distributed among the various practitioners is extremely complicated and, to date, not widely embraced. However, these changes are coming.

To succeed in the future health care arena, I believe orthopedic surgeons must have 2 prerequisites. First, there must be reliable data that not only report accurate diagnoses, procedures, and outcomes of treatment (risk-adjusted by medical comorbidities and economic status) but also include the financial costs of treatment. Second, orthopedic surgeons must participate in the decision-making process and the development of treatment algorithms that will be ever-increasing elements of medical practice. Who better than practicing orthopedic surgeons should recommend treatment guidelines based on best practice and prudent
economics?

The new landscape of medical practice isn’t coming—it has already arrived. It behooves us practicing orthopedic surgeons to be involved in the decision-making process that will determine musculoskeletal care and to partner with our hospital and insurance administrators to establish the parameters that will deliver efficient and high-quality care to our patients. ◾

Reference
1. Black EM, Warner JJ. 5 points on value in orthopedic surgery. Am J
Orthop. 2013;42(1):22-25.

CASE: McRobert’s maneuver fails
You are attempting an early term vaginal delivery of a 31-year-old G2P1 woman with type 2 diabetes mellitus and an estimated fetal weight of 4,100 g. The fetal head has delivered but retracted against the perineum, producing the “turtle sign.”

You call a shoulder dystocia emergency and request help. In sequence, you tell the mother to stop pushing, check for a nuchal cord, and cut a mediolateral episiotomy. Working seamlessly with your nurse, you place the patient at the edge of the bed, perform the McRobert’s maneuver, provide suprapubic pressure and apply gentle downward guidance to the fetal head. Unfortunately, with these maneuvers the baby does not deliver.

What is your next obstetric maneuver?

With alacrity, move on to an advanced maneuver. In this article, I outline your options for this advanced maneuver and describe the technique for execution. First, however, I discuss the amount of time you have to work with.

How long do you have to perform advanced maneuvers?
In managing a difficult shoulder dystocia, critical goals are to avoid permanent injury to the newborn, including brachial plexus injury, fetal asphyxia, central nervous system injury, and death. Many experts believe that the accoucheur has approximately 4 or 5 minutes to deliver the impacted fetus before the risk of these adverse outcomes rises substantially.^1-3 In one study, a head-to-body delivery interval of less than 5 minutes and 5 minutes or longer were associated with rates of hypoxic ischemic encephalopathy of 0.5% and 24%, respectively.²

Stay calm, move on. Given the time pressure for management, it is important to initiate an advanced maneuver, such as rotation of the fetal body or delivery of the posterior arm, when the initial sequence of McRobert’s maneuver, suprapubic pressure, and gentle downward guidance on the fetal head do not result in delivery. Repetitively repeating these initial maneuvers will increase the risk of an adverse fetal outcome. Stay calm and quickly move on to an advanced maneuver.

Advanced maneuvers
The two advanced shoulder dystocia maneuvers that often result in a successful birth are:

• rotation of the fetal shoulders
• delivery of the posterior arm.^4,5

In a prior editorial, I described in detail the Woods and Rubin rotational maneuvers.⁶ In this editorial, I focus on the technique for delivery of the posterior arm.

Delivery of the posterior arm
This maneuver to resolve difficult shoulder dystocia deliveries has been in the armamentarium of obstetricians since at least the mid-18th Century.⁷ The delivery of the posterior arm reduces the presenting fetal diameter from the larger bisacromial diameter to the smaller axilloacromial diameter. Experts estimate that this change results in a 2-cm decrease in the presenting fetal diameter, thereby facilitating delivery.^8,9

In describing posterior arm delivery, it is important to clearly define the anatomy of the upper extremity. The arm is the portion of the upper extremity from the shoulder to the elbow joint.  The long bone of the arm is the humerus. The forearm is the portion of the upper extremity from the elbow to the wrist. The long bones of the forearm are the radius and ulna.

Descriptions of how to deliver the posterior arm range from concise to detailed. A concise description recommends “inserting a hand in the vagina, grasping the fetal arm, and sweeping it across the chest.”⁹

These detailed instructions are provided by Dr. John Rodis, Chief of Obstetrics and Gynecology at St. Francis Hospital in Hartford Connecticut, in UpToDate:

Additional technical guidance. After grasping the fetal wrist and hand, pull the upper extremity against the fetal chest. Approaching the vaginal introitus, pull the wrist and hand toward the fetal ear nearest the maternal symphysis pubis.¹¹ These maneuvers may result in a fracture to the humerus, but this complication is acceptable given the risk of fetal asphyxia and death.

Approaches to grasping the posterior arm
The posterior arm may be in one of three positions, and your approach to each position will be different.

Fetal hand near the chin. Delivery of the posterior arm is relatively easy when the fetal hand is in this position. Grasp the wrist gently and guide it out of the vagina. The fetal wrist should be pulled toward the fetal ear closest to the maternal symphysis.

Fetal hand on the abdomen. In this position, the operator can exert pressure on the antecubital fossa with the index and middle fingers, resulting in flexion of the forearm at the elbow. This will bring the fetal hand and wrist to the upper chest. The wrist then can be grasped and pronated over the fetal chest. The wrist and forearm are then pulled upward along the chest toward the fetal ear closest to the maternal symphysis. 

Fetal upper extremity is extended with the hand next to the thigh. The most challenging situation is when the upper extremity of the fetus is extended along the trunk or behind the buttocks. In this situation the hand and wrist may be near the fetal thigh and very difficult to reach. In addition, the upper extremity may be tightly pinned between fetal trunk and maternal tissues, making it impossible to flex the forearm by gentle pressure on the antecubital fossa.

In this situation the operator’s hand must reach the fetal wrist and distal forearm, grasp these structures, and pull hard across the trunk to free the pinned upper extremity. The fetal wrist and distal forearm can be securely grasped using techniques pictured in the Figure. It can take 30 to 90 seconds for the operator to place a hand in the vagina, identify the posterior shoulder, follow the extended arm to the hand, and secure the wrist. Given the amount of time that it may take to accomplish the first steps of the maneuver, the nurse in the room should call out the time elapsed since the birth of the head at regular intervals to assist the obstetrician in pacing the speed of the intervention.

___________________________________________________________________________________________________

		Figure. When the fetal upper extremity is extended and the hand is near the fetal thigh the fetal upper extremity may be tightly pinned between maternal and fetal tissues. Gentle pressure in the antecubital fossa may not cause the forearm to flex toward the vaginal introitus. In this situation it may be very difficult to grasp the fetal wrist or forearm. The operator should be prepared to place their entire hand and forearm into the vagina to reach the fetal wrist (Top left). Two options for grasping the fetal wrist are with the index finger and middle finger (Top right), or by encircling the wrist with the thumb and index finger (Bottom left). For many obstetricians, the index and middle fingers extend much further from their wrist than the thumb. Consequently, when the fetal wrist and hand are against the fetal thigh it may be easier to reach the fetal wrist with the operator’s index and middle finger. However, many obstetricians find that the thumb and index finger provide a more secure grip of the fetal wrist.

______________________________________________________________________________________________________

When the posterior arm is fully extended and pinned between fetal trunk and maternal tissues it can be very difficult to reach the fetal wrist. To help successfully complete the maneuver, the obstetrician should visualize placing his or her hand and entire forearm up to the elbow in the vagina to reach the fetal wrist. It may not be necessary to insert the entire forearm in the vagina, but the operator should visualize this step so he or she is prepared for the possibility.Surprisingly, the hollow of the sacrum often provides sufficient space for inserting the hand and entire forearm of the operator. In this process the operator’s hand and forearm may be strongly compressed by maternal and fetal tissues, cutting off circulation to the upper extremity. The operator’s upper extremity may quickly become numb, resulting in a reduction in tactile sensation and strength.

If the posterior arm is positioned behind the back of the fetus, maneuvers similar to those described above can be used to grasp the wrist and pull the arm to the anterior side of the fetal trunk, followed by delivery of the posterior arm.

Practice, practice, and practice some more
Obstetric emergencies create a rush of adrenaline and great stress for the obstetrician. This may adversely impact motor performance, decision-making, and communication skills.¹² Low- and high-fidelity simulation exercises permit the obstetrics team to practice the sequence of maneuvers necessary to successfully resolve a shoulder dystocia, thereby reducing stress and improving performance when the emergency actually occurs.¹³ Simulating obstetric emergencies and visualizing the steps necessary to resolve an emergency are good approaches to prepare obstetricians for the most challenging emergencies. For the difficult to resolve shoulder dystocia, my recommendation is: “Deliver the posterior arm.”

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE: McRobert’s maneuver fails
You are attempting an early term vaginal delivery of a 31-year-old G2P1 woman with type 2 diabetes mellitus and an estimated fetal weight of 4,100 g. The fetal head has delivered but retracted against the perineum, producing the “turtle sign.”

You call a shoulder dystocia emergency and request help. In sequence, you tell the mother to stop pushing, check for a nuchal cord, and cut a mediolateral episiotomy. Working seamlessly with your nurse, you place the patient at the edge of the bed, perform the McRobert’s maneuver, provide suprapubic pressure and apply gentle downward guidance to the fetal head. Unfortunately, with these maneuvers the baby does not deliver.

What is your next obstetric maneuver?

With alacrity, move on to an advanced maneuver. In this article, I outline your options for this advanced maneuver and describe the technique for execution. First, however, I discuss the amount of time you have to work with.

How long do you have to perform advanced maneuvers?
In managing a difficult shoulder dystocia, critical goals are to avoid permanent injury to the newborn, including brachial plexus injury, fetal asphyxia, central nervous system injury, and death. Many experts believe that the accoucheur has approximately 4 or 5 minutes to deliver the impacted fetus before the risk of these adverse outcomes rises substantially.^1-3 In one study, a head-to-body delivery interval of less than 5 minutes and 5 minutes or longer were associated with rates of hypoxic ischemic encephalopathy of 0.5% and 24%, respectively.²

Stay calm, move on. Given the time pressure for management, it is important to initiate an advanced maneuver, such as rotation of the fetal body or delivery of the posterior arm, when the initial sequence of McRobert’s maneuver, suprapubic pressure, and gentle downward guidance on the fetal head do not result in delivery. Repetitively repeating these initial maneuvers will increase the risk of an adverse fetal outcome. Stay calm and quickly move on to an advanced maneuver.

Advanced maneuvers
The two advanced shoulder dystocia maneuvers that often result in a successful birth are:

• rotation of the fetal shoulders
• delivery of the posterior arm.^4,5

In a prior editorial, I described in detail the Woods and Rubin rotational maneuvers.⁶ In this editorial, I focus on the technique for delivery of the posterior arm.

Delivery of the posterior arm
This maneuver to resolve difficult shoulder dystocia deliveries has been in the armamentarium of obstetricians since at least the mid-18th Century.⁷ The delivery of the posterior arm reduces the presenting fetal diameter from the larger bisacromial diameter to the smaller axilloacromial diameter. Experts estimate that this change results in a 2-cm decrease in the presenting fetal diameter, thereby facilitating delivery.^8,9

In describing posterior arm delivery, it is important to clearly define the anatomy of the upper extremity. The arm is the portion of the upper extremity from the shoulder to the elbow joint.  The long bone of the arm is the humerus. The forearm is the portion of the upper extremity from the elbow to the wrist. The long bones of the forearm are the radius and ulna.

Descriptions of how to deliver the posterior arm range from concise to detailed. A concise description recommends “inserting a hand in the vagina, grasping the fetal arm, and sweeping it across the chest.”⁹

These detailed instructions are provided by Dr. John Rodis, Chief of Obstetrics and Gynecology at St. Francis Hospital in Hartford Connecticut, in UpToDate:

Additional technical guidance. After grasping the fetal wrist and hand, pull the upper extremity against the fetal chest. Approaching the vaginal introitus, pull the wrist and hand toward the fetal ear nearest the maternal symphysis pubis.¹¹ These maneuvers may result in a fracture to the humerus, but this complication is acceptable given the risk of fetal asphyxia and death.

Approaches to grasping the posterior arm
The posterior arm may be in one of three positions, and your approach to each position will be different.

Fetal hand near the chin. Delivery of the posterior arm is relatively easy when the fetal hand is in this position. Grasp the wrist gently and guide it out of the vagina. The fetal wrist should be pulled toward the fetal ear closest to the maternal symphysis.

Fetal hand on the abdomen. In this position, the operator can exert pressure on the antecubital fossa with the index and middle fingers, resulting in flexion of the forearm at the elbow. This will bring the fetal hand and wrist to the upper chest. The wrist then can be grasped and pronated over the fetal chest. The wrist and forearm are then pulled upward along the chest toward the fetal ear closest to the maternal symphysis. 

Fetal upper extremity is extended with the hand next to the thigh. The most challenging situation is when the upper extremity of the fetus is extended along the trunk or behind the buttocks. In this situation the hand and wrist may be near the fetal thigh and very difficult to reach. In addition, the upper extremity may be tightly pinned between fetal trunk and maternal tissues, making it impossible to flex the forearm by gentle pressure on the antecubital fossa.

In this situation the operator’s hand must reach the fetal wrist and distal forearm, grasp these structures, and pull hard across the trunk to free the pinned upper extremity. The fetal wrist and distal forearm can be securely grasped using techniques pictured in the Figure. It can take 30 to 90 seconds for the operator to place a hand in the vagina, identify the posterior shoulder, follow the extended arm to the hand, and secure the wrist. Given the amount of time that it may take to accomplish the first steps of the maneuver, the nurse in the room should call out the time elapsed since the birth of the head at regular intervals to assist the obstetrician in pacing the speed of the intervention.

___________________________________________________________________________________________________

		Figure. When the fetal upper extremity is extended and the hand is near the fetal thigh the fetal upper extremity may be tightly pinned between maternal and fetal tissues. Gentle pressure in the antecubital fossa may not cause the forearm to flex toward the vaginal introitus. In this situation it may be very difficult to grasp the fetal wrist or forearm. The operator should be prepared to place their entire hand and forearm into the vagina to reach the fetal wrist (Top left). Two options for grasping the fetal wrist are with the index finger and middle finger (Top right), or by encircling the wrist with the thumb and index finger (Bottom left). For many obstetricians, the index and middle fingers extend much further from their wrist than the thumb. Consequently, when the fetal wrist and hand are against the fetal thigh it may be easier to reach the fetal wrist with the operator’s index and middle finger. However, many obstetricians find that the thumb and index finger provide a more secure grip of the fetal wrist.

______________________________________________________________________________________________________

When the posterior arm is fully extended and pinned between fetal trunk and maternal tissues it can be very difficult to reach the fetal wrist. To help successfully complete the maneuver, the obstetrician should visualize placing his or her hand and entire forearm up to the elbow in the vagina to reach the fetal wrist. It may not be necessary to insert the entire forearm in the vagina, but the operator should visualize this step so he or she is prepared for the possibility.Surprisingly, the hollow of the sacrum often provides sufficient space for inserting the hand and entire forearm of the operator. In this process the operator’s hand and forearm may be strongly compressed by maternal and fetal tissues, cutting off circulation to the upper extremity. The operator’s upper extremity may quickly become numb, resulting in a reduction in tactile sensation and strength.

If the posterior arm is positioned behind the back of the fetus, maneuvers similar to those described above can be used to grasp the wrist and pull the arm to the anterior side of the fetal trunk, followed by delivery of the posterior arm.

Practice, practice, and practice some more
Obstetric emergencies create a rush of adrenaline and great stress for the obstetrician. This may adversely impact motor performance, decision-making, and communication skills.¹² Low- and high-fidelity simulation exercises permit the obstetrics team to practice the sequence of maneuvers necessary to successfully resolve a shoulder dystocia, thereby reducing stress and improving performance when the emergency actually occurs.¹³ Simulating obstetric emergencies and visualizing the steps necessary to resolve an emergency are good approaches to prepare obstetricians for the most challenging emergencies. For the difficult to resolve shoulder dystocia, my recommendation is: “Deliver the posterior arm.”

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE: McRobert’s maneuver fails
You are attempting an early term vaginal delivery of a 31-year-old G2P1 woman with type 2 diabetes mellitus and an estimated fetal weight of 4,100 g. The fetal head has delivered but retracted against the perineum, producing the “turtle sign.”

You call a shoulder dystocia emergency and request help. In sequence, you tell the mother to stop pushing, check for a nuchal cord, and cut a mediolateral episiotomy. Working seamlessly with your nurse, you place the patient at the edge of the bed, perform the McRobert’s maneuver, provide suprapubic pressure and apply gentle downward guidance to the fetal head. Unfortunately, with these maneuvers the baby does not deliver.

What is your next obstetric maneuver?

With alacrity, move on to an advanced maneuver. In this article, I outline your options for this advanced maneuver and describe the technique for execution. First, however, I discuss the amount of time you have to work with.

How long do you have to perform advanced maneuvers?
In managing a difficult shoulder dystocia, critical goals are to avoid permanent injury to the newborn, including brachial plexus injury, fetal asphyxia, central nervous system injury, and death. Many experts believe that the accoucheur has approximately 4 or 5 minutes to deliver the impacted fetus before the risk of these adverse outcomes rises substantially.^1-3 In one study, a head-to-body delivery interval of less than 5 minutes and 5 minutes or longer were associated with rates of hypoxic ischemic encephalopathy of 0.5% and 24%, respectively.²

Stay calm, move on. Given the time pressure for management, it is important to initiate an advanced maneuver, such as rotation of the fetal body or delivery of the posterior arm, when the initial sequence of McRobert’s maneuver, suprapubic pressure, and gentle downward guidance on the fetal head do not result in delivery. Repetitively repeating these initial maneuvers will increase the risk of an adverse fetal outcome. Stay calm and quickly move on to an advanced maneuver.

Advanced maneuvers
The two advanced shoulder dystocia maneuvers that often result in a successful birth are:

• rotation of the fetal shoulders
• delivery of the posterior arm.^4,5

In a prior editorial, I described in detail the Woods and Rubin rotational maneuvers.⁶ In this editorial, I focus on the technique for delivery of the posterior arm.

Delivery of the posterior arm
This maneuver to resolve difficult shoulder dystocia deliveries has been in the armamentarium of obstetricians since at least the mid-18th Century.⁷ The delivery of the posterior arm reduces the presenting fetal diameter from the larger bisacromial diameter to the smaller axilloacromial diameter. Experts estimate that this change results in a 2-cm decrease in the presenting fetal diameter, thereby facilitating delivery.^8,9

In describing posterior arm delivery, it is important to clearly define the anatomy of the upper extremity. The arm is the portion of the upper extremity from the shoulder to the elbow joint.  The long bone of the arm is the humerus. The forearm is the portion of the upper extremity from the elbow to the wrist. The long bones of the forearm are the radius and ulna.

Descriptions of how to deliver the posterior arm range from concise to detailed. A concise description recommends “inserting a hand in the vagina, grasping the fetal arm, and sweeping it across the chest.”⁹

These detailed instructions are provided by Dr. John Rodis, Chief of Obstetrics and Gynecology at St. Francis Hospital in Hartford Connecticut, in UpToDate:

Additional technical guidance. After grasping the fetal wrist and hand, pull the upper extremity against the fetal chest. Approaching the vaginal introitus, pull the wrist and hand toward the fetal ear nearest the maternal symphysis pubis.¹¹ These maneuvers may result in a fracture to the humerus, but this complication is acceptable given the risk of fetal asphyxia and death.

Approaches to grasping the posterior arm
The posterior arm may be in one of three positions, and your approach to each position will be different.

Fetal hand near the chin. Delivery of the posterior arm is relatively easy when the fetal hand is in this position. Grasp the wrist gently and guide it out of the vagina. The fetal wrist should be pulled toward the fetal ear closest to the maternal symphysis.

Fetal hand on the abdomen. In this position, the operator can exert pressure on the antecubital fossa with the index and middle fingers, resulting in flexion of the forearm at the elbow. This will bring the fetal hand and wrist to the upper chest. The wrist then can be grasped and pronated over the fetal chest. The wrist and forearm are then pulled upward along the chest toward the fetal ear closest to the maternal symphysis. 

Fetal upper extremity is extended with the hand next to the thigh. The most challenging situation is when the upper extremity of the fetus is extended along the trunk or behind the buttocks. In this situation the hand and wrist may be near the fetal thigh and very difficult to reach. In addition, the upper extremity may be tightly pinned between fetal trunk and maternal tissues, making it impossible to flex the forearm by gentle pressure on the antecubital fossa.

In this situation the operator’s hand must reach the fetal wrist and distal forearm, grasp these structures, and pull hard across the trunk to free the pinned upper extremity. The fetal wrist and distal forearm can be securely grasped using techniques pictured in the Figure. It can take 30 to 90 seconds for the operator to place a hand in the vagina, identify the posterior shoulder, follow the extended arm to the hand, and secure the wrist. Given the amount of time that it may take to accomplish the first steps of the maneuver, the nurse in the room should call out the time elapsed since the birth of the head at regular intervals to assist the obstetrician in pacing the speed of the intervention.

___________________________________________________________________________________________________

		Figure. When the fetal upper extremity is extended and the hand is near the fetal thigh the fetal upper extremity may be tightly pinned between maternal and fetal tissues. Gentle pressure in the antecubital fossa may not cause the forearm to flex toward the vaginal introitus. In this situation it may be very difficult to grasp the fetal wrist or forearm. The operator should be prepared to place their entire hand and forearm into the vagina to reach the fetal wrist (Top left). Two options for grasping the fetal wrist are with the index finger and middle finger (Top right), or by encircling the wrist with the thumb and index finger (Bottom left). For many obstetricians, the index and middle fingers extend much further from their wrist than the thumb. Consequently, when the fetal wrist and hand are against the fetal thigh it may be easier to reach the fetal wrist with the operator’s index and middle finger. However, many obstetricians find that the thumb and index finger provide a more secure grip of the fetal wrist.

______________________________________________________________________________________________________

When the posterior arm is fully extended and pinned between fetal trunk and maternal tissues it can be very difficult to reach the fetal wrist. To help successfully complete the maneuver, the obstetrician should visualize placing his or her hand and entire forearm up to the elbow in the vagina to reach the fetal wrist. It may not be necessary to insert the entire forearm in the vagina, but the operator should visualize this step so he or she is prepared for the possibility.Surprisingly, the hollow of the sacrum often provides sufficient space for inserting the hand and entire forearm of the operator. In this process the operator’s hand and forearm may be strongly compressed by maternal and fetal tissues, cutting off circulation to the upper extremity. The operator’s upper extremity may quickly become numb, resulting in a reduction in tactile sensation and strength.

If the posterior arm is positioned behind the back of the fetus, maneuvers similar to those described above can be used to grasp the wrist and pull the arm to the anterior side of the fetal trunk, followed by delivery of the posterior arm.

Practice, practice, and practice some more
Obstetric emergencies create a rush of adrenaline and great stress for the obstetrician. This may adversely impact motor performance, decision-making, and communication skills.¹² Low- and high-fidelity simulation exercises permit the obstetrics team to practice the sequence of maneuvers necessary to successfully resolve a shoulder dystocia, thereby reducing stress and improving performance when the emergency actually occurs.¹³ Simulating obstetric emergencies and visualizing the steps necessary to resolve an emergency are good approaches to prepare obstetricians for the most challenging emergencies. For the difficult to resolve shoulder dystocia, my recommendation is: “Deliver the posterior arm.”

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The clown/fool/jester is a recognizable figure in every culture. The clown is an archetype, a universal image that’s embedded in the brain. These images dwell in the unconscious mind. They can be animals, people, gods/goddesses, or objects (a tree, a house, a cross, or mandala) that are a staple in many myths and legends.

The clown lightens the mood; encourages us to laugh at ourselves (and the ridiculousness of life), pokes fun at convention, provides social commentary, and can get away with revealing that the emperor has no clothes. The clown is irreverent, flaunts taboos, and diffuses anxiety; in many cultures, the clown is a sacred healer, wisdom keeper, and serves as the community’s psychotherapist. The clown’s purpose is to help us look at the familiar from another perspective. This also is the purpose of psychotherapy; we psychiatrists help patients look at their old landscape with new eyes, and in so doing help them create new endings to their old stories.

It took me until midlife to embrace myself as clown healer, and I took this step only after many years of working with Native Americans as chief of psychiatry at the Phoenix Indian Medical Center. I went finally went public after meeting Dr. Patch Adams, perhaps the world’s most recognized humanitarian clown, more than 20 years ago.

This is the third year we have been conducting mental health clinics in the streets of Iquitos, Peru, which I have described before most recently last year . These street clinics are staffed by clowns who also happen to be health professionals representing many disciplines (doctors, nurses, psychologists, social workers, counselors, body workers, chaplains). They’re also part of a humanitarian clown trip that I make every year with Dr. Patch Adams and the Gesundheit! Institute in Hillsboro, W. Va., along with more than 100 clowns from around the world.

The impact of the clinics and on both ”patients “ and “therapists” has been profound. These encounters remind us that even in the presence of unimaginable suffering, connecting in this heartfelt way and remaining actively present in every moment makes suffering more bearable. They also remind us of the value of incorporating culture into treatment plans.

What is clown therapy?

Our clown-therapists will talk to people about anything that’s troubling them and work with them in open spaces (football fields, storefronts, loading docks, markets), sitting in a tight circle (with an interpreter for non–Spanish-speaking therapists) wearing a clown nose. We listen intently and are acutely present in every moment. We see people for 20 minutes and do not make diagnoses or prescribe pills, although we sometimes hand out amulets and give blessings.

As clown-therapists, we welcome the opportunity to get out of their heads and connect with people at the heart level. We delight in spontaneity, which facilitates opening channels into our unconscious minds, trusting that we will come up with something to say or do that will be helpful.

These clinicians can acknowledge suffering without becoming consumed by it … in the midst of crisis and/or pain they don’t “awful-ize” or “catastrophe-ize”; instead they have the capacity to identify people’s strengths and resilience and get a sense of what gives meaning to their lives. In a short time, such heartfelt connection can have a profound impact not only on the recipient but also the provider.

A case study

As a rule, we see people only once, but this year, I saw Maria, a 42-year-old woman twice. She was acutely suicidal, and after her morning prayers, decided today was the day she was going to kill herself. After 6 months of unbearable torment, she’d reached the end of her rope; she told me that her 20-year-old daughter had been raped 6 months earlier and was now pregnant. Maria’s family blamed her, saying that if she hadn’t divorced her husband 15 years earlier, this would not have happened. Maria knew she was not to blame, in which I concurred, but alas, she could not (as her family suggested) get over it and move on.

After listening, I told her I thought today was a miracle; this morning, she was ready to die, and this afternoon, we happened to show up on her street. I also said I believed the seriousness of her suicidal intent and told her she had two choices; I could hospitalize her, although I had no idea if that was even possible, or she could make me a promise – at least for today – that she would not kill herself.

Courtesy Gesunheit! Institute

I gave her an amulet that had been blessed by Navajo and Huichol shaman and said I wanted her to hold onto it during tomorrow’s morning prayers; she would feel our blessings and remember this miraculous day that we found one another. Perhaps tomorrow she could promise herself to also live for another day.

After the clinic, I couldn’t get her out of my mind, so after dinner I asked my clinic coordinator to check in on her the next day. We were going to be conducting another clinic not far from her home in a few days, and I asked her to invite Maria to the next clinic and to please bring her daughter, too.

Maria showed up not only with her 6-months’ pregnant daughter, but also with her younger 18-year-old daughter. Together, they told me the rest of the story. Both girls had been raped (the younger more than a year ago), and both by different maternal uncles. They had never spoken about it to anyone outside of their family, and although Maria had confronted her brothers, she refused to press charges. This is not a culture in which women prosecute their rapists.

Before we ended, I gave both girls an amulet and blessed the family; whatever they faced, they would face it better together; their love for one another would be showered on this new baby, and they would carry our blessings with them and those of many relatives all over the world.

In most Latin cultures, there is a strong belief in the power of spells, curses, and witchcraft, as well as in traditional healing practices and the power of faith. A critical element for successful healing in all cultures is the patient’s belief in the practice and in the practitioner.

As mental health professionals, we magnify our power not only with the pills we prescribe, but in also with the blessings and amulets we may bestow. And it doesn’t take a long time to connect at the soul level if you are actively in the moment, and it is in those miraculous moments that we are reminded of our shared humanity. Imagine if we used our 15-minute medication reviews to actually connect with people at this heartfelt level and talked about what’s really important to them. I’m thinking we could reduce our prescription writing by half and be reminded of the joys of psychotherapy.

Dr. Hammerschlag is chief of community mental health at the Gesundheit! Institute. He is also the author of several books on healing and spirituality, including Kindling Spirit: Healing from Within (New York: Turtle Island Press, 2012) and The Dancing Healers: A Doctor’s Journey of Healing With Native Americans (San Francisco: Harper, 1988). Dr. Hammerschlag’s website is healingdoc.com.

The clown/fool/jester is a recognizable figure in every culture. The clown is an archetype, a universal image that’s embedded in the brain. These images dwell in the unconscious mind. They can be animals, people, gods/goddesses, or objects (a tree, a house, a cross, or mandala) that are a staple in many myths and legends.

The clown lightens the mood; encourages us to laugh at ourselves (and the ridiculousness of life), pokes fun at convention, provides social commentary, and can get away with revealing that the emperor has no clothes. The clown is irreverent, flaunts taboos, and diffuses anxiety; in many cultures, the clown is a sacred healer, wisdom keeper, and serves as the community’s psychotherapist. The clown’s purpose is to help us look at the familiar from another perspective. This also is the purpose of psychotherapy; we psychiatrists help patients look at their old landscape with new eyes, and in so doing help them create new endings to their old stories.

It took me until midlife to embrace myself as clown healer, and I took this step only after many years of working with Native Americans as chief of psychiatry at the Phoenix Indian Medical Center. I went finally went public after meeting Dr. Patch Adams, perhaps the world’s most recognized humanitarian clown, more than 20 years ago.

This is the third year we have been conducting mental health clinics in the streets of Iquitos, Peru, which I have described before most recently last year . These street clinics are staffed by clowns who also happen to be health professionals representing many disciplines (doctors, nurses, psychologists, social workers, counselors, body workers, chaplains). They’re also part of a humanitarian clown trip that I make every year with Dr. Patch Adams and the Gesundheit! Institute in Hillsboro, W. Va., along with more than 100 clowns from around the world.

The impact of the clinics and on both ”patients “ and “therapists” has been profound. These encounters remind us that even in the presence of unimaginable suffering, connecting in this heartfelt way and remaining actively present in every moment makes suffering more bearable. They also remind us of the value of incorporating culture into treatment plans.

What is clown therapy?

Our clown-therapists will talk to people about anything that’s troubling them and work with them in open spaces (football fields, storefronts, loading docks, markets), sitting in a tight circle (with an interpreter for non–Spanish-speaking therapists) wearing a clown nose. We listen intently and are acutely present in every moment. We see people for 20 minutes and do not make diagnoses or prescribe pills, although we sometimes hand out amulets and give blessings.

As clown-therapists, we welcome the opportunity to get out of their heads and connect with people at the heart level. We delight in spontaneity, which facilitates opening channels into our unconscious minds, trusting that we will come up with something to say or do that will be helpful.

These clinicians can acknowledge suffering without becoming consumed by it … in the midst of crisis and/or pain they don’t “awful-ize” or “catastrophe-ize”; instead they have the capacity to identify people’s strengths and resilience and get a sense of what gives meaning to their lives. In a short time, such heartfelt connection can have a profound impact not only on the recipient but also the provider.

A case study

As a rule, we see people only once, but this year, I saw Maria, a 42-year-old woman twice. She was acutely suicidal, and after her morning prayers, decided today was the day she was going to kill herself. After 6 months of unbearable torment, she’d reached the end of her rope; she told me that her 20-year-old daughter had been raped 6 months earlier and was now pregnant. Maria’s family blamed her, saying that if she hadn’t divorced her husband 15 years earlier, this would not have happened. Maria knew she was not to blame, in which I concurred, but alas, she could not (as her family suggested) get over it and move on.

After listening, I told her I thought today was a miracle; this morning, she was ready to die, and this afternoon, we happened to show up on her street. I also said I believed the seriousness of her suicidal intent and told her she had two choices; I could hospitalize her, although I had no idea if that was even possible, or she could make me a promise – at least for today – that she would not kill herself.

Courtesy Gesunheit! Institute

I gave her an amulet that had been blessed by Navajo and Huichol shaman and said I wanted her to hold onto it during tomorrow’s morning prayers; she would feel our blessings and remember this miraculous day that we found one another. Perhaps tomorrow she could promise herself to also live for another day.

After the clinic, I couldn’t get her out of my mind, so after dinner I asked my clinic coordinator to check in on her the next day. We were going to be conducting another clinic not far from her home in a few days, and I asked her to invite Maria to the next clinic and to please bring her daughter, too.

Maria showed up not only with her 6-months’ pregnant daughter, but also with her younger 18-year-old daughter. Together, they told me the rest of the story. Both girls had been raped (the younger more than a year ago), and both by different maternal uncles. They had never spoken about it to anyone outside of their family, and although Maria had confronted her brothers, she refused to press charges. This is not a culture in which women prosecute their rapists.

Before we ended, I gave both girls an amulet and blessed the family; whatever they faced, they would face it better together; their love for one another would be showered on this new baby, and they would carry our blessings with them and those of many relatives all over the world.

In most Latin cultures, there is a strong belief in the power of spells, curses, and witchcraft, as well as in traditional healing practices and the power of faith. A critical element for successful healing in all cultures is the patient’s belief in the practice and in the practitioner.

As mental health professionals, we magnify our power not only with the pills we prescribe, but in also with the blessings and amulets we may bestow. And it doesn’t take a long time to connect at the soul level if you are actively in the moment, and it is in those miraculous moments that we are reminded of our shared humanity. Imagine if we used our 15-minute medication reviews to actually connect with people at this heartfelt level and talked about what’s really important to them. I’m thinking we could reduce our prescription writing by half and be reminded of the joys of psychotherapy.

Dr. Hammerschlag is chief of community mental health at the Gesundheit! Institute. He is also the author of several books on healing and spirituality, including Kindling Spirit: Healing from Within (New York: Turtle Island Press, 2012) and The Dancing Healers: A Doctor’s Journey of Healing With Native Americans (San Francisco: Harper, 1988). Dr. Hammerschlag’s website is healingdoc.com.

The clown/fool/jester is a recognizable figure in every culture. The clown is an archetype, a universal image that’s embedded in the brain. These images dwell in the unconscious mind. They can be animals, people, gods/goddesses, or objects (a tree, a house, a cross, or mandala) that are a staple in many myths and legends.

The clown lightens the mood; encourages us to laugh at ourselves (and the ridiculousness of life), pokes fun at convention, provides social commentary, and can get away with revealing that the emperor has no clothes. The clown is irreverent, flaunts taboos, and diffuses anxiety; in many cultures, the clown is a sacred healer, wisdom keeper, and serves as the community’s psychotherapist. The clown’s purpose is to help us look at the familiar from another perspective. This also is the purpose of psychotherapy; we psychiatrists help patients look at their old landscape with new eyes, and in so doing help them create new endings to their old stories.

It took me until midlife to embrace myself as clown healer, and I took this step only after many years of working with Native Americans as chief of psychiatry at the Phoenix Indian Medical Center. I went finally went public after meeting Dr. Patch Adams, perhaps the world’s most recognized humanitarian clown, more than 20 years ago.

This is the third year we have been conducting mental health clinics in the streets of Iquitos, Peru, which I have described before most recently last year . These street clinics are staffed by clowns who also happen to be health professionals representing many disciplines (doctors, nurses, psychologists, social workers, counselors, body workers, chaplains). They’re also part of a humanitarian clown trip that I make every year with Dr. Patch Adams and the Gesundheit! Institute in Hillsboro, W. Va., along with more than 100 clowns from around the world.

The impact of the clinics and on both ”patients “ and “therapists” has been profound. These encounters remind us that even in the presence of unimaginable suffering, connecting in this heartfelt way and remaining actively present in every moment makes suffering more bearable. They also remind us of the value of incorporating culture into treatment plans.

What is clown therapy?

Our clown-therapists will talk to people about anything that’s troubling them and work with them in open spaces (football fields, storefronts, loading docks, markets), sitting in a tight circle (with an interpreter for non–Spanish-speaking therapists) wearing a clown nose. We listen intently and are acutely present in every moment. We see people for 20 minutes and do not make diagnoses or prescribe pills, although we sometimes hand out amulets and give blessings.

As clown-therapists, we welcome the opportunity to get out of their heads and connect with people at the heart level. We delight in spontaneity, which facilitates opening channels into our unconscious minds, trusting that we will come up with something to say or do that will be helpful.

These clinicians can acknowledge suffering without becoming consumed by it … in the midst of crisis and/or pain they don’t “awful-ize” or “catastrophe-ize”; instead they have the capacity to identify people’s strengths and resilience and get a sense of what gives meaning to their lives. In a short time, such heartfelt connection can have a profound impact not only on the recipient but also the provider.

A case study

As a rule, we see people only once, but this year, I saw Maria, a 42-year-old woman twice. She was acutely suicidal, and after her morning prayers, decided today was the day she was going to kill herself. After 6 months of unbearable torment, she’d reached the end of her rope; she told me that her 20-year-old daughter had been raped 6 months earlier and was now pregnant. Maria’s family blamed her, saying that if she hadn’t divorced her husband 15 years earlier, this would not have happened. Maria knew she was not to blame, in which I concurred, but alas, she could not (as her family suggested) get over it and move on.

After listening, I told her I thought today was a miracle; this morning, she was ready to die, and this afternoon, we happened to show up on her street. I also said I believed the seriousness of her suicidal intent and told her she had two choices; I could hospitalize her, although I had no idea if that was even possible, or she could make me a promise – at least for today – that she would not kill herself.

Courtesy Gesunheit! Institute

I gave her an amulet that had been blessed by Navajo and Huichol shaman and said I wanted her to hold onto it during tomorrow’s morning prayers; she would feel our blessings and remember this miraculous day that we found one another. Perhaps tomorrow she could promise herself to also live for another day.

After the clinic, I couldn’t get her out of my mind, so after dinner I asked my clinic coordinator to check in on her the next day. We were going to be conducting another clinic not far from her home in a few days, and I asked her to invite Maria to the next clinic and to please bring her daughter, too.

Maria showed up not only with her 6-months’ pregnant daughter, but also with her younger 18-year-old daughter. Together, they told me the rest of the story. Both girls had been raped (the younger more than a year ago), and both by different maternal uncles. They had never spoken about it to anyone outside of their family, and although Maria had confronted her brothers, she refused to press charges. This is not a culture in which women prosecute their rapists.

Before we ended, I gave both girls an amulet and blessed the family; whatever they faced, they would face it better together; their love for one another would be showered on this new baby, and they would carry our blessings with them and those of many relatives all over the world.

In most Latin cultures, there is a strong belief in the power of spells, curses, and witchcraft, as well as in traditional healing practices and the power of faith. A critical element for successful healing in all cultures is the patient’s belief in the practice and in the practitioner.

As mental health professionals, we magnify our power not only with the pills we prescribe, but in also with the blessings and amulets we may bestow. And it doesn’t take a long time to connect at the soul level if you are actively in the moment, and it is in those miraculous moments that we are reminded of our shared humanity. Imagine if we used our 15-minute medication reviews to actually connect with people at this heartfelt level and talked about what’s really important to them. I’m thinking we could reduce our prescription writing by half and be reminded of the joys of psychotherapy.

Dr. Hammerschlag is chief of community mental health at the Gesundheit! Institute. He is also the author of several books on healing and spirituality, including Kindling Spirit: Healing from Within (New York: Turtle Island Press, 2012) and The Dancing Healers: A Doctor’s Journey of Healing With Native Americans (San Francisco: Harper, 1988). Dr. Hammerschlag’s website is healingdoc.com.