Full Moon Pies

AAOOOOOOOOOOOOOOO!  The 23rd is a full moon.  Time to get your werewolf self ready for the big howl.  Besides bringing out beasts and goblins, full moons are thought in the obstetrical world to bring out babies.  As an already overworked and overwrought poor little intern running around labor and delivery, this can’t be a good thing.

But are full moons actually related to the onset of labor? Most studies suggest that, in fact, they are not.  A 1979 study of 11,681 live births at UCLA hospital showed that there was no correlation of lunar cycle to births.  These results were reproduced in a smaller study of 3706 births in the 1990s in New York City.  However, some studies suggest otherwise.  One small Italian study suggests that there might be a small effect on multiparous patients (those that have had more than one baby) with the lunar cycle. 

Not only is tonight/tomorrow (the calendar says tomorrow but it looks full tonight) a full moon, but it is also a harvest moon.  Besides being a great Neil Young album, a harvest moon is when there is a full moon at the autumnal equinox.  Supposedly the harvest moon appears bigger and brighter than a normal full moon.  Time to get out the scythe and start farming.  

To celebrate the full moon, I made a traditional southern classic, the moon pie.  A moon pie is 2 graham cracker cookies filled with marshmallow and topped with chocolate.  To celebrate my day off, I made my own graham crackers and my own marshmallow.  Although it seems difficult, it isn't too tough.  Just takes a candy thermometer. Graham crackers require graham flour, which I know some people have had trouble finding.  I like Bob's Red Mill which is in the health food section with the other whole grains.

Full Moon Pies

For the cookies (adapted from Martha Stewart's baking)

1 1/2 cups all purpose flour

1 1/2 cups graham flour

1tsp baking soda

2 tbs cocoa powder

1/2 tsp salt

1 1/2 sticks unsalted butter at room temp

3/4 cup packed light brown sugar

2 tbsp honey

Preheat oven to 350.  Combine flour, baking soda, cocoa powder and salt and set aside.  In mixer, beat sugar, honey and butter until fluffy.  Slowly mix in flour, stir to combine.  On floured surface roll out cookies thin about 1/8 inch and cut with 1.5 inch round cookie cutter (or glass or jar which is what I used).  Place on baking sheet and bake about 7 minutes until brown and crisp.  

For the Marshmallow (from Food Network)

1/4 cup water

1/4 cup light corn syrup

3/4 cup sugar

2 egg whites

1 packet plain gelatin

2 tbsp cold water

1/4 tsp vanilla

Combine the 1/4 cup water, the corn syrup, and the sugar in a saucepan fitted with a candy thermometer. Bring to a boil and cook to "soft-ball" stage, or about 235 degrees F.

Meanwhile, in a standing mixer fitted with a whisk, whip the egg whites until soft peaks form. Sprinkle the gelatin over the 2 tablespoons water and let dissolve. When the syrup reaches 235 degrees F, remove it from the heat, add the gelatin, and mix. Pour the syrup into the whipped egg whites. Add the vanilla and continue whipping until stiff.

Transfer the mixture to a pastry bag fitted with a round tip. Pipe a "kiss" of marshmallow onto half of the cookies, and top with the rest to make sandwiches. Let set at room temperature for 2 hours.

For the Ganache

8 oz chocolate chips

1 cup heavy cream

Over double boiler on medium heat, melt chocolate and cream, stir together.  Dip cookies in ganache.  Also can make white chocolate for an extra drizzle

Abell, GO.; Greenspan, B. “Human births and the phase of the moon.” New England journal of medicine, v. 300 issue 2, 1979, p. 96.

Joshi, R.; Bharadwaj, A.; Gallousis, S.; Matthews, R. “Labor ward workload waxes and wanes with the lunar cycle, myth or reality?.” Primary Care Update for OB/GYNS, v. 5 issue 4, 1998, p. 184. 

Gabriele Ghiandoni, Roberto Secli, Marco B. L. Rocchi, Gilberto Ugolini, Does lunar position influence the time of delivery? Eur J Obstet Gynecol Reprod Biol. 1998 Mar;77(1):47-50.

Ginger Ale for the Ailments

Growing up, when I was sick my dad made me drink Gatorade—he was convinced that Gatorade is the nectar of the gods with the perfect balance of carbohydrates and electrolytes to cure any ailment.  Most other parents immediately went for, and still go straight to the ginger ale.  Ginger ale is pretty much the only drink in the hospital wards as well.  Every medical student has probably overdosed on diet Shasta more than once.  Even though it is ubiquitous, does ginger actually calm the stomach?

Interestingly, when looking for studies of the effects of ginger on nausea and vomiting, many focus heavily on nausea and vomiting in pregnancy.  A review article in Obstetrics and Gynecology in 2005 analyzed four small randomized control trials that showed effectiveness of ginger for reducing nausea and vomiting over placebo [1]. Ginger has also been shown to reduce postoperative nausea and vomiting, although is not as effective in chemotherapy related nausea and vomiting [2,3]. 

I’ve been working in the OB/GYN emergency room for the past three weeks.  I’ve taken care of a fair amount of women with significant nausea and vomiting in their early pregnancy.  Usually we give them pretty strong anti-nausea drugs and fluids to help them to feel better.   Even though ginger probably doesn’t help for women who have severe enough nausea and vomiting to cause dehydration, it is good to know that ginger can probably help for women with more mild symptoms.   The best part about ginger is that is very safe to take in pregnancy, so there is no harm in trying it, and most importantly, it is delicious.

To drown out memories of late night Shasta on call in medical school, I made my own ginger ale.  It is based on a very pungent ginger syrup that can be added to club soda, or if you are feeling not nauseous (or pregnant) could use it as a base for a coctail with dark rum or whiskey.  Very refreshing!

Ginger ale

2 tbsp fresh ginger grated

1.5 tsp powdered ginger

1 cup sugar

1 cup water

Club soda

Ice (optional)

Lime wedge (optional)

Over medium high heat, bring all ingredients to a boil and allow to cook until syrup is reduced to half and begins to darken.   Allow to cool, add about ¼ cup syrup to 1 cup of chilled club soda.  Add ice and a squeeze of lime juice. 

1. Borrelli  F, Capasso  R, Aviello  G, Pittler  MH, Izzo  AA.  Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting.  Obstet Gynecol.  2005;105:849–56.

2. Chaiyakunapruk  N, Kitikannakorn  N, Nathisuwan  S, Leeprakobboon  K, Leelasettagool  C.  The efficacy of ginger for the prevention of postoperative nausea and vomiting: a meta-analysis.  Am J Obstet Gynecol.  2006;194:95–9.

3. White, B.  Ginger: an Overview.  American Family Physician. 2007 June 1; 75(11): 1689-1691

Torte Reform

Unfailingly, each time I tell somebody that I’m doing OB/GYN, the first thing that they tell me is either, “Ooh babies” or “You’re brave--the malpractice insurance.” I’m naïve. I chose OB/GYN because I am passionate about the field, and because of my love, I feel willing to pay the high insurance and face the threat of lawsuits. Because the only obstetricians I know are part of an academic practice that covers malpractice insurance, they don’t openly discuss, at least with me, their fear of lawsuits. Even so, I think the dread of bad obstetrical outcomes is palpable in each decision that is made on a labor and delivery unit.

I know next to nothing about the legal system. However, I think as a physician I should learn some basics as lawsuits will most likely, unfortunately, be part of my life. Many healthcare practitioners have told me “tort reform is the answer” and I just nodded my head. I have no clue what tort reform is. According to the Agency for Healthcare Research and Quality, “torts are civil wrongs where the injured person asks for monetary damages from an individual in a situation where there is no contractual relationship.” Thus, tort reform includes legislation that caps payments for non-economic damages when a patient sues a doctor and wins.

As of 2003, 23 states had some tort reform legislated into their government. There is evidence to suggest that tort reform is effective at curbing malpractice fees. For example, in California, legislation was passed in 1975 to lower malpractice costs; by 2000 their insurance premiums increased by 167% whereas in the rest of the nation, fees increased tremendously by 505% [1]. It has also been shown that in California, defensive medicine is less employed and that health care costs are 5-9% lower without significant change in patient outcomes [2].

One of my favorite blogs, Academic OB/GYN, written by Dr. Nicholas Fogelson, recently discussed the importance of change within the country’s legal system in order to produce better obstetrical outcomes over the long term. This is in response to the recent National Institute of Health’s Vaginal Birth After Caesarian (VBAC) Consensus that convened this week. VBAC is a highly contended subject; having a vaginal delivery after a previous caesarian puts a woman at a low but existing risk of the uterus rupturing from the C-section scar being stressed during labor.

Many obstetricians refuse to do VBAC because of fear of litigation due to the risk of uterine rupture. The consensus concluded that VBAC trial was shown to be a safe option for most women [3]. Dr. Fogelson suggests that the apprehension to perform VBAC might be assuaged by “mini-tort reform” in which patients sign a release that in case of a uterine rupture during VBAC, they waive their right to sue. While this is a provocative idea, requiring unlikely consensus and collaboration among a highly divided obstetrical profession, I am not informed or experienced enough to have my own personal convictions on the topic.

I am so protected and coddled as a medical student. I have no concept of what it feels like to be the final decision maker in stressful or liable situations. It is easy to be idealistically devoted to vaginal delivery for every woman who desires it, but to take a stance on the complex and heavily weighted decisions that obstetricians make would be unfair. I do feel with full fervor, however, that it is important to do what is safest and best for our patients. Letting the terror of litigation overrun an entire field of medicine is expensive and can potentially produce worse patient outcomes.

What I am certain about and can propose however, is TORTE reform. As a rich intermediary between a pie and a cookie, this is one topic that there is only one right answer: YES! Tortes are traditionally made with eggs, sugar and nuts. In this recipe, which I very loosely based on a linzertorte, I’ve reformed the composition to have a Southern tinge as a dedication to the pecan pie. The dough is made from chopped pecans and almonds, as is the filling in a pecan pie with mixed nuts spiked with brandy, and it is topped with a gooey chocolate ganache. This is one torte reform we can all agree on (unless you don’t like nuts or chocolate; nobody will ever completely agree).

Nutty Torte Reform with Chocolate on Top

For the crust
½ cup blanched almonds
½ cup pecans
6 tbsp butter cut into cubes, kept cold
1/8 tsp salt
¾ cup cake flour
½ cup powdered sugar
1 egg yolk

For the filling
2 eggs
¼ cup walnuts
¼ cup pecans
¼ cup blanched almonds
(or you could do ¾ cup pecans or use other nuts such as macadamia nuts or hazelnuts)
1/3 cup brown sugar
1/3 cup corn syrup
2 tbsp brandy
2 tsp vanilla
Pinch of salt
Pinch of cinnamon
1 tbsp heavy cream

10 inch tart pan

For the chocolate ganache
1 cup chocolate chips
¾ cup heavy cream
Splash of brandy

Preheat oven to 400 degrees. Toast almonds and pecans for crust in oven for 7 minutes or until golden and fragrant. Toast the nuts for the filling on a separate baking sheet. Allow to cool. Blend in food processor for 30 seconds or until mealy but don’t overwork or it will start to look more like nut butter. Add flour, sugar and salt, pulse a couple of times to blend. Add egg and butter, pulse until blended. With hands, gently bring dough into ball and press into disc, don’t overwork, refrigerate for at least an hour.

Preheat the oven to 300 degrees. On a floured surface with parchment paper, roll out dough. If the dough becomes too sticky, you can press it into the tart pan with your fingers. Prick dough with fork and bake for about 15 minutes. While baking, whisk together filling ingredients. Once crust has started to brown, remove from oven, add filling and bake for another 25 minutes until filling has solidified and crust is brown. Allow to cool.

Over simmering double boiler, whisk together chocolate and cream until blended, add splash of brandy and pour over top of torte while cooling. Refrigerate for a few hours and eat!









1. Hellinger F et al. Malpractice Awards on the Geographic Distribution of Physicians. 2003. US Department of Health and Human Services Agency for Healthcare Research and Qualtiy. http://www.ahrq.gov/research/tortcaps/tortcaps.pdf
2. Kessler, David and McClellan, Mark “Do Doctors Practice Defensive Medicine?” The
Quarterly Journal of Economics, vol. 111, Issue 2, May 1996, pp. 353-390.
3. http://consensus.nih.gov/2010/vbacstatement.htm

Pregnancy Pudding

I love to eat (clearly). And, I love working with pregnant women and delivering babies. Unfortunately, these two passions do not coincide. Sure, pregnant women love to pack on the pounds and devour thousands of calories of delicious treats everyday. But, the second they go into labor, they are banned from consuming anything but clear liquids in almost every labor and delivery suite in America.

Why?

The story goes back to 1946 when Mendelson wrote a ground-breaking paper showing that pregnant women are at high risk of aspirating their stomach contents into their lungs if they required emergency surgery and intubation (when a breathing tube is placed in the airway for safety during anesthesia) ¹. Since the time that Mendelson’s groundbreaking paper was published, the fear of aspiration has permeated the minds of all OB/GYNs and anesthesiologists, banning food from the labor suite. Aspiration is an absolutely devastating outcome which can cause significant morbidity and can be fatal. Aspiration rarely occurs in the modern day L&D ward, but it should be prevented at all costs.

Can prohibiting oral intake actually prevent aspiration? This has never been proven, and is extremely difficult to study based on the rare occurrences of aspiration. In order to study this properly, there is a need for a very high study volume to detect a difference in aspiration rates for those that eat versus those that don’t. Even so, there is limited data on the effects of labor outcomes for fasting versus eating women.

Recently, an article was written in the NY Times discussing an analysis by the Cochrane Review². The Cochrane Review is a database of meta-analyses of randomized control trials of high quality, and is an excellent, unbiased source of information. This particular review compiled 5 studies looking at studies of eating or consuming sports drinks during labor. They concluded that “there is no justification for the restriction of fluids and food in labor for women at low risk of complications.”

The analysis is complemented by a study recently published in the British Medical Journal³. This study was a randomized trial of 2426 low-risk, non diabetic subjects randomized to clear liquids or a low residue diet. The low residue diet group did not have a statistically significant difference in Cesarean rate, APGAR scores, or vomiting, and thus seemingly did not greatly affect birth outcomes. 

 

I do NOT make any recommendations to eat during labor. The American College of Obstetrician Gynecologists recently published guidelines recommend to not change any rules⁴. Thus, we will continue to fast. Even so, this is an area that needs more well designed, strongly powered studies, especially since many women are so miserable during labor and simply want something to eat. Anesthesiology has advanced incredibly since 1946 and has many new techniques and medicines to prevent aspiration. Beyond this, less than 1% of people require intubation for emergency surgery because epidural and spinal anesthesia are used for C-sections the majority of the time. 

Hopefully, for my sake and the sake of everyone around me, by the time I get pregnant and have babies, the rules will have changed and I can gobble it up. (I didn’t eat during my triathlon, and pooped out in the run coming in 5^th from last!) In preparation, I will make some pregnancy pudding, because what could be better to eat during labor than homemade chocolate peanut butter pudding (maybe toast, but I can dream)? It’s filling, delicious, and easy on the stomach, with carbohydrates and proteins to give you energy for the long push. Most homemade puddings have raw eggs in them (not good for the pregnant ladies), but you can make a great pudding with just milk and cornstarch (and peanut butter and chocolate). And if you’re not gestating currently, feel free to partake as well.

Recipe adopted from Bon Appétit January 2009:

Chocolate peanut butter pregnancy pudding

½ cup sugar

5 teaspoons cornstarch

1/8 teaspoon salt

2 ¼ cups whole milk (honestly, you can do it with skim or 1% and I eliminated the heavy whipping cream from the recipe and replaced it with milk. This is not meant to give you massive indigestion)

1/2 cup creamy peanut butter

4 oz (about 2/3 cups) semi-sweet chocolate chips

1 tsp vanilla

Whisk first 3 ingredients in large saucepan to blend.

Gradually whisk in milk. Whisk over medium heat until mixture comes to boil.

Then boil until thick, whisking constantly about 30 seconds (this step can sometimes take longer, but you’ll be able to see it thickening).

Whisk in peanut butter; boil until thick again, whisking often, about 1 minute.

Remove from heat, add chocolate chips and stir until melted, add vanilla.

Cover and chill at least a few hours ahead of time.

1. Mendelson CL. The aspiration of stomach contents into the lungs

during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-206.

2. Singata M et al. Restricting oral fluid and food intake during labour. Cochrane Database Syst Rev 2010; 1:CD003930.

3. O'Sullivan, G., et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ: British Medical Journal 2009; 338:784.

3. ACOG Committee Opinion No. 441: Oral intake during labor. Obstetrics and Gynecology 2009. 114(3): 714.