Chapter 12 ~ WC 7703 *** last edited 01-21-2025 @ 12:13 pm
Two of the most popular obstetrical interventions ~ Induction and Episiotomy
Induction vs. Mother Nature
The ‘normal’ length of labor is nine months, give or take a few days. The most frequent time for a healthy pregnant woman to spontaneously go into labor is the ten days surrounding the pregnant woman’s due date (Excepted Date of Confinement or “EDC”) is the four days before the due date, and first 6 days beginning with the due date, officially named by the obstetrical profession as the
However, Mother Nature triggers “moving day” for the baby with the release of the natural hormone oxytocin from the mother’s pituitary gland. This naturally causes the uterus to begin contracting regularly. In the vast majority of labors, progress in labor is spontaneous and eventually the baby is born. But not infrequently things do no progress as expected and the laboring woman or her doctor thinks the labor should be induced or sped up with the artificially produced hormone Pitocin.
Evidence-based research on the elective induction labor
The obstetrical profession is firmly convinced that Pitocin is chemically identical to oxytocin and that it is an equally effective or ‘natural’ way to trigger the uterine contractions that dilate the cervix over the course of many hours and eventually result in the spontaneous birth of the baby.
As a manufactured drug, package insert for the manufactured drug Pitocin comes with a two-page insert that describes its chemical composition (complete with molecular diagrams) and its chemical effect on a pregnant woman’s uterus.
This list of attributes and unintended side-effects describes Pitocin as a hard-to-control, powerful drug can result in the unexpected rupture of the laboring uterus and the death of both mother and baby and states that the prescribing physician should be present in the hospital.
As an L&D nurse in five different hospitals during from the mid-1960s and to 1980, all the hospitals I worked in never required the obstetrician to remain in the hospital while his patient’s labor was being induced or augmented with Pitocin.
A quick search of the scientific literature on labor induction also reveals an increase in operative deliveries (forceps and vacuum extraction) and C-sections, especially for first-time mothers (CS as high as 35 percent).
There are also questions about the effects of Pitocin on the fetus, due to the longer harder labors associated with induction, a possibly premature labor and the long-term consequences of the drug itself. It should be noted that there is absolutely no testing of drugs on children less than 6 years of age.
None of the drugs used on pregnant women have ever been tested to determine if they are safe for fetuses and neonates. No one has a clue about the long-term consequences of Pitocin, narcotics, anesthetics or the drugs used in epidurals.
Drugs routinely have many effects beyond those desired in the moment. Genomic research has identified that some individuals have small errors in their DNA that result in a paradoxical or toxic effect from drugs that are generally helpful or at least without harmful side-effects.
A Newsweek article in July 9, 2000 carried a story about “designer drugs”, which are chemically tailored to the specific DNA of a unique patient population. In a study of a particular cancer drug, researchers discovered that 0.3% of the population had a missing letter in their DNA code for that drug. People with this DNA error had potentially fatal reactions to this drug.
Mothers in labor are routinely given several different drugs without any way to know if their unique DNA code or the DNA of their unborn baby makes either or both of them vulnerable to toxic side effects. The propensity to have an adverse reaction is multiplied by the number of drugs received. These risks are then doubled as the drugs are being given directly to the mother and delivered to the baby via the umbilical cord.
For the baby, whose virgin brain is being influenced by these substances, the risk of side effects is both immediate and life long. Studies done in Scandinavia indicate that narcotic use during labor (within 10 hours of birth) results in a statistically significant increase in drug abuse and addiction of narcotized fetuses as they become teens and young adults. (Jacobson, et al, 1990, Jacobson, Nyberg, Eklund, Bygdeman & Rydberg, 1988)
Another open question is the sharp increase in childhood autistic disorders. Autism reached epidemic proportions in the early 1990s and has continued to rise every year since. A July 2000 cover story for Newsweek identified that more children now suffer from the scourge of autism than childhood cancer or Downs Syndrome – as high as 1 out of 500.
Autism severely interferes with the ability of children to relate to other people and the external world. The severity of autism spans the spectrum of disability from mild to the most severe form, which requires the child to be institutionalized. While no association has been definitively established, there is a statistical link between the increase in labor induced with Pitocin and the increase in autism.
Newsweek article quoted Dr. Eric Hollander, director of an autism clinic at Mt. Sinai Medical Center in New York, as reporting that 60% of his autistic patients were the product of a Pitocin-induced labor (the rate of inductions in 2000 was approximately 20%).
According to research by Doctors Thorpe & Breedlove, (1996), “80% of US women receive epidurals … narcotics are added to epidural analgesia to speed and enhance pain relief. These drugs cross the placenta to the fetus”. There is also no way to determine if the fetus has a particular gene that makes it more vulnerable to an unexpected effect. In addition there is an increased risk of drug interactions when more than one drug is present at the same time, which is frequently the case during labor. Perhaps the epidemic increase in childhood autistic disorders is a result of drug interactions between Pitocin used to accelerate labor and the cocaine-based drugs and narcotics used in epidural anesthesia that normally accompany induced or augmented labors.
Natural Oxytocin vs. the Parke Davis Rx Pitocin?
The use of an artificial hormone as compared to the natural hormone is another one of those areas of study that has for the most part escaped the 20th century. The official assumption of the medical community is that the uterus doesn’t really care whether the hormonal trigger for regular contractions is endogenous (naturally secreted from within) or exogenous (from without, i.e, a drug). However, in the last few years there has been more scientific interest in various aspects of this question. In a book entitled “The Oxytocin Factor”, Dr Kerstin Uvnas Moberg, a researcher in Sweden, points out that natural oxytocin is the hormonal opposite of the “fight or flight” response triggered by various adrenal hormones. She refers to oxytocin as the hormone of “calm and connection”. Dr. Moberg’s research reveals oxytocin as the powerful hormone involved in sex, childbirth, bonding, breastfeeding as well as relaxation and feelings of calm.
In order to understand why the administration of the artificial hormone as a pharmaceutical drug might be drastically different from the effects of natural oxytocin in a normal labor, I have taken the liberty of a brief detour into the biology of oxytocin.
“…a coordinated system connected like threads in a marvelous web”
There are two types of hormones, one known as ‘steroids’ (composed of fats related to cholesterol) and the other group called peptides or polypeptides, which consist of small proteins. Oxytocin is universal peptide in all mammals, unchanged over millennia, which plays an important role in the life and wellbeing of both genders. Unlike steroids, peptides hormones do not enter the cell itself but instead activate receptors on the outer surface of cell membranes. In other words, they are like keys that turn on the cell, instead of a substance that is incorporated into the cell. One of its unique features is the place in the brain where oxytocin is created – the pituitary — which is a bulbous gland surrounding the optic nerve and the nuclei of the hypothalamus. The hypothalamus is the seat of our emotional life and coincidentally, the hypothalamus is physically at the very core of our brain, deep down at the exact center.
There are two different ways that oxytocin peptides work in our bodies. First it is a hormone that triggers reactions in distant organs and tissue all over the body. In this mode, oxytocin circulating in the bloodstream delivers a chemical message or a ‘key’ to initiate biological responses in the uterus, breast or other sensitized tissue. In the other mode oxytocin is a signaling substance within the nervous system, delivering messages directly via long nerve fibers extending out from the pituitary gland to target tissue in the brain itself. Certain nerves release endogenous (natural) oxytocin into the blood vessels that connect with the pituitary gland’s frontal lobe. In this way oxytocin stimulates the pituitary’s release of prolactin (breastfeeding hormone), growth hormone (GH) and adrenocorticotropic hormone (ACTH). In its natural state — produced in the mother’s own brain, instead of given in an IV — oxytocin influences activity in other nerve receptors and signals biological effects in other body systems.
Another of the unique aspects of oxytocin is that it has both short and long term effects, many of which are paradoxical. For example, initially it increases blood pressure and then switches over to its opposite effect and the blood pressure drops. There are several hormonal effects that have this yes/no, stop/go reaction. According to Dr. Moberg: “The body’s innate system of checks and balances is complex; oxytocin is constantly present and working in many different ways. The effects of this coordinated system are connected like threads in a marvelous web”. [P. 80]
In addition to triggering uterine contractions during sex and labor and the let-down reflex for breastfeeding mothers, the physical, psychological and mental effects of oxytocin include:
Less fearful, more sociable and nurturing
Enhanced social memory
Increased calm and less pain
Reduced muscle tension
Improved learning ability
Effects on blood pressure — both increase or lower, depending on other hormone levels
Balancing body temperature, increasing temperature on front-side of body
Regulating digestion
Regulating fluid levels
Growth and healing of wounds
Effects on other hormones
So the unanswered question that is so ripe for scientific inquiry is whether the artificial source of hormone used to induce labor – Pitocin – might well be only half-a-loaf!
The size of the artificial hormone molecule (Pitocin) is slightly larger than that of natural oxytocin and may be unable to cross the blood-brain barrier. If so, this would prevent Pitocin from functioning as a nerve signal inside the brain, the way natural oxytocin does. For instance, one of the effects of natural oxytocin is to induce a feeling of calm and to reduce perceptions of pain. Midwives and others who see a large number of unmedicated labors are often surprised at the amazing ability of women to cope effectively with what seems like a hard and no doubt painful labor. It looks as if something has enhanced the mother’s ability beyond the realm of normal life. However if you ask women who have been induced with Pitocin whether they experienced any heightened sense of calm, you’ll hear a resounding ‘no’. As for pain, Pitocin induction is regularly described as ‘it hurt like hell’ and so typically these women will ask for pain medication or an epidural.
A natural labor depends on endogenous oxytocin. It precedes at its own internal pace and sets its own rhythm. Could it be that natural oxytocin balances the painful effects of the hormone on the uterus (which causes regular effective contractions) with pain-reducing aspects of oxytocin? This would provide the mother with the hormonal basis for effectively coping with labor, via decreased muscle resistance and increased tolerance for pain and a calm attitude. It’s a question worth exploring, one that an obstetrical profession freed from the overwhelming pressure to perform Cesareans, no longer intimidated by a dysfunctional standard of ever-escalating intervention, and relieved of the relentlessly escalating anxiety over their unfair exposure to malpractice litigation, might just find to be a topic worthy area of study.
The Rightful Use of Episiotomy in the 21st Century
There are only two “right uses” of episiotomy in physiological childbearing, regardless of the century. The first and most frequent reason is fetal distress unresponsive to the usual measures to correct (position change, not pushing for a while, maternal O2, etc). In this case the baby will need to be rescued from any additional delay or added pressure of maternal pushing and episiotomy can help facilitate that. The second and more rare reason is because the mother has become exhausted and asks for an episiotomy to help her baby be born without additional time or effort on her part. The use of episiotomy for any other reason in a normal birth is not ‘medically’ justified, although either the doctor or patient may ‘negotiate’ for its use, provided such a decision is the result of fully informed and voluntarily consent.
As for the scientific literature justifying the use of episiotomy, there isn’t any and never was. Every five years a new study debunking the routine use of episiotomy is published and then ignored like all those that came before it. Given that preamble, it will be no surprise to learn that the most recent statistics on this ever-so-intimate surgical procedure documented that about a third of women in the United States who gave birth vaginally in 2000 had an episiotomy. That is about 1.3 million unnecessary and painful surgical procedures. I
n a review published in Ob.Gyn.News on June 1 2005 (Vol. 40 • N0 11), entitled “Routine Episiotomy Offers Women No Benefits or Relief, Review notes longer recovery, some harm”, the situation was described this way by the researchers:
“Routine use of episiotomy for uncomplicated vaginal births provides no maternal benefits and may harm some who would have had lesser injury without a surgical incision, according to a literature review. When providers restricted their use of episiotomy, women were less likely to have severe perineal lacerations and to need suturing, and were more likely to have an intact perineum and to resume sexual intercourse earlier, reported Katherine Hartmann, M.D., University of North Carolina at Chapel Hill, and her associates.”
“The routine use of episiotomy has been standard for years, with apparently limited research to support it,” Carolyn M. Clancy, M.D., director of the Agency for Healthcare Research and Quality, which sponsored the study, said in a statement.”
In an interview of Jay Goldberg, M.D., director of the fibroid center at Thomas Jefferson University Hospital in Philadelphia, Dr Goldberg said. “Although episiotomy is among the most common surgical procedures performed on women, it is the only one in which neither informed consent nor patient assent is obtained before performing the procedure.
No practitioner would think of attempting amniocentesis, external cephalic version, cesarean section, forceps-assisted delivery, or vacuum-assisted delivery without first discussing this with the patient; however, cutting a woman’s genitalia, usually unnecessarily, is thought to be in the realm of practitioner discretion,” said Dr. Goldberg, who has written extensively on the use of the common procedure. [emphasis added]
None of the studies reviewed found pain to be lessened by routine episiotomy. The evidence showed that the procedure did not protect women against … incontinence, pelvic organ prolapse, and difficulties with sexual function in the first 3 months to 5 years after delivery (JAMA 2005;293:2141-8).
The risk of a woman having an episiotomy during a spontaneous vaginal birth is based more on physician than patient characteristics, according to Jay Goldberg, M.D. Dr. Goldberg and his colleagues prospectively collected data between August 2002 and October 2003 on 55 health care providers who together performed 3,536 spontaneous vaginal deliveries with 969 episiotomies (27%) at three Philadelphia hospitals. ….. board-certified [ACOG-certified obstetricians] cut more episiotomies than did non-certified practitioners [i.e., family practice physicians and professional midwives].
Education slowly will change practice patterns among practitioners who value an evidence-based approach over a “how I’ve always done it” one, he said. For other practitioners, an audit methodology is probably needed to reduce episiotomy rates.
The investigators estimated that about 1 million episiotomies could be avoided annually. They called on clinicians to change their practice patterns, noting that episiotomy use is heavily driven by local professional norms, experiences in training, and individual practitioner preference rather than by variation in the needs of individual women at delivery.
This evidence could help many women with uncomplicated births avoid a procedure that is of no benefit to them, she added.” [ Ob.Gyn.News; “Routine Episiotomy Offers Women No Benefits or Relief, long recovery, some harm” 06/01/05]
What does this mean for Childbearing women and 21st Century Obstetricians?
All across the board the appropriate response is: “Just say No!”. Except for the issue of fetal distress and maternal exhaustion, ALL other rationales have been debunked. A cut is NOT better than a tear, its ISN’T easier or better to sew up an incision than a natural laceration, cutting an episiotomy DOESN’T save the mother’s perineum.
Class dismissed.
As for the topic of ‘natural’ lacerations, the use of physiological management vastly reduces the number of serious lacerations. Additional helpful skills can be learned by physicians and midwives to reduce this number even farther.
However, lacerations still occur about 20-30% of the time but as the research has demonstrated, an episiotomy would not have been better. Some lacerations will benefit from suturing while others don’t need stitches. The non-suturing of 1st and 2nd degree tears has been studied in the UK and is a method used by midwives both here and abroad for over a decade with very good results. In the Ob.Gyn.News review of episiotomy quoted above, they also note that: “Some evidence suggested that leaving the perineal skin unsutured after an episiotomy may confer some benefit.”
What all this adds up to is a 21st century relationship to episiotomy by both physicians and patients that is much simpler and far more satisfactory, biologically and personally, for all concerned.
Chapter Twelve
The theme of this chapter is to reunite the story that was split asunder in the first 10 chapters. At issue is the rehabilitation of the maternity care system, that is, a science-based birth care as the foremost standard for healthy women with physiological management, regardless of the status of the caregiver (physician or midwife) and regardless of the location of the labor (home, hospital or birth center).
As a standard, physiological management includes social and psychological support and the big question is how one does that in a system currently organized around high-end, very profitable technologically-based care.
It is also necessary to describe what it looks like (how a physician would conduct him or herself) and how one bills for birth as a biologically event supported physiologically and managed under the rules of aseptic technique, instead of conditions of “surgical” sterility.
And finally, how does one end the political and social controversy and leave us a stable condition that empowers consumers, midwives and socially conscious citizens to make the necessary changes?
Simplifying the Situation by Simplifying Language (move else where??)
Obviously one does not have to be a midwife to use the principles of midwifery – anyone, male or female, physician, nurse or midwife may employ these sound strategies. In the 20th century the false association of ‘midwifery’, that is, the discipline of physiological management, with the person of the midwife as an enemy of the medical profession, continues to cause mischief even today. Most obstetricians don’t want to be thought of as practicing ‘midwifery’, but they can operate out of the principles of physiological process, and use physiological management for normal labor and birth. A simple vocabulary correction would permit us to disengage the type of care from the type of caregiver, which would make the conversation about 21st century science-based birth services more effective.
From Time Immemorial, the word ‘midwifery’ referred to that entire spectrum of care for normal pregnancy and childbirth, and those who provided that type of care were either ‘midwives’ or man-midwives. Mothers-to-be considered themselves to be ‘maternity’ patients who received ‘maternity’ care. The idea of obstetrics as a medical and surgical practice was first introduced to provide care in abnormal situations only. As providers of medical services, doctors no longer referred to themselves as ‘man-midwives’ but rather as obstetricians.
By the 1930s, all care for pregnancy and childbirth, whether for normal or abnormal circumstances, was called ‘obstetrical care’. By this time the idea of midwifery and midwives had been erased from the medical profession’s vocabulary. Until the last few decades, hospital accommodations for all categories of childbearing women were called “maternity wards”. Nowadays all childbirth-related services have been subsumed into the idea of “obstetrical”, with no one speaking of ‘maternity care’, maternity patients, or maternity wards.
I suggest that the category of care to healthy women with normal pregnancies should properly be called maternity care and provided to maternity patients. The proper care for healthy women is physiologic. In this model, it would be the status of the mother — healthy vs. states of disease or complications – that organizes the type of care provided, rather than the status of the care provider. It is not logical for obstetricians to provide ‘obstetrical’, ie. medically/surgically interventive, care to healthy women.
Maternity care, whether it is offered by a male or female, physician, nurse or midwife, would still be physiological management because that is the foremost standard of care for a healthy woman. With this new vocabulary, an obstetrician could provide maternity care to healthy women and obstetrical care to those with complex situations or complications.
Safe Maternity Practices for the 21st Century
The challenge for the 21st century is to bring about a fundamental restructuring of maternity care in the United States. This is an economic as well as a humanitarian issue, as only the ‘social’ model of maternity care is designed to address the social, psychological, educational and developmental needs of new mothers and their families. Worldwide, the global economy depends on the use of physiological principles and low-tech, inexpensive methods of midwifery care for normal birth services to retain its competitive edge. The US must also utilize these safe and cost-effective forms of care in order to compete in a global economy. In the US the social model of childbirth, which depends squarely on physiological management for its success in providing care to healthy women with normal pregnancies, must become the foremost standard of care. At least 70% of the childbearing population is healthy and have normal pregnancies.
Under this system, management strategies would be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than by the occupational status of the care provider (physician, obstetrician, midwife). At present, who the woman seeks care from (doctor vs. midwife) determines how she is cared for. In a rehabilitated maternity care system, physiological management for healthy women would be the foremost standard, regardless of the status of the caregiver (physician or midwife) and regardless of the location of the labor (home, hospital or birth center).
A Win-Win System and the Rise of Personal Preference of Individual OBs
After obstetrical education is freed from the need to think of birth as always and only a surgical procedure, a spectrum of opportunities will open up. If obstetrics were an integrated, holistic discipline, the principles of physiological management would be part of the bedrock of its practice. This would not only include the physical aspects (right use of gravity) but also the psychological and social, thereby creating a ‘new frontier’ of practice options. Depending on personal temperament, obstetricians would get to choose between the obstetrical complication end of the spectrum or the ‘people part’. Many OBs like developing one-on-one social relationships with the patients they see and are even somewhat envious of the relaxed schedule that midwives enjoy. These physicians like providing ‘maternity’ care and the opportunity to develop a genuine relationship with their maternity patients, provide care at a slower gentler pace, without all the stress and malpractice anxiety typically associated with a busy obstetrical practice.
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What Healthy Woman Maternity Care in a Hospital Setting Would Look Like
To Midwife, the Verb
This describes the active ‘verbs’ of maternity care based on the theory of simple kindness, which propagates ‘omni-directional’ verbs. This is a personal construct of mine based on the idea that “love does not kill to save”, and observes that kind verbs are omni-directional or reversible. For example, if we say “I help you” OR “you help me”, as the object of that verb’s action, my ‘safety’ is the same at either end – one of us helps, the other is helped, and all is well. However, if we use the example of “I cut you” (as in episiotomy or C-section), I really will not want you to cut me as a casual act. It will NOT be OK with me to be cut, while it may be OK with me do the cutting.
If you examine the customary “verbs” of midwifery – support, care, treat with respect, etc — they are fundamentally omni-directional, where as many routine interventions of “usual and customary” obstetrical practices entail the use of forcible means or surgical penetration. They seek to protect the doctor and hospital at the expense of the mother and baby. That is fundamentally unethical and must be addressed.
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How to Make the System work for everyone Re-write for “Voice” i.e., tone of reconciliation
The main and the plain reading of the scientific literature brings one to the logical conclusion that physiological management is the safer and most cost-effective form of care for a healthy population. This leads us to the natural and compelling conclusion that our current hospital-based maternity care system must be rehabilitated.
A newly formulated national health care policy would integrate physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. That standard must be based on criteria arrived at through an interdisciplinary process that INCLUDES the traditional discipline of midwifery as an independent profession and integrates the input of childbearing women and their families into the process.
It is especially important to include testimony from those families who had complications following cesarean surgery or who found it virtually impossible to arrange for a subsequent normal labor and birth after a cesarean (VBAC).
Obviously changes in medical education and obstetrical practice will both be necessary, as well as changes in the way compensation for maternity care is calculated. Physicians who provide maternity care to a healthy population would be required to either utilize the successful strategies of physiological management themselves, cede the care of healthy women to those who do, or obtain truly informed consent for substituting medicalized obstetrical care with its well-documented dangers. Fully informed consent would require true informational transparency relative to the documented consequences of medicalized labor and normal birth conducted as a surgical procedure.
Scientifically correct information must be routinely provided on the limitations and problems associated with the medicalization of labor – i.e., drugs, anesthesia, and medical interventions and procedures that abnormally limit mobility or confine the laboring women to bed. This severely limits or eliminates access to time-tested strategies of physiological management and right use of gravity, thus increasing artificial stimulation of labor and operative delivery and all their associated complications.
Obstetricians must provide valid information during the last trimester of pregnancy that includes the short and long term complications associated with major medical and surgical procedures performed during the labor – continuous electronic fetal monitoring, restriction of oral nourishment, IVs, labor stimulating/inducing drugs, off-label use of drugs (ex. Cytotec), narcotic medication, epidural anesthesia, indwelling bladder catheters, episiotomy, vacuum extraction, forceps and a 27% cesarean section rate. The benchmark for this transparency should be the same information about complications that is reported to physicians in the scientific literature and obstetrical trade papers, such as Ob.Gyn.News. This should be faithfully restated for childbearing parents in lay terms that are appropriate for their concerns.
Transformation in our national maternity care policy would require that:
- Medical educators learn and teach the principles of physiological management to medical students, interns and residents
- Practicing physicians learn and utilize these same skills
- Fully informed consent for obstetrical management of healthy women be provided that includes true informational transparency relative to the documented consequences of medicalized labor and normal birth conducted as a surgical procedur.
- Hospital labor & delivery units be primarily staffed by professional midwives, with incentives for current L&D nurses who wish to retrain for hospital-based midwifery practice to do so at minimal expense to themselves
- Third party payers fairly reimburse all practitioners for the professional’s time spent facilitating normal childbirth, which helps avoid the need for medical and surgical intervention, as well as reimbursing for medical and surgical procedures
- Tort law (medical malpractice) reform be enacted so that doctors are not inappropriately judged by outdated medical criteria that are not evidence-based
In a rehabilitated maternity care system, professional midwives, family practice physicians and obstetricians would all enjoy a mutually respectful, non-controversial relationship. Appropriate maternity care would be provided by all three categories of professionals in all three birth settings as appropriate – hospital, home and birth center – without prejudice, controversy or retaliation against the childbearing family or against other care providers. By making maternity care in all settings equally safe and equally satisfactory, families would not be forced to submit to forms of care that are not appropriate for their needs or that waste our economic resources.
This rehabilitative process could be launched by the California state legislature or a public policy organization such as the Pew Charitable Trust which could convene a blue-ribbon panel consisting of scientists from all the pertinent disciplines – public health, epidemiology, sociology, anthropology, psychology, biology, child development, law, economics, midwifery, perinatalogy and obstetrics. Such a highly respected forum would study these problems and provide unbiased, fact-based news for the press and broadcast media to report. This public exploration must include listening to childbearing women and their families as a class of experts in the maternity experience.
Such a panel would produce interdisciplinary recommendations for a reformed national maternity care policy. This would include methods to reintegrate midwifery principles and practice into this expanded system of maternity care.
Ultimately such exploration and recommendations would result in legal and legislative changes affecting doctors, hospitals, midwives and the health insurance industry. Such a system would then be respected and used equally by all maternity care providers with the backing of hospitals, health insurance and medical malpractice carriers, and state and federal reimbursement systems (Medicaid / MediCal) etc.
Unfinished Draft /// End Section Conclusion / wrap-up of political controversy
Midwives and Obstetricians — Enemy or Friend of The State?
In a democratic society the function of government is determined by consent of the governed. Sanctity of life and protection of vulnerable populations– infants and children, pregnant women, the ill, injured, disabled, the mentally incompetent — are all considered to be the legitimate duty of The State. At our insistence, elected representatives pass laws authorizing public agencies to do this – law enforcement, child protective services, medical boards to name a but a few — and we hold agents of the government responsible for achieving those goals.
In the early part of the 20th century, the obstetrical profession considered its care of childbearing women to be an extension of the State’s obligation to protect the vulnerable. This perspective was originally based on the notion that epidemics of puerperal sepsis and maternal deaths were inevitable occurrences (since the needs of medical education required that childbearing women be aggregated in institutions). Given that as the background, puerperal sepsis had to be vigorously controlled via the conduct of childbirth by under surgically-sterile conditions. The two US titans of the 20th century obstetrical profession – Drs DeLee and Williams — were personally convinced that normally childbirth was inherently pathological.
This conclusion was fueled by their observations that even (read ‘especially’) when childbirth was conducted as a sterile surgical procedure by trained obstetricians on women under general anesthesia, complications still abounded. According to their theories, the doctors were not at fault (!), so it must be the women themselves or the nature of their biology that was to blame. Given this as a starting point, it was only logical for the obstetrical profession to conclude that their profession was an extension of the government’s role of beneficent to and protection of vulnerable populations. By that definition, the physiological principles of midwifery was assumed to be a deficient and old-fashioned form of care, an ‘enemy of the state’ no longer to be tolerated by ‘modern’ society.
In this equation, the natural conclusion is simple. If the obstetrical profession is a ‘friend’ of the State, helping to carry out its functions, then the entire midwifery profession (and all its practitioners) must be an enemy of the state. This describes the present-day relationship of organized medicine, state legislatures, court systems, state medical board and society in general to the principles of physiological care, midwifery as a discipline and midwives as providers of maternity care.
Its assumed that the obstetrical profession saves babies, thus the failure to use the care of the obstetrician is to risk the unnecessary or ‘preventable’ death or disability of vulnerable women and their unborn/newborn babies. What this adds up to is a ‘crime’ on the part of the parents and malpractice on the part of the practitioner for any failure to make liberal use of electronic fetal monitoring, labor stimulating drugs, conduct of birth as a surgical procedure, instrumental or operative delivery, etc. Under this system of medicalization, physiological process and midwives are both enemies of the state.
However, when this odd and unexamined assumption – an unproven hypothesis — is opened up to the rigors of unbiased scientific inquiry, the conclusions arrived at are dramatically, startlingly different. In fact, they are the opposite. Scientific sources make it clear that routine obstetrical interventions and birth as a surgical procedure for healthy women are always more dangerous than the use of physiological principles, conjunction with traditional social and psychological support and appropriate access to obstetrical services for complications.
The science-based standard of care for healthy women is physiological management.
Period.
Physicians who provide maternity care to a healthy population are required to either utilize the successful strategies of physiological management themselves, cede the care of healthy women to those who do, or obtain truly informed consent for substituting medicalized obstetrical care.
Period.
The obstetrical profession became a prisoner of their own project when it set up this extreme contrast, one that identified itself as a ‘friend’ of the State, based on its potential for protecting mothers and babies. Since institutionalized medicalization and obstetrical intervention for a healthy population isn’t able to deliver on that promise, it is another example of the double barreled shot gun with one bore twisted back and aiming straight at the conventional practice of obstetrics. Defined by its own criteria, the judgment is harsh.
The Real Enemies of the State Are Ignorance, Prejudice and Disease States
However, nothing is to be gained by simply making obstetrics the bad guy. First, it’s not true. Second, generating new controversies and hard feelings would be a stumbling block, preventing the achievement of very worthy goals. So lets wipe the slate clean and just start over. The real enemies are neither doctors nor midwives. They are ignorance, prejudice, disease states and medical complications, congenital anomalies, lack of access to appropriate medical services and a tort law system that holds us all hostage to unnecessary medicalization and particularly victimizes the obstetrical profession, and indirectly, the rest of society.
Physiological Management for Healthy Women –
The Bell that Can’t Be Unrung…
Obstetrics as a scientific discipline must once again learn, teach and utilize physiological management for healthy women. To do that, midwives are suggesting, in the strongest of terms, that an exchange of expertise is in order. It is as much the responsibility of physicians to be familiar with the time-honored philosophy, principles and skills of midwifery as it is the duty of midwives to know the principles of anatomy and asepsis. Midwives are in agreement that modern obstetrics has much to teach and much to contribute to the wellbeing of the families it serves.
The Late Dr. Galba Araujo, formally professor of obstetrics from Brazil, in an article urging an “articulated model of midwifery” into contemporary obstetrics stated:
“We have learned much from the traditional (midwife) and respect is mutual between our parallel groups. We have learned to teach our (obstetrical) students less invasive delivery and above all, to use the vertical position for the mother. Perhaps this is the most valuable lesson among the many we have learned.”
Midwives have availed themselves of both formal and informal study of obstetrical science. Likewise, the honorable but unassuming traditions midwifery — the art of being “with women” — the quietness of spirit, the patience with nature, the intimacy skills which serve childbearing families so well are also of great value to the bio-medical sciences. We believe that physicians cannot begin to examine their prejudices without specific information on the nature of these principles and the opportunity to build personal and professional relationships with those who practice physiological management of normal birth.
In spite of the fears of many within the obstetrical community, midwives do not represent a feminist conspiracy to eliminate the obstetrician. Quite the obverse — midwives seek to augment, supplement and complement the contemporary medical model of care. The jewel in the crown of independent midwifery is that it is not intrinsically in conflict with the true purpose and glory of obstetrical care — the compassionate correction of dysfunctional states and the treatment of pathological ones. The immutable standard of maternity care is the same the world over and through out history, it is the same in every language — the goal is and will remain the practical wellbeing of the mothers and babies it serves. Here on the brink of the 21st century, the first duty of maternity caregivers of every educational and experiential background must be to bring about a cooperative and complimentary system that truly functions in the best interest of childbearing families.
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The time to eliminate prejudice is upon us.
This philosophy of reconciliation is perhaps best described in a little-known story told about Eleanor Roosevelt during the years that she was mother of young children as well as First Lady of the land. When asked what she put first in her life, her husband (who was President of the United States), or their children, she replied that “together with my husband, we put the children first“. I have always appreciated that story as portraying the ideal relationship between physicians and midwives — that together we put the practical wellbeing of the mother and baby first.
WE, the People, came together to form a more perfect union.
WE, the People, cannot stop perfecting that union until it includes science-based birth care for all healthy women with normal pregnancies.
Draft material from other sources
Conservative & Responsible Maternity Care
I am not old enough to remember what it was like when the physiological care of midwives was norm for normal birth, but I am old enough to have been an L&D nurse when maternity care was primarily provided by GPs. While care in the hospital was often not consistent with . Obstetrician-attended birth were the minority and that choice was usually associated with doctors’ wives and care of the very wealthy.
The management style of these doctors was conservative, as defined by the classical principles of conservation. In regard to childbirth, the ability of the practitioner to bring about a vaginal birth was seen as a value, while Cesarean section was rightly seen as a dangerous procedure to be used sparingly and then only when all other avenues had failed. The older general practice physicians had trained in the 1930s and 40s and began their practice when the statistical majority of childbirth still occurred at home. These older doctors had a history of working with midwifery assistants who proved the bulk of the labor care at home at the direction of the GP and in some cases, simply conducted all the normal births themselves, with the physician only being called when there was a problem.
As a labor room nurse in the early 1960s, GPs and obstetricians both delivered breeches and twins vaginally, with little or no ‘special’ attention or preparation. Both of these situations were considered a variation of normal vaginal birth and the outcomes for these mothers and babies were consistent with those of other normal vaginal births.
Even complications such as a marginal placenta previa were managed “conservatively”, with the professional skill of the practitioner informally judge by his ability to avoid a Cesarean. Except for emergency C-sections, all intrapartum Cesareans required the physician to get a second opinion and that doctor had to be one that was not a part of the same group practice.
Every Cesarean performed was reviewed by the obstetrical morbidity and mortality committee meeting each month. Any physician whose C-section rate was substantially above average was cautioned and if the rate stayed too high, would be put on probation (which required a proctor physician to work in conjunction with him) until the rate was not brought back into line with the overall norms forte institution. In 1961 our hospital had a 3% Cesarean section rate.
Deconstructing Conservative and Responsible Maternity Care
During the first ten years of my L&D nursing career, I noticed the incremental elimination of GPs from those physicians with obstetrical privileges. During the decade of the 1960s, the scale tipped slowly towards a majority OBs, but still a fair number of the older GPs who were well known and well liked in the community. By the 1980s the GPs were gone but a few new non-obstetricians from the newly minted ‘specialty’ of family practice medicine were providing maternity care.
However, the scope of practice of family practice doctors was incrementally restricted over the next two decades by policies passed by the hospital obstetrics department. The chief of OB, who is responsible for the OB department policies, was always elected by a vote of the physicians with obstetrical privileges. As board-certified (ACOG) obstetricians came to dominate the obstetrical staff, the majority of doctors predictably choose a different obstetricians each year to be chief of staff. It has been a century-long agenda of the obstetrical profession to reduce the number of non-obstetrician providers of childbirth services. This resulted in increasingly restrictive policies, as non-obstetricians physicians were no longer permitted perform Cesarean surgery (even though they were licensed as ‘physicians and surgeons’) and also prohibited to attend breeches or twins or VBACs.
The return of Conservative and Responsible Maternity Care
Aside from the ethical principle of autonomy of healthy and mentally competent adults is the disturbing issue of an obstetrical profession that is apparently being held hostage to a radical form of maternity care for healthy women, which seeks to make surgical birth a ‘standard of care’ for the obstetrical profession. Due to policies set by hospital obstetrical and anesthesia departments, obstetricians are being restricted to a level of obstetrical care well below that of first year obstetrical resident.
Obstetricians now need a permission slip from the hospital administration or chief of the anesthesiology department in order to provided care for a planned VBAC. In many case, obstetricians are forbidden, through formal or informal OB department policies, to provide vaginal birth services to mothers with twin or breech pregnancy. (This also applies to providing backup services to midwives or accepting hospital transfer of home birth clients.)
The result of a disenfranchised obstetrical profession is a sky-rocketing C-section rate, which in my professional life (1961 to the present) has gone from 3 to 27 percent. Identified risks of cesarean includes 33 well-known complications (including a 13-fold increase in emergency hysterectomies) compared to only 4 specific risks for normal vaginal birth [see MCA’s systemic review “What every pregnant woman needs to know about Cesarean Section” at www.maternityWise,org]. Childbearing women who are delivered by Cesarean section are two to four times more likely to die from the intra-operative, post-operative or downstream complications of Cesarean surgery than from normal vaginal birth. More than a dozen operative and post-op complications for the mother are associated with Cesarean including maternal death, maternal brain damage, anesthetic accidents, drug reactions, infection, accidental surgical injury, hemorrhage, emergency hysterectomy, blood clots in the lungs, need to be admitted to ICU, need to be on life support, inability to breastfeed.
Potentially-lethal complications and protracted difficulties extend into the postpartum period, post-cesarean reproduction, post-cesarean pregnancies and post-cesarean labors. Reproduction complications include secondary infertility, miscarriage and tubal pregnancy. Delayed or downstream complications in future pregnancies include placental abruption, placenta previa, placenta percreta, uterine rupture, and maternal death or permanent neurologically impairment.
Risks to babies include accidental premature delivery, surgical injury during the C-section, respiratory distress, increased rates of admission to NICU. Risks to babies in subsequent pregnancies include placenta abruption/stillbirth, death or permanent neurological disability (do to uterine rupture), lung disease and increased rates of both childhood and adult asthma.
For this reason, the reduction in operative deliveries associated with physiological management is an important tool in the reduction of maternal mortality and perinatal loss in future pregnancies. A large number of women with identified pregnancy risks such as VBAC or breech baby at present are totally unable to get appropriate obstetrical care. Some of these women are choosing instead to be cared for by midwives and other are choosing unattended home births.
These parental choices may address the family’s own personal dilemma, but it doesn’t address the underlying problem. The major social problem here is a disenfranchised obstetrical profession – doctors forbidden to do doctoring — and the run-away costs, both personal and economic that are occurring subsequently. This prevents the United Staes from having a truly conservative and responsible maternity care system, which is also a handicap in a global economy, preventing the US from being competitive around the world.
The solution lies in three specific areas of reform. One is the need for tort law reform in combination with ACOG policy statements and position papers that recognize physiological management as an appropriate category of care provided by obstetricians to healthy women with normal pregnancies, in which the mother neither desires or requires interventionist obstetrical care.
The second is for medical educators to acknowledge that physiological management is the foremost standard for healthy women worldwide. This would permit them to learn the principles of physiology themselves and subsequently to teach physiological management to medical students and in obstetrical residency programs, with the expectation that physiological principles would be routinely utilized for healthy women.
And last but not least is the staffing of labor and delivery units of hospitals by professional midwives as practitioners who are authorized to provide the full spectrum of physiological care to healthy women. On the continuum of physiological management, the ‘birth’ or ‘delivery’ is not a separate activity requiring the services of a surgical specialist, but rather a normal part of normal maternity care as provided by the hospital-based midwife. At the request of either the mother or the obstetrician, the physician may be called to ‘catch’ the baby, but it would not be required by hospital policy.
Part and parcel to this changed relationship with hospital-based midwifery is also the ‘normalizing’ or rehabilitating of relationships with community-based midwifery, so that complementary professional relationships can develop between community midwives and hospital obstetricians. This would lead to the integration of community midwives into the health care system and result in “relocated home births” for that category of women with significant risk factors that can be reduced by early and easy access to medical services.