30 July 2011

Routines I Don't Get the Point Of

After discussing the Hep B vaccine with a friend recently, I was thinking of all the various procedures that are routine during pregnancy, childbirth, and the neonatal period, and I realised that I really don't get the point of a lot of them.  Well, that's not completely true.  I understand why they're done, I simply disagree that they're necessary.  In general, my philosophy is "leave well enough alone unless the procedure has a definite benefit and that benefit definitely outweighs any risk".  Anyway, I thought I'd give a brief run-down of my thoughts on these.

  • Hep B - I'll start with this one since I mentioned it in the intro paragraph.  In the UK, Hep B isn't routinely given to children, unless the child is at risk in some way.  In the US, however, it is routinely given to all infants in the first 24 hours!  Despite the lack of routine vaccination of infants in the UK, it remains uncommon.  That's one reason I don't understand the routine vaccination of infants for it.  I know it can be spread through childbirth, but if the mother does not have Hep B, and neither do the child's other caregivers, then surely the child does not need to be vaccinated for it?  Especially since it is primarily spread by sex and/or drug use, two things an infant surely isn't doing.  I understand the desire to avoid Hep B, since it isn't exactly a pleasant thing, but it seems to me that routine vaccination doesn't make a lot of sense.  Given that rates of Hep B infection are low in the UK, where routine vaccination for it isn't done, I have to wonder how many cases of Hep B are actually prevented by giving it routinely (I'm not speaking about giving it to those who are a higher risk).  It seems to me, though, that it makes more sense to leave well enough alone and focus on reducing risk factors as needed.  Just my opinion.
  • prophylactic eye drops - I have to admit that I get a bit sad when I see photos of newborns and notice the greasy eyes, meaning the child has received these eye drops.  Again, this isn't routinely done in the UK, but is in the US.  As far as I know, these eye drops are given to prevent eye infections in the newborn that are caused by gonorrhoea or chlamydia.  However, if the mother does not carry these STDs, then the child doesn't need this procedure.  I also can't imagine that the widespread use of antibiotics even in infants who do not need them doesn't have some adverse effect (I'm thinking of antibiotic resistance, but perhaps that doesn't play a part in this); silver nitrate is sometimes used instead of erythromicin, but this can irritate the child's eyes..  I do think it's important for the child to be able to clearly see during those early hours and days.  No, the child cannot see very far in the early days, but he can see far enough to see his mother's face, so I don't see how impeding his already limited vision is a good thing if it's not necessary.  
  • immediate cord clamping - this is done in the US & UK.  However, delayed cord clamping has been shown to be beneficial and benign.  Dr Nicholas Fogelson has written a lot on this topic, so I'll put up a link to his blog.  I've found his blog to be quite informative and thought-provoking; I don't agree with him on everything (though I do agree with him on this), but I've found him to be professional, willing to admit when he doesn't know something, and quite knowledgeable on this topic.  Until recently, it's also been standard to immediately clamp & cut the cord when a child needed resuscitation, but hopefully the BASICS trolley will become the standard so delayed cord clamping can be done in those cases, too.
  • vaginal exams (VE), during pregnancy & labour - VEs during pregnancy aren't routinely done in the UK (though at least some midwives will ask the mother if she wants a membrane sweep towards the end of pregnancy, unfortunately), but they are often done during labour.  I love this link that discusses the issues with routine VEs.  Basically, while a VE can tell you where you are and how long it took to get there, it cannot predict how long it will take to reach full dilation, and it can introduce a risk of infection, particularly if the waters have gone.
  • group B strep (GBS) testing - This isn't routinely done in the UK, but is in the US, as far as I know.  GBS infection in a newborn is rare, but it can be quite serious, so I understand the desire to know if the mother is carrying GBS and to take action accordingly.  However, a woman who tests positive for GBS during her pregnancy may no longer have it at delivery, and vice versa.  When a woman tests positive, prophylactic antibiotics are given during labour, but this presents its own problems.  For one, there's the issue of antibiotic resistance, since GBS is no longer sensitive to some antibiotics.  A review also found that giving antibiotics isn't improving outcomes for the infants.  More research needs to be done, since the review said that there was a lot of bias in the studies they found.  Since it seems that knowing about GBS status isn't improving outcomes, though, I personally see no need to know.  I would've been given antibiotics had I not delivered Kieran within a certain amount of time after my waters had gone (I was given 3 days before an induction date, but went on into labour and delivered within 12 hours), or if I'd developed a fever.  I think these are sensible precautions, since infection is more likely after the waters have broken and fever can be a sign of infection.  But I don't see the benefit of routine testing if the prophylactic treatment isn't improving outcomes. 
I'll leave the list at that for now and spare my readers from more ranting. ;-)

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