Trapped on the Wrong Side of History ~ Chapter 11 ~ unpublished manuscript

The obstetrical profession mistakenly ascribed absolute value to things of relative worth.

This confusion of cause and effect means that inappropriate generalizations are being made from a specific situation.

Chapter Eleven

Like the 1970s, 80s and 90s, the first years of the 21^st century were a sequel to the same underlying definition of female reproduction as a pathological process. This meant the same legal  and billing code classification of normal birth as a surgical procedure and the obstetrically interventive process with the addition of highly technological electronic fetal monitoring.

All these interventions had become the ‘business as usual” standard, with elective induction and/or or scheduled C-sections being used even more often or even earlier in the process.

But the late 20th and early 21st century was most notable for an order-of-magnitude change that equalled in audacity the critical decisions made by Drs DeLee and Williams’ in the early 1900s. This was (is) a genuine effort within the obstetrical profession to promote the elective or non-medical use of Cesarean as a replacement for normal birth in healthy women. If adopted, this would result in the second most radical change in childbirth practices in the history of planet Earth.

A lot of thoughtful people are thoroughly convinced that a nice scheduled C-section is the “modern” best choice. In 2000, elective or ‘prophylactic’ Cesarean section for healthy women (often referred to as the ‘maternal choice’ Cesarean) was proposed for the second time, as the new standard for obstetrical care.

Unlike the 1984 “Prophylactic Cesarean” paper by Feldman and Friedman, which was published in the prestigious New England Journal of Medicine but nonetheless was obscure to the lay public), this time the idea was presented very publicly on Good Morning America.

Dr. Ben Harer, then president of ACOG, was interviewed by Diane Sawyer on GMA. Dr Harer repeated the century-old ideas of DeLee and Williams and others that described vaginal birth as damaging to both mother and baby.

Where Dr. DeLee had proposed the ‘prophylactic’ use of forceps in the early 1900s, Dr Harer proposed ‘elective’ Cesarean in early 2000s. According to him, C-section was clearly safer for the baby and “no big difference” risk-wise for the mother.

He and many other obstetricians assumed that most women who have a vaginal birth will need corrective surgery later in their life to repair the damage. With that in mind, the post-operative complications of one, two or three C-sections were believed to be no more risky for the mother, since cesarean surgery was believed to eliminate pelvic surgery later on.

Here are excerpts from the transcript of the show, taped at a time when the Cesarean rate was significantly lower than it is now:

Diane Sawyer: “Each year, one in every five** babies in America comes into the world through a cesarean section, the country’s most common surgery.”  

**that number has increased to one in three

Diane: “Some obstetricians are now calling the cesarean section preferable to vaginal births.”

Diane Sawyer: “ . . . (doctors) believe that women should at the very least have the option to choose between the two . . . . and that insurance companies should basically pay … equally and treat them equally.”

Dr. Harer: “…Yes …. women should be given the facts and then given the choice.”

Diane: “…and there’s a higher rate of problems with vaginal birth, than with cesarean section?”

Dr. Harer: “Yes, for the baby, the risks are far higher for vaginal delivery . . .than for an elective cesarean section at term.** For the mother, the immediate risks for a cesarean section are a little higher ….

** this is not a truthful statement — Cesarean surgery NOT safer for either mother or baby!

Dr. Harer: …. but the longer term, risks of pelvic dysfunction, incontinence . . . . . . those risks are higher for vaginal birth. Over the long term I think that the risks balance out, that there really is no big difference.”  {Note: this statement also is not backed by any scientific evidence}

The show ended as a charming Diane Sawyer assured the viewers that this ‘obviously’ controversial position would surely occasion additional coverage by GMA, so “stay tuned” for the updates.

Apparently the idea of Cesarean surgery as the 21^st century standard of care was not at all controversial to viewers, as this topic quickly became a non-story, never to be heard of again on Good Morning America.

 

 

 

 

 

Obstetrics ~ 2000 and beyond

“The more things change, the more they stay the same” certainly applies to obstetrics. We think of our lives, our hospitals and our expectations as dramatically different from the typical overworked and underfed woman having her 6th (or 16th!) baby at the turn of the 20th century.

As a maternity patient in teaching hospital in 1910, the laboring women would have been admitted to an open ward full of women, each lying in her bed and laboring under the effects of scopolamine. Her labor would have been medically managed by nurses, who listened to fetal heart tones every half hour with a fetoscope and routinely administered shoots of morphine and scopolamine every 2 or 3 hours per standard Doctor’s Orders. Under the amnesic influence of twilight sleep, our 1910 labor patient would have restrained in her bed until it was time to be taken by stretcher to the delivery room and put to sleep with general anesthesia.

 

As ‘clinical material’ for medical students, the surgical procedure of vaginal delivery (and all that entailed) would be conducted by a student or intern who was being supervised by an obstetrical professor. After the birth, she would be too groggy to hold the baby for many hours or even know whether she had a boy or a girl.

 

 

 

21st Century Obstetrics — the same level of obstetrical control while using different technologies

Contrast that with the experience that the contemporary laboring woman had. In the year 2000 and beyond, the typical maternity patient would be much less likely to be poor or a ‘grand multipara’ having an umpteenth baby. It would be statistically unlikely for her to be cared for by a medical student or obstetrical resident. Instead she would be healthy with a normal pregnancy and having a first or second baby, with a private obstetrician in charge of her care.

While being cared for by a “private obstetrician” sounds very appealing, the reality is very different from what most women expect, which is that their doctor will be there in the room with them while they are in labor. But obstetricians are trained as surgeons, which is to say aren’t present during the long hours of labor. When a labor patient presents herself to the L&D staff for admission, the nurse calls her doctor, who then legally authorizes the nurse to formally admit the patient and provides  directions for how the nurse should manage the patient’s labor.

So the downside of private obstetrical care is that, unlike interns and residents who are consistently present, her doctor will not be physically present in the hospitals until it’s time to come in and ‘deliver’ the baby. Before that, nurses will mainly manage her labor via the telephone while the OB is in absentia,  or maybe briefly stop by during his/her normal pre or post office hours hospital rounds.

Upon admission to the labor & delivery unit, our 21^st century obstetrical patient would be ushered to a single occupancy LDR. She would not hear other women screaming or cursing, nor would she be ‘prepped’.

She would however be immediately hooked up to continuous electronic fetal monitoring or EFM, to legally record the unborn baby’ status at the time it’s mother was admitted to the hospital’s L&D unit.

The the new labor patient would likely have an IV started, and statistically-speaking, Pitocin added to be sure that her labor progressed at a predictable rate.

to better detect the fetal distress associated with the use of Pitocin and permit the staff to do a timely emergency C-section if the situation got out of hand. When the labor contractions got more painful, an epidural would replace the narcotics and scopolamine drugs previously given in labor and save her from the indignity of a hood over her head, four-point restraints and literally ‘loosing her mind’ for the many hours of her labor. Once the epidural catheter was in her back, she would to have her blood pressure very closely monitored, so an automatic BP cuff would be placed on her arm.

Since she couldn’t feel the lower half of her body, she wouldn’t be able to void on her own so a Foley catheter would be placed in her bladder and hooked up to a bag to collect the urine. In most hospitals, the catheter is left in place until after the baby is born (saves time if a crash CS should have to be done), but this also means that she will push during the second stage with the 10cc Foley balloon in her bladder (a fluid-filled ball approximately the size of a walnut). With every expulsive contraction, the Foley balloon also being pushed down into the upper end of her urethra, stretching the soft tissue and perhaps over-stretching the urinary sphincter.

Opinions differ as to whether leaving the Foley in during pushing increases the incontinence rate after childbirth but some hospitals take it out based on the idea that it is not good technique. This issue would also apply to women who had a Cesarean after many hours of futile pushing in second stage.

When it was time for the baby to be born, the obstetrician will be called at home or his or her office. When the doctor arrived, the 21^st century mother would no longer be separated from her family by being trundled away on a stretcher to the delivery room. Instead, the delivery room would be brought to her in a form of a bed that turned into a delivery table with stirrups and cupboards that opened up to provide state of the art delivery room equipment and supplies.

The epidural she already had would take the place of the general anesthesia that used to be given in preparation for surgical delivery. This would spare both her and her baby from the dangers of anesthetic gases and allow her husband to stay by her side during the ‘procedure’ of vaginal birth. She would be permitted to hold her baby soon after its birth, since she wasn’t under the influence of consciousness altering anesthetics.

According to interviews conducted in 2002 & 2006 of healthy childbearing women who had recently given birth under obstetrical management:

93% reported continuous electronic fetal monitoring during their labor 
86% were given IVs (and prohibited from drinking or eating) 
74% of women required to give birth lying on their back,
71% immobilized / confined to bed / not permitted to walk during labor 
67% rate of artificial rupture of membranes,
63% of labors induced or accelerated with prostaglandins and/or Pitocin 
63% epidural anesthesia rate 
58% had a gloved hand inserted into their uterus after birth 
52% catheterizations / indwelling bladder catheter,
35% episiotomy rate, 30% cesarean surgery,
13% instrumental delivery by forceps or vacuum extraction.

[Listening to Mothers Survey, 2004 & 2006 @ www.childbirthconnection.org]

It should be noted that these statistics apply to healthy women with normal pregnancies. The operative rate for the healthy portion of our childbearing population is more than 70% (aggregated rate of 35% episiotomies, 30% Cesarean section rate & 13% forceps /vacuum extraction). Added to this already dismal list of disruptions in biological process is the increasingly accepted notion of scheduling elective Cesareans for healthy women before they have a chance to go into labor. If anyone wonders why this is so, the answer lies in the ‘new’ obstetrics and the crucial decision made by DeLee and Williams.

Having defined obstetrics as a hybrid surgical specialty (combined with gynecology)  in the late 1800s, obstetrical residents have been taught ever since to conduct normal birth as a surgical procedure. This surgical designation is the reason physiological management is not taught in medical school, why labor and delivery units are a restricted area, why doctors wear OR scrub clothes, suit up for delivery with a sterile, long-sleeved doctor’s gown, wear a surgical cap and mask. Vaginal birth as a surgical procedure has to be under the tight control of professionals.

As a ‘procedure’ it is something the doctor does, instead of the mother, and is why we say “the doctor delivered the baby”, instead of saying “the mother gave birth”. It is also the reason that normal birth has a surgical billing code and correspondingly hefty price tag.

As a highly medicalized process, care for childbirth had already been moved out of the main steam of normal life and reconfigured to fit the protocols for an appropriate surgical environment. The social and emotional needs the mother and the father and the historically social nature of childbirth all have to be subsumed to the needs of the institutional needs for insuring ‘sterility’.

The primary focus became the technical details of maintaining their sterile technique, which neither add to the safety of the childbearing women or allow the birth attendant to directly address what are the real needs of spontaneous biology (right use of gravity) or the mother’s own physical and psychological experience.

As a result, the mother and the father were both psychically erased from the picture for the first seventy-five years of the 20th century. While hospitals no longer bar the father or other family members from a vaginal delivery in the LDR, when childbirth become Cesarean surgery, everyone but the father is excluded and he quickly become an outsider that must depend on the good graces of the anesthesiologist for permission to remain with his wife. The dad’s participation and conduct in the OR suite are tightly controlled and in cases instances of urgency, he can be barred completely.

But most detrimental of all is the systemized loss of physiologically-based birth services and its replacement by the inappropriate idea of normal birth as a surgical procedure. The purposeful non-teaching of normal physiology in medical school, combined with the unwarranted use of interventionist obstetrics, wreaks havoc on the biology of childbirth.

The surgical delivery of healthy women as an American custom has not and will not improve outcomes and actually is associated with an increase in maternal mortality. Countries that rely on simple low-tech techniques of physiologic childbirth practices do much better than the US.

In fact, All we have gotten out of birth as a surgical procedure is a surgical billing code for a normal biological event, disproportionate expense and huge piles of bio-hazardous waste, topped off by those all-to-familiar pictures of the mother-to-be lying on her back under sterile sheets with her legs in stirrups and her doctor suited up like the Michelin Man, peering over his surgical mask at her. This did not buy us better babies and so far we have no reason to believe that scheduled C-sections would do any better and lots of evidence that it ups the danger.

Standardization versus Customization: The 20^th century industrialization of normal birth was a process for standardizing care, an attempt to make it more efficient in manner not far removed from the industrialization of manufacturing and other process-related businesses.

But the biology of childbirth, the physical, social and psychological needs of the mother-to-be cannot be deconstructed and dealt with like objects on a conveyor belt that will be assembled together farther down the line. The individual needs that each childbearing woman presents to her caregiver are unique and change minute by minute. They require the moment by moment attention of the caregiver, which a priora means the physical presence of the childbirth attendant through out active labor and birth. As in a piloting a plane, the pilot or co-pilot has to be there and be engaged on a moment by moment basis. What laboring women need is not standardization but customization.

The reasons that physiological management – a process of customization — was displaced are legion. The most central one is the simple fact that physiological management is held in distain and not taught in medical school. It was considered to be ‘woman’s work’, as can be seen by assigning the long hours and of supportive care during labor to nurses and low paid ancillary staff and the exciting, well-compensated photo finish to physicians. In the absence of physiologically-based methods, a number of policies, procedures and medical devices must inevitably be called upon to take the place of these classically non-interventive methods.

The list is lengthy but a few rise to the top in terms of their negative effect – EFM, induction or augmentation of labor with Cytotec and Pitocin, epidural, anti-gravitational positions and coached pushing, episiotomy, vacuum extraction, liberal use of Cesarean as a strategy to prevent cerebral palsy in babies and/or pelvic floor damage in mothers and the idea of “maternal choice’ Cesareans as the 21st standard of care. The word usually used to indicate the process for using all this ‘stuff’ is the ‘cascade of interventions’.

The Cascade of Intervention: The obstetrical profession has never acknowledged the domino effect, also called the cascade of interventions, associated with highly medicalized childbirth. This cascade occurs when an obstetrical procedure — for example, induction of labor — triggers the need for other interventions, such as continuous EFM and epidural anesthesia.

The cascade of interventions can so disturb the biological process that it results in iatrogenic-induced fetal distress that requires a variety of emergency interventions, including Cesarean section. This inherently complex chain of events and the large number of problems encountered during the labor and vaginal birth, make Cesarean surgery look a problem solving strategy, especially if the large number of lawsuits associated with vaginal birth were factored in.

Can continuous Electronic Fetal Monitoring and Cesarean eliminate Cerebral Palsy? — the obstetrical profession’s own research says “No”

Since 1975 there has been a 6-fold increase in the routine use of electronic fetal monitoring (EFM) on low-risk mothers. The obstetrical profession hoped to eliminate cerebral palsy and other neurological complications through the expanded use of EFM, combined with the liberal use cesarean section whenever the fetal monitor strip indicated a possible problem. EFM is the most frequently used medical procedure in the US – 93% of all childbearing women are continuously hooked up to this equipment during labor. Many health insurance carriers reimburse hospitals $400 an hour for continuous electronic monitoring in labor.

However, the consensus of the scientific literature has never supported the routine use EFM. One recent study noted that the ability of continuous EFM to detected potential cases of cerebral palsy during labor is only 00.2%, not because the electronics of the equipment are flawed but because the premise is incorrect. In spite of these faulty assumptions, the universal use of EFM on low-risk women continues unabated and has resulted in a sky-rocketing Cesareans section rate that was not associated with better outcomes.

In 2003, 1.2 million Cesarean surgeries were performed in the US (27.5% cesarean rate) at a cost of $14.6 billion. Our current Cesarean rate is over 31% and climbing. The public and the press never seem to question the unlikely idea that normal childbirth is somehow made safer and better by turning it into an expensive and risky surgical operation as documented in the above series of intraoperative photos.

Yet the obstetrical policy of ‘pre-emptive strike’ has not made the tiniest bit of difference in the incidence of CP and similar neurological conditions. This verifiable fact is now gratefully used in court to defend obstetricians facing litigation.

@@@

The Routine use of Continuous EFM –
A Failed Experiment:

Thirty years of continuous electronic fetal monitoring of all laboring women, combined with the liberal use of cesarean section in event of even the slightest suspicion of fetal distress, failed to reduce the rate of cerebral palsy and other neurological disabilities. This is a well-documented fact and widely acknowledged by the obstetrical profession itself.

In July of 2003, a report by the American College of Obstetrician and Gynecologists (ACOG) Task Force on Neonatal Encephalopathy & Cerebral Palsy stated:

“Since the advent of fetal heart rate monitoring, there has been no change in the incidence of cerebral palsy. … The majority of newborn brain injury does not occur during labor and delivery. …. most instances of neonatal encephalopathy and cerebral palsy are attributed to events that occur prior to the onset of labor.”

This report is widely regarded as the “most extensive peer-reviewed document on the subject published to date and has the endorsement of six major federal agencies and professional organizations, including the CDC, the March of Dimes and the obstetrical profession in Australia, New Zealand and Canada.

The September 15, 2003 edition of Ob.Gyn.News stated that:

“The increasing cesarean delivery rate that occurred in conjunction with fetal monitoring has not been shown to be associated with any reduction in the CP [cerebral palsy] rate…   … Only 0.19% of all those in the study [these diagnosed with CP] had a non-reassuring fetal heart rate pattern….. If used for identifying CP risk, a non-reassuring heart rate pattern would have had a 99.8% false positive rate (N.Engl. J. Med 334[10:613-19, 1996). The idea that infection might play an important role in [CP] development evolved over the years as it became apparent that in most cases the condition cannot be linked with the birth process. ” [emphasis added]

An August 15, 2002 report in Ob.Gyn.News stated that:

“Performing cesarean section for abnormal fetal heart rate pattern in an effort to prevent cerebral palsy is likely to cause as least as many bad outcomes as it prevents. … A physician would have to perform 500 C-sections for multiple late decelerations or reduced beat-to-beat variability to prevent a single case of cerebral palsy.” [emphasis added]

Unfortunately, delayed and downstream complications for mothers and babies that are associated with EFM and the liberal use of Cesarean surgery makes this policy extremely counterproductive.

People wrongly assume that EFM is the equivalent of an electrocardiogram (EKG) for the unborn baby, but this is a serious misunderstanding of the technology. Electronic monitoring is simply an elaborate mechanism to count and graphically display the pulse rate of the unborn baby. The machine merely transposes the acoustic signal of heart rate into a printed paper graph and video display, which makes visible the four auditory markers of fetal well-being (baseline heart rate, variability, accelerations and absence of pathological decelerations).

Listening to the baby with a fetoscope (special non-electronic stethoscope for listening to fetal heart tones) or an electronic doptone can provide the same on-going data (same four markers) on the well-being of the unborn baby without the interpretive errors, physical restrictions and unrealistic expectations associated with the use of continuous EFM.

Despite a success rate of only 00.2%, most hospitals bill around $400 an hour for continuous EFM. Regularly listening to fetal heart tones with an electronic Doppler for one full minute immediately after a contraction, (called Intermittent auscultation or ‘IA’) permits the same data on the four auditory markers of fetal well-being to be obtained.

While intermittent auscultation is more time-intensive, IA for low and moderate-risk labors is equally as effective as continuous EFM, with the added benefit of a greatly reduced cesarean rate (4% vs. 26%). This is, in part, because it unhooks healthy mothers from machines and permits laboring women to move around freely. No longer tethered to the bed by electronic wires, the mother is able to change positions frequently, walk, use hot showers or deep water for pain relief and make “right use of gravity” These practices reduce fetal distress and the need for Pitocin-augmentation of labor, pain medication, anesthesia and instrumental and operative delivery.

The other blue elephant in the room that no one is talking about – according to the scientific literature, elective Cesarean surgery isn’t a reliable method to prevent the pelvic floor problems sometimes associated with childbearing; “purple pushing” during 2^nd stage labor identified as damaging to the soft tissue of the birth canal; study confirming that traditional upright positions provide the most room for baby to be born normally

Cesareans not safe or effective for preventing pelvic problems: Having debunked the ‘prophylactic’ use of Cesarean to prevent cerebral palsy in babies, elective C-section is now being promoted as a prophylactic procedure to eliminate pelvic floor problems later in the woman’s life. However, reputable research also does not support the use of elective Cesarean surgery as either a safe or a reliable method to achieve this goal.

In an article entitled “Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?”, Dr Peter Bernstein, MD, MPH, Associate Professor of Clinical Obstetrics & Gynecology and Women’s Health at the Albert Einstein College of Medicine, reported on the failure of the obstetrical profession to practice evidence-based medicine as it applies to this topic. Addressing the popular notion that pelvic floor damage and incontinence were the inevitable result of normal birth (to which cesarean surgery was the proposed remedy), Dr Bernstein observed:

“…these adverse side effects may be more the result of how current obstetrics manages the second [pushing] stage of labor. Use of episiotomy and forceps has been demonstrated to be associated with incontinence in numerous studies. Perhaps also vaginal delivery in the dorsal lithotomy position [lying flat on the back] with encouragement from birth attendants to shorten the second stage with the Valsalva maneuver [prolonged breath-holding], as is commonly practiced in developed countries, contributes significantly to the problem.”

A guest editorial published in Ob.Gyn.News; August 1, 2002 by Dr. Elaine Waetjen debunked the idea that elective cesareans can reliably prevent the need for pelvic surgery later in life. She stated that a: “[physicians] would have to do 23 C-sections to prevent one such surgery.”

Non-physiological pushing styles and positions are risky for mother and baby: Another report in published in Ob.Gyn.News, March 15 2003, councils against “purple pushing”, which is when the mother holds her breath and pushes so long that she temporarily uses up all her oxygen and gets purple in the face. Prolonged pushing of this type can cause tiny blood vessels [capillaries] in the face to break and sometimes blood vessels in the mother’s eyes will rupture, leaving a tell-tale bright red spot in the corner, similar to the damage that accompanies a black eye. The technique that causes this is the Valsalva maneuver, a combination of prolonged breath-holding and “closed-glottis” pushing.

The author, Lisa Miller, CNM, JD is a former labor and delivery nurse, a nurse-midwife and also an attorney. Her report identifies the general idea of ‘directed’ pushing as an undesirable practice that interferes with normal physiology. Directed pushing usually means the mother is being coached by the doctor or labor room nurse to hold her breath to a count of ten and push as long and hard as possible.

This is the familiar scene in which the mother lies in bed on her back, while her husband helps to hold her legs up in the air and with every uterine contraction, the hospital staff exhorts her to push “harder, harder, harder, hold it, hold it, now come on, give it all you’ve got, one more push, come on, just a little longer, we can see a little bit of the baby’s head, don’t waste your contraction, etc”, until the mother is out of breath and purple in the face. This style of “shout it out pushing” is biologically unnecessary and counterproductive for several reasons.

The hospital’s coaching policy assumes the mother’s natural biological urge to push is inadequate or that she wouldn’t know how to push, therefore labor attendants must instruct the mother to hold her breath to a count of ten for three times for each pushing contraction. Purple pushing is uncomfortable, undignified, and, when contrasted with the ‘right use of gravity’, usually counterproductive. It is not recommended by evidence-based studies because it disturbs the oxygen-carbon dioxide balance and causes a dangerous rise in the mother’s blood pressure.

Most regrettably, is an unspoken criticism that somehow the mother isn’t doing it quite “right” or that she isn’t trying quite hard enough. Even more disturbing is the anxiety it introduces into the labor room, which gives everybody in the room the idea that either childbirth is a race with a big prize for the fastest birth or the baby is in serious trouble and the staff is tying to get it out before it dies or they have do a crash C-section. Neither is true for 99.99% of healthy women.

The author states that:

“Long Valsalva’s maneuvers — or “purple pushing”— and standard supine [i.e. lying on one’s back] positioning should be reconsidered. …. Long Valsalva pushing can adversely affect maternal hemodynamics, which in turn adversely affects fetal oxygenation

Purple pushing–or closed-glottis pushing–during which the patient holds her breath for 10 seconds while pushing is safe in the approximately 80% of low-risk pregnancies. But that doesn’t mean it works best … in high-risk cases, the baby can’t tolerate that kind of pushing.

….near-infrared spectroscopy used to evaluate fetal effects revealed that closed glottis and coached pushing efforts led to decreased mean cerebral 02 saturation and increased mean cerebral blood volume. All Apgar scores were below 7 at one minute and below nine at five minutes. [i.e. both are sub-optimal Apgar scores indicating a transient stress on newborn]

Open-glottis pushing, on the other hand, allows the patient to exhale while bearing down and leads to minimal increase in maternal blood pressure and intrathoracic pressure, maintained blood flow, and decreased fetal hypoxia.”

Right and wrong use of gravity: At a meeting of the Radiological Society of North America two radiologists from the University Hospital, Zurich, Switzerland described a pelvimetry study using magnetic resonance imaging (MR) to determine which maternal positions provided the most room for the baby to be born.

The study contrasted the conventional supine position (mother lying flat on her back) to positions in which the mother was squatting or an all-fours ‘hands and knees’ position. A report on their presentation, aptly entitled “Upright Positions Offer Most Room for Delivery”, was published in Ob.Gyn.News [2002;Volume 37 • No 3]. They measured the space available for the baby to pass through at the three critical landmarks of the childbearing pelvis –intertuberous diameter, interspinous diameters, and the sagittal outlet. They discovered that upright positions provided an average of slightly more than a centimeter at each of these junctions.

“Upright birthing positions provide significantly more room for delivery in terms of pelvic dimensions, compared with lying supine, Dr. Thomas Keller said. He and his colleagues …who performed MR pelvimetry on 35 non-pregnant women to compare pelvic bony dimensions in the supine, hand-to-knee, and squatting positions.

These differences are statistically significant and confirm the advantages of birthing positions long practiced in other cultures, the study’s coauthor Dr. Rahel Kubik-Huch noted during an interview. [emphasis added]

… the theoretical ideal would thus be to adopt the hand-to-knee position to help the presenting part through the interspinous diameter, and to squat rather than remain supine as the [head] traverses the sagittal outlet, said Dr. Kubik-Huch.”

This silly little centimeter of extra space between lying down and standing up can easily be the difference between a spontaneous vaginal birth with a healthy baby and a difficult one that required unusually long and hard pushing, the use of forceps or vacuum to extract the baby or even a Cesarean section that may leave both mother and baby in need of prolonged or specialized care after the birth. It turns out that the ‘right use of gravity’ during the 1^st and 2nd stage of labor is the best way facilitate a normal birth. By avoiding the use of obstetrical forceps or vacuum, the soft-tissue of the mother’s pelvis and the unborn baby’s brain are protected from the damage associated with either prolonged pushing or instrumental deliveries.

Chapter 12

The Bible of Science Based Birth Care ~

The next issue is the efficacy (safety + cost-effectiveness) of the system of obstetrical management for a healthy population of childbearing women. If obstetrical management is to replace physiological forms of maternity care, we should be certain the replacement system is scientifically sound one that uses evidence-based practices. For an objective determination on this issue, there are two excellent, well-respected sources that we may turn to. The first is a scientifically researched publication known as ‘A Guide to Effective Care in Pregnancy and Childbirth’ and the second is a survey of contemporary maternity care practices entitled “Listening To Mothers”, commissioned by the Maternity care Association of New York City and conducted by Harris Poll Interactive in 2002.

To determine the scientific aspect of current obstetrical practices we’ll first look to the published work of Drs Ian Chalmers and Murray Enkins and their life-long work — the bible of evidenced-based maternity care — entitled ‘A Guide to Effective Care in Pregnancy and Childbirth’ (GEC). It is a compilation of all pregnancy and childbirth related studies published in the English language in the last 30 years.

The Guide to Effective Care identifies six levels effectiveness/efficacy, ranging from the positive end of ‘clearly beneficial’ (category 1) to the negative end (category 6) of ‘likely to be ineffective or harmful’. Using the preponderance of available evidence, Drs Chalmers and Enkins rated each ‘standard’ maternity-care practice and regularly used medical/ surgical interventions for safety and efficacy. Based on these categories, the G E C cautions that:

“Practices that limit a woman’s autonomy, freedom of choice and access to her baby should be used only if there is clear evidence that they do more good than harm”

“Practices that interfere with the natural process of pregnancy and childbirth should only be used if there is clear evidence that they do more good that harm”

As measured by the six categories identified in the Guide to Effective Care, the “standard of care” presently as provided by obstetricians is extremely discordant when measured by scientific principles (both in practice and in interpretation of scientific studies) and evidence-based practice parameters.

Contemporary obstetrics reverses the recommended safe practices, with those identified as most beneficial and least likely to cause harm (List #1) being the last or least used and those identified as most likely to be ineffective or harmful (List #6) being the primary or routinely used methods. This vastly increases the number of medical and surgical interventions used and the complications occurring, both immediately and downstream.

Maternity Center Association Report “Listening to Mothers”

 Information on the childbearing woman’s experience of childbirth and the care she received is strangely missing from most obstetrical sources. For that information we turn to the October 2002 report by the Maternity Center Association “Listening to Mothers: Report of the First National US Survey of Women’s Childbearing Experiences” conducted by the Harris Interactive Polling Service.

The Maternity Center Association (MCA) of New York City, is a non-profit organization established in 1918. It promotes safer maternity care and develops educational materials for expectant parents on ‘evidenced-based’ maternity practices — that is, policies that are based on a scientific assessment of the safety and effectiveness of commonly used methods and procedures.

The MCA commissioned a survey of healthy mothers with normal pregnancies (no premature babies, multiple gestations, breech or sick mothers) who gave birth in the last 24 months to track contemporary obstetrical trends and the quality of care received by healthy childbearing women. The full report (some 60 pages long) is available on the Internet at www.maternitywise.com.

MCA Study Concludes ~ No ‘normal’ birth in American Hospitals

According to the “Listening to Mothers” survey, 99% of healthy pregnant women do not receive science-based maternity care from their obstetrical providers. The average healthy mom was exposed to 7 or more significant medical interventions and/or surgical procedures during a ‘normal’ labor and birth. The document notes that in the previous 24 months (Oct 2000 to Oct 2002) there were virtually NO ‘natural’ births occurring in hospitals. The entire hospitalized population of healthy mothers-to-be were subjected to one or more major interventions. The only women who had a normal birth without medical or surgical interventions were those who had their babies at home or an independent birth center.

It also documented a significant gap between scientific evidence and standard obstetrical practice. Healthy, low-risk women in the United States often receive maternity care that is not consistent with the best research and in fact, is often directly in opposition to scientific recommendations. According the MCA, many people are not aware of the following major areas of concern:

~ The under-use of certain practices that are safe and effective

~ The widespread use of certain practices that are ineffective or harmful

~ The widespread use of certain practices that have both benefits and risks without enough
awareness and consideration of the risks

~ The widespread use of certain practices that have not been adequately evaluated for safety and effectiveness

According the ‘Listening to Mothers’ survey, the majority of childbearing women did not receive the safer and more satisfactory type of care delineated in the top 3 categories (those established as beneficial) and instead were exposed to a plethora of practices in the bottom 3 categories which were rated as of unknown or unproven effectiveness, unlikely to be effective or known to be harmful. These statistics are for healthy women at term with normal pregnancies. Intervention rates would be higher for women medical complications. I posted these stats previous chapters but duplicate them here to make it easier for the reader to understand the extreme disconnection between the four ‘values/goals’ of ethically-based scientific care what is actually being provided in American hospitals.

93%        Continuous electronic fetal monitoring;

86%        IV fluids and denial of oral food and water

74%        Immobilized or confined to bed due to physician preference,
hospital protocols or the limitations imposed by multiple medical devices
(EFM, IVs, epidural catheter, Foley bladder catheter, etc)

71%        Push and deliver with mother lying flat on her back

67%        Artificial rupture of membranes

63%        Epidural anesthesia

63%        Pitocin induced or accelerated uterine contractions

58%        Gloved hand inserted up into the uterus after the delivery

to check for placenta or remove blood clots

52%        Bladder catheter

35%        Episiotomy

24%        Cesarean delivery (12.6% planned/12.4% in labor

11%       Operative – one-half forceps, half vacuum extraction

In a population that was essentially healthy (95% +/-), an astounding 75% of women had some form of surgery performed – episiotomy, forceps, vacuum extraction or Cesarean section. Using the classical definition of operative delivery (CS or forceps/vacuum extraction) the rate for 2002 would be 38% or 2 out of 5. This is twice the rate of operative deliveries reported by physicians in the early 1900s who merely performed operative procedures on 1 out of 5. Intervention rates would be much higher for women with premature labor, multiple pregnancies or frank medical complications.

The Listening to Mothers survey is consistent with data from the CDC’s (Center for Disease Control) National Center for Health Statistics Vol. 47, No 27, on The Use of Obstetric Interventions 1989-97. It documents a steady annual increase since 1989 in each of these interventions.

A press release dated June 6, 2002 based on the NCHS report “Births: Preliminary Data for 2001” [NVSR Vol. 50, No. 10. 20 pp] for the year 2001 documents a 24.4% CS rate (the same rate as identified by the Listening to Mothers survey). Statistics for the year 2003 show an even higher Cesarean rate – 26.1 in the US and 26.8 in California. http://www.cdc.gov/nchs/releases/02news/birthlow.htm)

As a result of the Listening to Mothers survey, the Maternity Center Association’s recommended:

“ ..more physiological and less procedure-intensive care during labor and normal birth”.

Cesarean Surgery as the 21st century Standard of Care

The cumulative effect of a hundred years of unopposed obstetrical politics is a well-funded and so far remarkably successful 21st century campaign by organized medicine to replace the expectation of a normal vaginal birth (described as far too risky, defined as the obstetrician’s personal risk of litigation) with scheduled Cesarean surgery. Incredibly enough, replacing normal low-risk biology with scheduled abdominal surgery is also being promoted as the better, safer, cheaper and, even more surprising, the ultimate expression of a woman’s “right to choose”. Of course, the claims of improved safety or lowered cost do not square with the facts, but that crucial information has never made it into the media.

Here is an example of how the 21st century’s ‘new obstetrics’ (circa 1910) is promoting Cesarean Section as the rising star of “industrialized childbirth” (the author’s choice of words):

“A measure of how safe Cesareans have become is that there is ferocious but genuine debate about whether a mother in the thirty-ninth week of pregnancy with no special risks should be offered a Cesarean delivery as an alternative to waiting for labor. The idea seems the worst kind of hubris. How could a Cesarean delivery be considered without even trying a natural one? Surgeons don’t suggest that healthy people should get their appendixes taken out or that artificial hips might be stronger than the standard-issue ones. Our complication rates for even simple [surgical] procedures remain distressingly high.

Yet in the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process that evolution gave us.

Currently, one out of five hundred babies who are healthy and kicking at thirty-nine weeks dies before or during childbirth—a historically low rate, but obstetricians have reason to believe that scheduled C-sections could avert at least some of these deaths. Many argue that the results for mothers are safe, too. [The Score; Dr. Gawande, the New Yorker, Oct 2007]

The obstetrical profession is once again confusing cause and effect, as they did in the early 20th century. The 21st century version of goes like this: The outcome of a hundred years of increasingly heavy interference in the biology of normal birth is still a very problematic experience for the obstetrician profession, with a high rate of operative deliveries and long-term morbidity such as maternal incontinence, babies with cerebral palsy and a lot of lawsuits. A negative association is again drawn between these problems and the fundamental nature of childbearing biology, resulting in an assumption that elective Cesarean surgery is the better and safer than normal vaginal birth.

Cesarean section is the ultimate operative intervention and is associated with a birth-related emergency hysterectomy rate 13 times greater than vaginal birth. Complications of Cesarean in subsequent pregnancies include placenta abruption, placenta previa, accrete and percreta. The rate of placental anomalies rises with each subsequent pregnancy, making it the ‘gift’ that keeps on giving.

The rate of maternal mortality associated with post-cesarean placenta percreta is 7 to 10 %, even in the very best most prepared hospitals. Additional risks to fetuses and infants in post-cesarean pregnancies include placental abruptions (increased fetal demise & stillbirth rate) and uterine rupture. For the baby, being born by cesarean increases the rate of respiratory distress and admission to NICU. A Cesarean birth also increases the rate of asthma during childhood and as an adult by 33 percent.

Other common surgical interventions such as episiotomy, forceps and vacuum extraction are strongly associated with pelvic organ dysfunction and maternal incontinence after the birth. These pelvic floor problems are not, as some obstetricians claim, merely collateral damage of normal birth but are the predictable consequence of a failure to make right use of physiological principles, especially spontaneous labor and the right use of gravity. Claims to the contrary are another example of confusing cause and effect.

Despite all the iatrogenic and nosocomial problems associated with the 21st century “obstetrical package”, obstetricians are exceedingly proud to define a 90% intervention rate for healthy women as a better, safer, cheaper and more elegant form of care. But when potentially life-saving obstetrical interventions are applied to healthy women with no life threatening problem (i.e., no pre-existing complication of pregnancy or labor), it introduces unnatural and unnecessary dangers. These intrinsically risky medical and surgical procedures create other complications that increase mortality and birth injuries.

An example of this detrimental effect would be the “prophylactic” administration of a blood transfusion to everyone before traveling in a car, just in case of a serious automobile accident. Obviously, this expensive, risky and poorly targeted procedure would expose an astronomical number of healthy people to potentially fatal allergic reactions, hepatitis and HIV infections. The great cost to the health care system would divert medical services from the genuinely ill and injured to a healthy cohort that actually does not need or benefit from them.

In an eerie way, Cesarean as the ‘new’ new obstetrics of the 21st century brings the obstetrical profession back full circle to its origins in 1910, when birth as activity accomplished by the mother was first replaced by a surgical procedure in which the mother was simply a passive vessel. Cesarean surgery reduces the 21st century childbearing woman and her whole family to the status of outsiders who have no real decision-making role or legitimate opportunity for active participation.

For surgical delivery, ‘normal’ is the highly technical process of surgically incising into the uterus in an OR full of obstetrical and neonatal specialists and surgical scrub nurses and extracting the baby, who is then handed off to a perinatalogy team. The mother’s job is to lay still, be passive, let the doctor do his work and be grateful. Except as it relates to her potential to sue the doctor or hospital, she is a non-entity whose personal preference are irrelevant. Just as it was in 1910, the mother is the least important person in the surgical event of her own birth. Again it is the doctor who is the hero in the drama of childbirth. As was true of 20th century obstetrics, 21st Century obstetrics is about obstetricians.

Chapter 13

Unrealistic Expectations & Lawsuits ~ a vicious cycle for everyone

 The poet Ralph Waldo Emerson once wrote: “There is no wall like an idea”. That is also an issue for birth attendants, as people have the idea that high-tech obstetric care can control or eliminate all possible problems, and like a thick brick wall, and no amount of information to the contrary is able to dissuade them.

Since 1910, the obstetrical profession has eagerly promoted the idea that normal birth is a surgical procedure but legally, this is a double-edged sword. It creates the idea of childbirth as an event under total control of the physician-surgeon. The resulting unrealistic expectations makes doctors and hospitals much more vulnerable to litigation whenever there is any problem. First off, it’s not true. As an L& D nurse and midwife, I know the difference between an operation and normal childbirth. I have seen hundreds of babies come out before the obstetrician arrived, but have never once seen anyone’s tonsils or gallbladder take themselves out before the surgeon arrived.

The combination of unrealistic expectations and dashed hopes inevitably results in malpractice litigation. When these statistically predictable complications occurred despite the obstetrician’s best efforts, the heartbroken parents believe they have been wronged by their doctor. Most of the time, this is not the fault of individual obstetricians, but rather a system predicated on erroneous assumptions that marches forward in locked step, promising something that no human can do –control the biology of anther person so as to guarantee zero risk and a hundred percent perfection. This ultimately fuels a vicious cycle of escalating interventions, matched by run-away lawsuits, outrageous malpractice premiums, inflated maternity care costs, dissatisfied customers and thanks to the elective use of unnecessary Cesarean surgery, preventable maternal-infant deaths. 

19^th century childbirth-as-pathology locks the obstetrical profession out of 21^st Century science: Over the last couple of decades, the medical profession as a whole has broadened its base by acknowledging and working with the mind-body continuum. However, the obstetrical profession has never revisited their historical relationship with birth as a pathological aspect of female reproduction. As a result obstetrics focuses more and more tightly on the laboring uterus as a pathological organ, relating to childbirth as if the uterus were a carburetor that needed to be tinkered with, the baby was a spark plug that needed to be removed and the mother’s social and emotional needs were an inconvenient distraction to the real work of the obstetrician.

Despite a daunting list of surgical complications, the Cesarean section rate continues on an unrestrained upward spiral. While the high rate of surgical delivery (31% for 2006) is usually blamed on the large number of older mothers, multiple births and fertility treatments, it turns out that the largest rate of increased in primary Cesarean surgery is for healthy women giving birth to a single baby at the term. [Lisa Miller, CNM, JD; Advanced Fetal Monitoring, Nov 8-9, 2007] The higher the income of the mother and the lighter her skin color, the greater likelihood that her baby will be delivered by Cesarean surgery, so obviously it is not medical factors that are fueling the aggressive use of these obstetrical interventions.

The Cesareans surgery rate in 2006 was 31%. The last year we have economic data for is 2003, during which 1.2 million Cesarean surgeries were performed at a cost of $14.6 billion. As a measure of just how much money $14.6 billion is, it should be noted the economic damage from by the Loma Prieta earthquake in the San Francisco area in1989 was estimated to be only $6 billion and more recently, the US contributed $10 billion dollars to Pakistan since 2001 in an effort to fortify the Pakistani government’s anti-terrorism efforts.

In spite of hemorrhaging money on a system that does not improve outcome, public health officials are predicting a 50% Cesarean rate by the end of the decade. Some hospitals are actually replacing labor rooms with additional operating rooms in anticipation of the dramatic rise in C-sections.

Most inexplicably, there is a move within the obstetrical profession to promote electively scheduled Cesarean for healthy women as the preferred standard of care for the 21st century. Unnecessary Cesarean surgery is the ultimate iatrogenic intervention in normal birth. One recent study from France identified a 3½ times greater maternal mortality rate in electively scheduled Cesareans in healthy women with no history of problems or complications during pregnancy. Another study on the elective or non-medical use of Cesarean surgery documented an increased mortality and morbidity for newborns.

Were Cesareans to become the 21^st century standard, it would triple the current rate to 4 million surgical deliveries every year. This would make C-sections six times more frequent that the second most common hospital procedure — the 700,000 upper GI endoscopies done every year to diagnose ulcers and stomach cancer. Cesarean as the new obstetrical standard would put childbirth surgery smack in the middle of our healthcare system, making American medicine more about elective Cesarean surgery than treating people who genuinely need medical services. It would provide yet another opportunity for women and babies to be exposed to hospital-acquired, drug-resistant infections. Already a quarter of all hospitalizations are related to pregnancy and childbirth. An additional 2 1/2 million Cesareans every year would bump this number up quite a bit, as a result of re-admissions for various post-operative complications of mothers and babies.

Pink for girls, Blue for boys and Green for planet-friendly maternity care

Obstetrics for healthy women already has an outsized carbon footprint, especially as it relates to routinely scheduled induction of labor and elective Cesareans surgery. It is a resource-intensive system that requires more than its share of the environmental pie. In particular, million more Cesareans mean more medical schools to train a ballooning numbers of obstetrical surgeons and anesthesiologists. It means more operating rooms, more highly-specialized hospital staff, more nurses, more vehicular traffic, more electricity, more water, longer hospital stays.

Additional surgeries and prolonged hospitalizations mean an increased number of drugs-resistant infections to be added to the thousands of hospital-acquired infection each year and more insoluble antibiotics in human urine which cannot be filtered out and wind up back in our drinking water. It also generates huge quantities of bio-hazardous garbage piling up in land fills. This process of intensive medicalization feeds back on itself, as hospital-based care becomes both cause and effect of nosocomial complications. This translates into the need to build more hospitals, more roads, more traffic and all the other infrastructures that generate more carbon-laden emissions.

Medicalizing normal birth is also responsible for an outsized economic burden — the unproductive cost of unnecessary intervention. This severely hampers our ability to compete in a global economy against other countries that, wisely for them, have not saddled themselves with this albatross. Maternity care policies for healthy women in the vast majority of other countries, both developed and developing, do not routinely medicalize healthy women with normal pregnancies. Many EU countries, Japan and other highly developed countries depend on time-tested methods of physiological management provided by professional midwives and general practice physicians. Obstetrical care is used appropriately whenever there are complications. This small carbon footprint equates to “green maternity care”.

Doing it “Smarter”

Worldwide, the economic drain associated the use of obstetrical interventions on healthy women, particularly the high Cesarean rates, is causing some countries to rethink their national maternity care policy. For example, the C-section rate Britain had crept up to 25% and was still increasing. The UK has historically had a midwife-based system but in the last 20 years, English midwives have been used as labor room nurses. As such, they were carrying out the medicalized procedures of the obstetrical staff, instead of independent professionals providing physiological management. In February 2007, the Ministry of Health in the UK announced the reconfiguring of the National Health Services to reduce the medical costs associated with normal childbirth. During debate in the British House of Commons on July 11th, Prime Minister Gordon Brown noted that by 2009, every healthy childbearing woman in the UK would be able to choose among three options:

1. Physiological care by a community midwife in the mother’s home
2. Physiological care in a local midwife-led unit based in a hospital or community clinic
3. Medicalized care in a hospital, supervised by a consultant obstetrician, for mothers who may need specialist care to deliver safely or may want epidural pain relief               [The Guardian, Feb 6, 2007]

This will bring Britain back into alignment with their historical maternity care practices, other EU countries and the entire developing world. The majority of the world is using the cost-effective model of physiological management as their standard of care for healthy women, which is approximately 80% of the childbearing population in most countries.

Safe, Simple & Satisfactory alternatives to Birth as a Surgical Procedure

Aseptic technique is the standard of care used around the world by professional birth attendants who provide physiologically-based maternity care. This protects mothers and babies from infection through a body of knowledge and a variety of effective methods, including hand-washings and universal precautions. In practical application, it means nothing ever touches the mother that has come into contact with any source of contamination – body fluids of others people or sources of ordinary dirt. All materials and supplies that could conceivably come in contact with the mother’s birth canal or the newborn baby are guaranteed to be clean, dry and free of pathogens. Sterile supplies are used anytime an instrument or gloved hand must enter into a sterile body cavity or touch tissues that have been cut or lacerated.

Labor and birth as an aseptic rather than surgical event allows continuity of care, permitting laboring women to be cared for by the same caregiver — physician or professional midwife– through out the process of both labor and birth. It also does not result in the social isolation of the childbearing mother from her family. Under aseptic conditions, the spontaneous vaginal birth of the baby is not considered to be a surgical procedure. No special environment or equipment is required such as a specially-designed bed with obstetrical stirrups. The doctor or midwife does not have to be “gowned and masked” nor does the mother have to lie still on her back or be admonished not to touch anything. The common sense conditions for aseptic technique allow the mother to move about and use physiological positions and the ‘right use of gravity’. Aseptic care does not overshadow the mother’s psychological and social needs. Her family, including other children, can be present when the baby is being born.

The necessary sterile supplies for normal birth are simple — a pair of sterile gloves, a sterile scissor to cut the cord, a sterile umbilical clamp and a sterile towel to make a suitable surface upon which to set these instruments. Accompanying this short list of sterile supplies is the liberal use of clean linens, paper towels, disposable under pads and diapers, sanitary napkins and appropriate trash receptacle.

Aseptic practices do not restrict attendance of normal birth to doctors trained in the surgical specialty of obstetrics and gynecology. It does not require two separate professions providing sequential care – a nurse for labor and a doctor for the birth. It does not disturb the normal process of labor or birth. It prevents nosocomial infection without requiring a surgeon, a surgical environment or billing as a surgical procedure under a surgical code.

The Importance of a Non-Surgical or “Physiological” Billing Code

No effort to reform our national healthcare system can afford to ignore the medicalizing of normal childbirth. No effort to reform this inappropriately medicalized system can afford to ignore the issue of the surgical billing code for normal birth. Presently, there is only one billing code for the entire spectrum of birth-related care and that is a surgical code. Because obstetrics is a surgical specialty, normal childbirth has unfortunately been classified as a surgical procedure for most of the 20^th century. A surgical diagnostic category automatically generates a surgical billing code, which produces an entirely different (and expensive) kind of care and a different form of reimbursement.

This surgical designation means the care provided during labor, birth and immediately after the birth, is divided up into billable units and parceled out between multiple service providers. This is the most expensive way possible to pay for maternity care. It eliminates continuity of care and makes the use of physiologically-based practices impractical. Under our current system, non-medical forms of care are so poorly reimbursed that hospitals would quickly find themselves out of business if they did not purposefully increase the number of billable procedures done on each maternity patient.

However, a simple solution is at hand and that is a specific billing code for normal childbirth. To provide continuity of care and to fairly compensate birth attendants, maternity care for a healthy population must allow the physician or midwife to use a non-surgical billing code for physiologically-based childbirth services. A physiological billing code would permit primary birth attendants to be appropriately paid for their full-time presence during active labor as well as the birth and the time and professional responsibility taken for the immediate postpartum and newborn period of care.