Where Has All The Surgical Skill Gone?

I recently saw an article on the use of Carbetocin vs. Pitocin in C-sections to reduce the risk of postpartum hemorrhage (PPH).

At first, I thought this article was about a new drug being promoted to be more useful than longstanding existing drugs for PPH, principally Pitocin, a synthetic version of the naturally occurring oxytocin. I find many of these articles on new medications look more like a cure in search of a disease than a new drug which significantly changes the practice of medicine. After reading the article, I was somewhat more convinced that it was, indeed a reason to at least review the choices for the management or prevention of PPH.

So, what does this mean for mothers? PPH is the leading cause of maternal death globally and is defined as excessive bleeding after childbirth. Each year worldwide 70,000 women die from PPH.

PPH, like most other causes of maternal death and injury, is preventable and treatable. Each year 14 million women experience PPH. Uterine atony (a softening of the uterus leading to the lack of contractions) is the main cause of uterine hemorrhage.

Although 95 percent of all maternal deaths occur in low-income countries. Whoever, the U.S. is the only developed country with an increasing maternal mortality rate. With the introduction of a new medication to control PPH, I thought it might be useful to review the current methods of dealing with it. Do we really need a newly minted drug for PPH, undoubtedly more expensive than existing measures for controlling PPH, or is this simply a new drug to rake in money for Big Pharma. Most new drugs are too expensive to use, and even if they work as advertised, the cost and insurance haggling make their use impractical.

The problem is not that we don’t have enough choices to treat PPH, but rather that there are so many different choices. A good surgeon should be familiar with all the treatment options for PPH and be able to make a choice for the best treatment for a patient.

The oldest medication to increase uterine contractions is methergine. It has been around for several hundred years. It was promoted to physicians about 200 years ago as a way to make labor very swift so they would not be detained long in any patient’s house. Methergine worked well, but that wasn’t the problem. It worked too well causing uterine rupture, fetal distress, and hypertension and could be somewhat unpredictable.

Women used to manage labor and delivery, but during the 1700s, wealthy families began to have male physicians come to their homes for deliveries. I did a podcast on the history of obstetrics which goes into this shift of care from women to men.

Another choice for managing PPD is oxytocin. Pitocin is the pharmaceutical version of the natural oxytocin, developed about 70 years ago. Oxytocin is stored in the posterior pituitary and secreted when the correct signals from the uterus or breasts reach the pituitary gland. In natural labor, oxytocin is secreted after the cervix has softened, at about 5 centimeters of dilation. Initially, Pitocin was sold in pill form (known as buccal Pit) to be placed between the mother’s cheek and gum. Again, the problem with the buccal Pit form of Pitocin is not that it worked, but that it was unpredictable and could sometimes work too well.

The other big problem with these meds when used to induce labor is that they could be removed or stopped if too much has been given. Recognizing that fact, pharmaceutical companies began making Pitocin in a liquid form which could be given either as a shot in a muscle (IM) or an IV solution. The advantage to using Pitocin as an IV solution is that the half-life is only a few minutes. If there is an issue with too many contractions, the Pitocin dosage can be decreased in just a few minutes by simply stopping the IV solution rate of flow.

In my practice, I had a love-hate relationship with Pitocin. I find the use of Pitocin for induction (before a woman's body naturally produces oxytocin) barbaric because the baby's head is being used as a battering ram. To my knowledge, the effect or consequences to using the baby’s head as a battering ram for induction have never been studied and hence have never been proven safe, although safety has been and still is, as far as I know, unquestioned. We have no idea how this practice affects intelligence, ADHD, etc.

For control of PPH, if Pitocin is given IV push, two serious events occur. Blood pressure drops precipitously and after a very firm uterine contraction, uterine atony sets in and brisk hemorrhage follows. One dose of IV push Pitocin is enough to convince most of us to not use Pitocin that way.

As I said above, to avoid PPH a surgeon needs to have two qualities: judgment and surgical skill. Of the two judgment is the most difficult to attain. The surgeon needs to know what surgery to do, when to do it and how to do it. The best way to have a good surgery and a good outcome is to have a mental picture of what your incisions will look like. That is critical. In my experience, like an artist, I must see the situation in my mind and then commit my mental picture into reality with my hands.

A Midwestern Doctor, a Substack blogger, recently posted "The Forgotten Art of Surgery." He raises an important issue.

As technology has advanced, it's made once-impossible feats in medicine achievable, but at a cost. The reliance on expensive products has gradually replaced the innate skills doctors once depended on….Electrocautery is a prime example of how technology can diminish surgical skills. While it simplifies surgery by eliminating the need for finesse, I've observed that younger doctors trained primarily with electrocautery are worse in the operating room, especially in specialties like OBGYN.

I certainly agree. For the sake of this discussion, there are two types of electrocautery, with two different currents for two distinct purposes. One form is used for cutting by some doctors instead of a scalpel. The idea is to move quickly and have less bleeding. I personally hate this method of cutting because it is so destructive to body tissue. It increases time to heal, risk of infection, and post-op pain. Coagulation cautery is a second way to use cautery, With coagulation cautery, the instrument is used to coagulate specific bleeding sites, especially blood vessels.

Consider C-section surgery. First, there are many layers which need to be navigated in C-section surgery, as apparent in the picture accompanying this Substack article. There are seven parts to a good C-section surgery.

1. Make the smallest incision possible,

2. Avoid cautery because it is so destructive,

3. Use your fingers to open the cut and minimize arterial and venous damage (they will stretch, and move out of the way),

4. Control the incision to control damage,

5. Minimize coagulation cautery (also very destructive),

6. Surgery is completed only when the bleeding is controlled. and

7. Get in and get out.

If you are really interested in the ins and outs of how to do a C-section, I do have a video course about it.

Keep the incision out of the uterine arteries, tributaries for the uterine arteries, and ureters. Remember, surgery is done when the bleeding is done. Otherwise your patient will end up in one of ProPublica’s maternal mortality articles.

Only after the baby is delivered will I use dilute Pitocin. In the forty years I was in practice, I’ve given two units of blood to one postpartum mother.

So, why use Carbetocin? Would I use Carbetocin if I were still practicing? Probably not. I had several old tried-and-true friends, dilute Pitocin, methergine and fundal massage, often over-looked today. I suspect fundal massage is often avoided today because message requires diligence and effort, but it works very well without the usual interventions.

Today fundal massage is hardly known and not well understood.

I’m not talking about the procedure the nurses use to express blood from the uterus or vagina. I’m discussing the small circle, about two inches in diameter around the naval used to reach the uterus. Fundal massage done this way is very effective. I once massaged a uterus for eight hours, but the patient did not need a blood transfusion.

I have not needed any of the so-called modern methods of managing PPH. And in 6000 births, no patients have died from anything.

We have many effective tools to prevent PPH even without the new medication Carbetocin. Nobody should die in this country from preventable obstetric disease.

NO EXCUSES!