Palin's Medical Records II

According to the NYT today, the Palin campaign has refused to give any interviews or provide any documents with respect to Sarah Palin's health records. Like her refusal to hold a press conference in the campaign, this makes Palin uniquely shielded from accountability in modern times. But there is a public record of what Larry Altman called in the NYT today "the much-discussed circumstances surrounding the birth of her fifth child last April."

So here goes. What follows is all from the public record - from the Anchorage Daily News and the New York Times in three articles here, here, and here. I recommend the originals rather than this summary. I've added some context by talking to leading obstetricians about medical questions I am not competent to answer. It's a remarkable story, whatever your take on it. Since this person could well be the president in the next four years, it may be worth your time to ponder the narrative she has laid out.

We do not know when exactly Sarah Palin discovered she was pregnant at age 43.

We do know that she says she had an amniocentesis to determine for genetic abnormalities. That test, routinely used to determine if an unborn child will be aborted, discovered that Trig had Down Syndrome. Around 90 percent of such babies are indeed aborted. But Palin, admirably to my mind, chose life. The test, however, is also a serious if small risk to the life of the unborn child. The risk is calculated between a 1 in 200 and 1 in 1500 chance of precipitating a miscarriage. Very, very few pro-life activist women agree to an amniocentesis because it can endanger the life of the unborn child with no tangible benefits for the child. Other risk-free methods of predicting the chance of Down Syndrome exist - but would occur later in pregnancy or would not be as accurate. Palin says she decided to take the risk to the life of her unborn child to help prepare her mentally for the task of raising a child with special needs. And, at 43, with Down Syndrome much more common among the offspring of women in their forties, such a test would be routinely offered.

Palin told very few people about the pregnancy. We are even told she kept the news from her husband for three days, who was away at the time. She finally announced the news at 7 months pregnant. She did so, according to the Anchorage Daily News, to

a handful of reporters as she was leaving work ... then headed to a reception at the Baranof Hotel to feast on king crab.

Here is the New York Times' account of breaking the news:

“We’re expanding,” the governor said brightly, said the deputy press secretary, Sharon Leighow. “You’re expanding state government?” one of the reporters asked. “No, my family’s expanding,” she said. “I’m pregnant.” The trio fell silent, dropping their eyes from the governor’s face to her belly.

“You’re kidding,” one finally mustered.

The news was greeted in Alaska with universal shock, even among her closest staff:

People just couldn't believe the news. "Really? No!" said Bethel state Rep. Mary Nelson, who is close to giving birth herself.     "It's wonderful. She's very well-disguised," said Senate President Lyda Green, a mother of three who has sometimes sparred with Palin politically. "When I was five months pregnant, there was absolutely no question that I was with child."

At the time she was seven months' pregnant. According to the Anchorage Daily News last March:

She's known as a fashion plate, but said she hasn't been dressing differently to cover her barely perceptible bulge.

According to the New York Times last month:

The governor, thin to begin with, began an elaborate game of fashion-assisted camouflage. When Vogue photographed her, five months pregnant, for a profile in January, she hid in a big green parka. At work, she wore long, loose blazers and artfully draped accessories.     “All of a sudden she had this penchant for really beautiful scarves,” recalled Angelina Burney, who works across the hallway from the governor in Anchorage.

Whatever her fashion strategy, Palin says she was keen to show that a pregnant woman could be a full-time governor of Alaska. Even the much greater complications of a 43 year old with a Down Syndrome child would not deter her from proving her feminist mettle.

And so at a little more than eight months' pregnant, 43 years' old, with a Down Syndrome unborn child, Sarah Palin made an extraordinary decision. She was going to fly from Alaska to Texas and back in the last month of pregnancy. This is usually prohibited by airlines and strongly advised against by doctors. Palin's own doctor, Cathy Baldwin-Johnson, insisted (when she was prepared to talk to the press) that Palin did not ask her whether it was OK to fly. Many airlines bar pregnant women from flying in their final month of pregnancy because of the obvious risk of labor beginning mid-flight. But at eight months' pregnant with a special needs child, a child who would need special attention during any delivery, Palin flew a total of over 8,000 miles on commercial planes, risking a delivery in mid-air without a doctor or nurse, which could have been very dangerous and even fatal to her child.

But the risk of flying to Texas from Alaska in such an advanced stage was nothing compared to what came next. According to the Anchorage Daily News:

Early Thursday [April 17] -- she thinks it was around 4 a.m. Texas time -- she consulted with her doctor, family physician Cathy Baldwin-Johnson, who is based in the Valley and has delivered lots of babies, including Piper, Palin's 7-year-old. Palin said she felt fine but had leaked amniotic fluid and also felt some contractions that seemed different from the false labor she had been having for months.

According to the New York Times:

Around 4 a.m. on the day of her presentation, Ms. Palin stirred in her hotel room to an unusual sensation. According to The Anchorage Daily News, she was leaking amniotic fluid. She woke her husband and called her doctor back home. Go ahead and give the speech, said the doctor, Cathy Baldwin-Johnson, who declined to comment for this article.

To confirm what an extraordinary decision this was, the Dish asked several distinguished OB-GYN specialists from some of the top hospitals and medical schools in the country what they would advise any woman in such a position to do. As you might expect, every doctor urged that any woman whose water has broken or whose amniotic fluid may be leaking in the eighth month of pregnancy should immediately seek medical attention. If your water breaks at 4 am, with a special needs child, you call for an ambulance. Period. This isn't a judgment call. It's an emergency. The least you should do is get the fluid tested and your potential labor checked out.

Here is one typical expert obstetrician's response:

"Water breaking" and "amniotic fluid leaking" are synonymousno difference.  Once the amniotic sac has broken enough to cause leakage of fluid, there are several possibilitiesone is that labor could start soon, which, in someone with previous pregnancies, would be typical.

There are several concerns about waitingthe main one is that the risk of infection, to both mother and infant, increases dramatically after 24 hours.  At full term in an uncomplicated pregnancy most obstetricians would advise the patient to wait for up to 24 hours, and, if labor hadn't occurred, induce labor at that time.

The second concern, if there was a large leak, is that the loss of fluid would increase the risk of the umbilical cord being compressed, affecting the baby's oxygen supply.  In the setting of a preterm infant, especially one known to have a complication, the consequences of infection are greater. The other concern with infants less than 36 weeks, especially white infants, is that their lungs might not be ready to breathe air, in which case they would need immediate care from a neonatal specialist at delivery.    

Usually, the classic "water breaking" is unambiguous to both patient and provider.   Sometimes, it can be hard to tell by the history alone, since some of the normal changes in pregnancy can lead to discharges that can be hard to distinguish from amniotic fluid.  It's usually pretty easy to tell by examining the fluid under the microscope, and, if there's still doubt, there are some other tests that can be done.   

I think that the majority of obstetricians, given a 44 year old with 4 previous deliveries and a known Down syndrome pregnancy at less than term with a question of ruptured membranes, would advise her to be seen at a hospital (especially if out-of-town and the question of traveling was on the table) to have these tests performed; given the malpractice risk, very few would be comfortable making the diagnosis over the phone.

But Palin says she did indeed talk through her symptoms with her doctor over the phone. She went to no hospital and took no tests to check on her own health or the health of her special needs unborn child. And the gamble appears to have paid off:

Palin kept in close contact with Baldwin-Johnson. The contractions slowed to one or two an hour, "which is not active labor," the doctor said.     "Things were already settling down when she talked to me," Baldwin-Johnson said. Palin did not ask for a medical OK to fly, the doctor said. "I don't think it was unreasonable for her to continue to travel back," Baldwin-Johnson said.

Baldwin-Johnson "declined to comment" for the New York Times, although she had previously spoken about the pregnancy to the Anchorage Daily News.

Hours after her 4 am scare, Palin gave a speech on energy policy to the governors' meeting, and, amazingly, no one guessed anything about her condition:

“Nobody knew a thing,” said Gov. Linda Lingle of Hawaii. “I only found out from my security detail on the way home that she had gone into labor and that she had gone home to Alaska.”

But whoever told Lingle that Palin had already gone into labor was wrong, according to Palin's doctor. Despite contractions and leakage of amniotic fluid/water breaking, labor had not begun. In fact, Palin later said that the labor had to be induced so that Trig was born around 29 hours after the original amniotic fluid leak/water breaking. This is remarkable given the fact that successive labors tend to be progressively shorter and shorter. A fifth child is usually delivered rather swiftly. But it is not impossible. From one OB-GYN specialist consulted by the Dish:

It's very possible that it could take that long, especially if it was a small [amniotic fluid] leak. Again, there is something of a dividing line based on the gestational age and other complicating factors.

Every woman and child and birth is different and Palin's account is certainly within the realm of possibility, if highly unusual. An expert reminds:

There are a lot of factors we don’t know in this case. Had she had an exam the day before and knew she was not dilating, that would change my view, but in the absence of an exam there’s a possibility she could deliver instantly.

So far as we know, she had had no such exam. Maybe she did. But with no medical records, it's impossible to know. But she gave the speech and took a flight back to Alaska. Remarkably, the flight attendants were unaware of her condition:

Alaska Airlines ... leaves the decision to the woman and her doctor, said spokeswoman Caroline Boren. Palin was very pleasant to the gate agents and flight attendants, as always, Boren said. "The stage of her pregnancy was not apparent by observation. She did not show any signs of distress," Boren said.

The Palins have said that she was determined to have her son on Alaskan soil, and given Todd Palin's history of involvement with Alaskan independence, that certainly makes sense. One can only concur with this: “She wanted to get back to Alaska to have that baby,” said a friend, Curtis Menard. “Man, that is one tough lady.”

Although Palin had had an amniocentesis to prepare her mentally for the birth, the rushed delivery meant she had not had the time to prepare some of her children:

Inside Ms. Palin’s room, her daughter Willow, 14, immediately noticed her new brother’s condition, according to People magazine. “He looks like he has Down syndrome,” Willow said. “Why didn’t you tell us?”

Although two other births were announced on the Mat-Su Medical Center's website for April 18, the hospital has no public record of the birth of Trig Palin on its only register, but the registry is optional. The Dish also talked to a reporter who was present at the hospital that day and confirmed as an eye witness that Palin was indeed there, sleeping in another room, recovering from labor. It's a remarkable story and worth laying out in full. What you make of it is up to you. Personally, I just don't know what to make of it any more, but feel a responsibility to lay out the facts as they exist in the public domain. For the record.