Brave New World of Evidence-based Maternity Care ~ Chapter 11
Chapter 11
Occupational Newspaper For Doctors ~ Quotes from “Ob.Gyn.News”
and evidence that ACOG policy promotes “Flat Earth Obstetrics”
faith gibson, LM (2005)
The trade paper “ObGynNews” is promoted as “the Leading Independent Newspaper for the Obstetrician / Gynecologist”. It is a “Reader’s Digest” for doctors. Articles on new or interesting aspects of obstetrical practice are published in a hard copy of ObGynNews every two weeks. However, the 33 articles referred to in this document have only been available on line since March of 2001 so all the following excerpts are from material published in the last 18 months.
They reveal important things about the contemporary and conventional practices of obstetrics and its relationship (or lack thereof) with ‘evidence-based’ practice. In reading these reports of obstetrical research, we see that obstetrics has become a prisoner of its own project. Tactics have replaced strategy.
The obstetrical strategy for preserving and protecting the health of healthy women has become the use sequential use of medical, surgical and technological interventions even though the use of each and every intervention is associated with quantifiable medical complications and the concomitant use of them frequently triggers a malignant effect that spirals out of control, to the ultimate detriment of mothers or babies. To put this in spiritual terms, “love does not kill to save”.
The present obstetrical practices excuse any level of harm as long as it was well-meaning, as long as it conforms to “standard” care. But “standard” care is not a scientifically derived, evidence-based ideal but rather is a contrived conclusion, a self-fulfilling, self-serving function of organized medicine. It is the aggregate of what obstetricians are doing which means that if 90% of doctors routinely use a host of interventions, then the physician who fails to intervention is guilty of “sub-standard” care — i.e., malpractice.
I encourage anyone with the slightest curiosity to go online at www.eObGynNews.com and read any of these articles that interest you in their entirety. They are all quite short – ½ page to at the most, 1 ½ pages. You can sign in as “other health care provider”. Go to the “back issues” hot link, and click on the publishing date of the article you want to read. Scroll down until you find the specific article you’re looking for and click on “full text”.
The major question raised by these studies as reported in ObGynNews is; “Why aren’t they ‘news’ for the rest of us? Why is it that ONLY doctors know about the many risks of interventionist obstetrical care and the cascade of complications they frequently lead to?”
These reports on the conclusion of obstetrical research chronicle the many complications associated with various routine interventions. They often highlight the synergetic effect of these interventions as they are combined with each other and as complications, multiplied by each other, further compound the situation. What can quite easily be seen is a straightforward path from the medical routines and protocols – something as common as putting the mother in bed with IV Pitocin running or continuous electron fetal monitoring — that triggers a series of “minor” complications. Soon these complications turn major and eventually the mother becomes a statistic – she is an operative delivery, her baby is in the NICU or she has a “post-cesarean” pregnancy or is suffering from pelvic floor dysfunction (for example incontinence) as a result of her forceps or vacuum extraction delivery. Then she will be a ‘statistic’ used by ACOG to justify ‘maternal choice” Cesarean surgery to “protect” her pelvic floor.
This material as published in ObGynNews documents that physicians are indeed “informed”. They can’t say they didn’t know ‘cause nobody told them and they were too busy to read all those long research paper. ObGynNews is the “Reader’s Digest” of obstetrics. The forward to a 1966 obstetrical text stated that “there can be no alibi for not knowing what is known” and so if exposure to this data constitutes knowing, then they have no alibi and the issue becomes what they do (or don’t) with this information. However, information does not seem to modify the official agenda of ACOG, which at present is induction at 40 weeks or a “maternal” choice Cesarean. Nor does it lead to individual obstetricians providing “fully informed” consent in which the parents are made as knowledgeable as the average physician reader of ObGynNews. Why don’t physicians provide this information? Who gains from this institutionalized ignorance?
What I see as the most relevant of issues is that these articles are not being promoted by their authors to Associated Press, Reuters Heath Services or National Public Radio or local TV stations as were the ones that so quickly and so quietly eliminated obstetrical support for vaginal breech, natural labors in VBAC mothers and home-based maternity care. So read this presentation of that material – the equivilent of “white water rafting” through 33 relevant articles in ObGynNews. See for yourself. Ask why you have never heard any of these things before. Ask why this “news” is not showing up your newspaper, why isn’t Neal Cohen talking about this on NPR’s Talk of the Nation?
The Maternal Choice Cesarean – ACOG’s the ‘ideal’ standard of care?
To put the following excerpts from ObGynNews in context, I have included a very short excerpt from a segment on “Good Morning America” (Jun 2000) promoting the “maternal choice” cesarean by obstetrician Ben Harer, MD, then president of the American College of Gynecologists:
Diane SAWYER … One in five now have cesarean sections but you say cesareans are safer and in fact better, and that in the future, women should be able to choose and in fact that maybe they should be routine.
Dr. Ben HARER: 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, but the longer term risks of pelvic dysfunction, … incontinence, pelvic dysfunction–those risks are higher for vaginal birth and over the long time I think that the risks balance out, that there really is no big difference..
The big question here the validity of the idea that “the risks balance out” and “there really is no big difference” between the complications (long and short term) of spontaneous vaginal birth and elective “patient choice” Cesarean. Nothing in these articles supports that notion. In fact, it is a “false and misleading claim” of the most blatant kind.
Equally of concern is the question of whether the current medicalized, instrumental and surgical interventions in vaginal birth are not the cause of the pelvic floor and pelvic organ dysfunction. What does the literature read by the average obstetrician actually say about the well-known risks of Cesarean surgery, especially as contrasted with normal vaginal birth? What does it say about the complications of instrumental delivery? What are physicians saying to one another and is this fundamentally different from what they are saying in the press? Read on….
Lack of efficacy of continuous electronic monitoring and its role in raising the Cesarean section rate without lowering the over-all preinatal mortailty:
“A 1995 meta-analysis of all nine randomized controlled trial found that the monitored patients had higher rates of Cesarean sections, forceps, vacuum use for fetal distress; higher overall Cesarean section rates; and fewer neonatal deaths due to hypoxia. Overall perinatal mortality did not differ significantly between groups…
“….electronic fetal heart rate monitoring is tied to higher intervention rates and lower mortality due to hypoxia (reduced oxygen). “So you save one fetus in every 1,000 births that you monitor.” [the routine use of EFM in low-risk pregnancies increases Cesarean surgery rate by apporox. 10% or 100 CS out of every 1,000 women electronically monitored or 100 CS perform for every fetus “saved”] (1)
FDA Reviews Continue on New Fetal Monitor Designed to help detect fetal hypoxia October 1 2002 • Volume 37 • No 19
“… currently available monitoring methods all have their shortcomings. Auscultation is impractical and requires one-to-one nursing, …. Auscultation also is not being widely taught, he added.”
“Midwives manage a significant proportion of uncomplicated deliveries in Sweden. The cesarean section rate is 11%, compared with a rate in the United States of approximately 20%.”
Fetal heart rate abnormalities — higher with cytotec inductions:
“Cytotec … was associated with a higher incidence of fetal heart tracing abnormalities. In a randomized study of 111 obstetric patients, Cytotec (misoprostol) had a quicker induction of labor, averaging 24 hours until delivery, compared with 30 hours with either Cervidil or Prepidil, Nevertheless, Cytotec was associated with a significantly higher incidence of fetal heart tracing abnormalities and contraction abnormalities (50%), compared with Cervidil (14%) and Prepidil (11%). Cytotec was associated with a higher mean number of adverse events (3.5 per patient), compared with Cervidil (0.4 per patient) and Prepidil (0.2 per patient). The abnormalities in the fetal heart occurred as little as 3 hours after Cytotec administration, raising important concerns about potential outpatient use…”(16)
C-Section to Prevent Cerebral Palsy: Results May Be a Wash, cause as least as many bad outcomes as it prevents”
“Performing cesarean section for abnormal fetal heart rate patterns in an effort to prevent cerebral palsy is likely to cause as least as many bad outcomes as it prevents” …..the false-positive rate for these abnormal fetal heart patterns was 99.8% (N.Engl. J. Med 334[10:613-19, 1996)
“Extrapolating from this study, Dr. Hankins calculated that a physician would have to perform 500 C-sections for multiple late decelerations or reduced beat-to-beat variability to prevent a single care of cerebral palsy. But since Cesarean section carries a roughly 0.5% risk of future uterine rupture, those 500 C-sections would result on average in 2.5 uterine ruptures. This in turn would cause one case of neonatal death or cerebral palsy….”“So I’ve prevented one case of cerebral palsy and I’ve caused one.” Concluded Dr. Hankins, professor and vice chair of ob.gyn at the University of Texas, Galveston.
Moreover, those 500 women who underwent C-section because of an abnormal fetal heart rate pattern face substantial morbidity related to their surgery, including a 5 to 10 fold increase in relative risk of infection, a 5-fold increase in [blood clots] as well as a 10- to 20-fold increase in future risk of placenta previa and acreta, he added. [*placenta accreta is when the placenta grows abnormally into the deep structure of the uterus or even grow through the uterus and attaches to the bladder or bowel (known as a ‘percreta’). Accreta or percreta is a life threatening complication and frequently requires an emergency hysterectomy to stop the bleeding]
Elective C-section Revisited –surgical dangers of CS, failure of “maternal-choice” cesrean to prevent pelvic floor problems:
“Cesarean surgery causes more maternal morbidity and mortality than vaginal birth. In the short term, C-Section doubles or triples the risk of maternal death, triples the risk for infection, hemorrhage and hysterectomy, increase the risk of serious blood clots 2 to 5 times and causes surgical injury in about 1% of operations.”
In the long term, cesarean section increases the mother’s risk of a placenta previa, accreta or percreta, uterine rupture, surgical injury, spontaneous abortions and ectopic pregnancies while decreasing fecundity. Babies delivered by cesarean have a higher risk of lung disorders and operative lacerations.”
Cesarean babies also suffer triple the rate of asthma as adults (9).
…would have to do 23 C-sections to prevent one such surgery [for organ prolapse or incontinence) later in life. So instead of offering elective cesarean in an attempt to prevent future prolaspe or incontinence, we should be examining what we can do in our management of vaginal deliveries to protect pelvic floor function”.
Long Term Complications in post Cesarean pregnancies:
“The rise in cesarean rate over the last several years may portend an increase in the incidence of placenta accreta… The maternal mortality rate with placenta accreta is 7%. Even when physicians are prepared and well equipped, the condition can be extremely dangerous. the patient ended up going into cardiac arrest during the procedure and had postoperative complication that kept her in the hospital for 20 days.” (4) The rate of placenta accreta in patients with placenta previa was 5% if no prior C-section, 25% with one prior C-section and 50% with two or more prior C-sections … prepared for substantial hemorrhage and make sure proper help is on hand. That may include a urologist if suspicion that the placenta has eroded into the bladder), a vascular surgeon, a radiologist, a neonatologist … and plenty of nurses. “Don’t hesitate to perform a hysterectomy. Prepare for a 4-hour surgery with an average 4-liter blood loss, You may need to use up to 20 unites of packed red blood cells (5)
Uterine rupture which is more likely with single-layer closures:
Single-layer closure after low transverse cesarean sections may leave women 5 times more susceptible to uterine rupture in a subsequent trial of labor compared with double-layer closure. Obstetricians moved away from two-layer closures after C-section because one-layer closures seemed sufficient and shortened operative time. The alarming study results should prompt further investigation of the safety of their approach…. Three percent of the 398 women (12) who had a one-layer closure after C-section developed symptomatic uterine rupture during trial of labor, compared to 0.6% (3) of the 1,251 women whose C-sections were closed with two layers of sutures.(5B)
Using estimated fetal weight as a reason to do Cesareans not justified:
“Estimated fetal weight can be used as a guidepost in directing obstetric management …but should not be used to dictate cesarean sections, researcher determined in a 4-year study.” … “If all of the women in this group had undergone Cesareans, they 32 unnecessary operations would have been performed to prevent 2 shoulder dystocias. Dr Mullin estimated that 133 to 522 Cesareans would have to be performed to prevent one permanent brachial nerve injury. (6)
Respiratory distress increased by use of Cesareans:
Sever preeclampsia (toximia of pregnancy with high blood pressure) accounts for nearly 2/3 of all Cesarean deliveries but the procedure offers no inherent benefits to patients with this condition. In the study, mothers and infants who were delivered vaginally had a significantly lower incidence of respiratory distress. Other outcomes were either equal … or worse for those in the C-section group …the incidence of pulmonary compromise was 3 times higher in women in the C-section group, with rates of 26% vs 8%, respectively. The difference was nearly as high among neonates: More than half –52%– …delivered by C-section had respiratory distress syndrome, compared to 18% who were delivered vaginally. (7)
Severe RDS (Respiratory Distress Syndrome) caused by failure to test for lung maturity before elective induction/Cesareans:
“One third of severe neonatal respiratory distress cases could be avoided if physicians tested for fetal ling maturity before performing elective deliveries…” “In 37 week babies, there’s almost a 39 times higher frequency of sever RDS, compared to term babies….at 38 weeks the risk of RDS is 13-fold higher than at term” …a frequency of 1 in 1,000 deliveries at 38 weeks or 3 in 1000 at 37 weeks [or one of every 333]. (8)
Increased Adult Asthma and its association with Cesarean delivery: “Birth by Cesarean section may lead to asthma in adulthood” “The babies in the C-section group had more than a 3 times greater risks for having asthma in adult hood, compared to those in the vaginal delivery group.” (9)
Questioning the wisdom and safety of CS for birth defects:
“Although many physicians consider cesarean section the standard of care for a wide variety of fetal anomalies, there is no basis for this practice in the literature” “In the absence of well-controlled studies, cesarean section should continue to be investigated, but not considered the standard of care,”. “But for most anomalies there is no convincing evidence that a C-section provides neonatal benefit, and it clearly increases maternal risk and morbidity. In all cases where the anomaly is fatal, the delivery should be vaginal because the maternal risks of C-section are too great if the baby is not going to survive anyway.”(11)
Rate of labor induction up 2 1/2 times in 8 years:
The rate of labor inductions in the United States [more than] doubled in from 1990 to 1998” “Labor inductions [which include Pitocin use to augment latent or slow labors] increased from 9.5% of all birth nationwide in 1990 to 19.4% in 1998. If women who underwent elective cesarean …. were not included, the overall rate in 1998 would have been almost 23% [this means that inductions when up from 9% to 23% in 8 years] White race, higher education and early prenatal care were each associated with approximately 100% increase in labor induction. Nulliparious (first baby) had a higher rate than multiparious women (2 or more previous babies) (13)
Based on observational data & experience, Scientific Data Doesn’t Support Postdates Pregnancy Guidelines
Oct 15 2002 • Volume 37 • No 20
Observational data and clinical experience—not randomized controlled data—have led to the currently accepted guidelines for managing postdates pregnancies.
Yet these guidelines govern the practices of most obstetricians in the United States … “There is very little evidence for what we do. …. There have been two randomized controlled trials comparing the effects of monitoring, fetal testing, and induction on perinatal mortality and morbidity in postdate pregnancies. Both have found no significant difference in adverse outcomes or cesarean section rate….
“The jury is still out. So the question is ‘When should we begin antenatal surveillance, and should we induce?’” For many years, obstetricians have believed the truism that the best way to decrease perinatal mortality is to terminate the pregnancy before adverse events occur. Yet whether induction at 41 weeks increases the risk of an operative delivery without preventing perinatal death is still not clear.
There is also no evidence in the literature that testing between 40 and 42 weeks’ gestation improves outcomes, though many obstetricians believe it does. At 41 weeks, most obstetricians will deliver a baby if the cervix is favorable. “However, this is entirely based on observational data,”
After 42 weeks, observational studies have shown that there is a drop-off in amniotic fluid, which is felt to be a sign of poor renal function in the fetus. ACOG guidelines—again, based on observational data—maintain that oligohydramnios is an indication for delivery, he added. If the cervix is unfavorable or the Bishop score is low, immediate delivery may put the woman and baby at risk for a failed induction, he said. In these cases, the obstetrician should use the Foley balloon or misoprostol [Cytotec]. In his practice, …. prefers to induce around term…
Fetal heart rate abnormalities — higher with cytotec inductions:
“Cytotec … was associated with a higher incidence of fetal heart tracing abnormalities. In a randomized study of 111 obstetric patients, Cytotec (misoprostol) had a quicker induction of labor, averaging 24 hours until delivery, compared with 30 hours with either Cervidil or Prepidil, Nevertheless, Cytotec was associated with a significantly higher incidence of fetal heart tracing abnormalities and contraction abnormalities (50%), compared with Cervidil (14%) and Prepidil (11%). Cytotec was associated with a higher mean number of adverse events (3.5 per patient), compared with Cervidil (0.4 per patient) and Prepidil (0.2 per patient). The abnormalities in the fetal heart occurred as little as 3 hours after Cytotec administration, raising important concerns about potential outpatient use…”(16)
PROM — Induction, expectant management equally safe, vaginal exams not safe
“Its equally safe to immediately induce labor in healthy pregnant women with PROM or to manage her expectantly, ideally for no more than 24 hours.” … “Spontaneous labor occurs in 85% of women within 24 hours and in 95% of women within 72 hours.” “…the onset of labor within 24 hours of membrane rupture is not associated with increased risk of neonatal infection if the women is not already infected with group B streptococcus. Risk increased in women who had more than 7 digital [vaginal] exams. Infections morbidity more influenced by the interval between vaginal examination and delivery rather than the rupture of membranes and delivery. …the clock starts ticking after a vaginal exam, induction with prostaglandin gel increased the risk of neonatal infection even further.” (14)
Labor Induction for Marcosomia Not Justified – Expectant management significantly lowers Cesarean rate:
“Labor induction for the sole indication of suspected macrosomia cannot currently be justified, … Instead, these patients should be managed expectantly. Many obstetricians feel that if babies are getting big they have to do something early. Our study shows that, based on the literature, we should leave them alone. The rate of Cesarean delivery was significantly lower with expectant management than with labor induction (9% compared with 17%) … expectant management was associated with a significant increase in the rate of spontaneous vaginal delivery (82% compared with 71%). Apgar scores also did not differ significantly”. (15)
Ultrasound Comparable to Educated Guess in Predicting Birth Weight Head-to-head comparison October 1 2002 • Volume 37 • No 19
A guess is nearly as good in predicting birth weight at term as estimates based on ultrasound measurements or maternal characteristics, Dr. Gerard G. Nahum said at the annual meeting of the American College of Obstetricians and Gynecologists. A head-to-head comparison of various methods of predicting birth weight at 37-42 weeks of gestation in 81 nondiabetic gravid women found that none of 20 ultrasound fetal biometric algorithms was significantly more accurate than guesses based on population-specific birth weights or estimates based on maternal characteristics, said Dr. Nahum of Duke University, Durham, N.C.
The wisdom of physiological pushing in second-stage labor;
Delaying pushing until the mother experiences Ferguson’s reflex can minimize her fatigue and does not increase the likelihood of fetal trauma during second-stage labor. “We should try to take advantage of natural physiologic function as much as possible during birth,”
Many women experience a latent resting period near the time of complete dilation that is characterized by a decrease in uterine activity. This usually lasts about 20 minutes and is a time when the mother can rest and collect herself before beginning to actively bear down, Then, when the fetal head descends past the ischial spines (+1 station), the mother feels the sudden strong urge to bear down. This is Ferguson’s reflex, and it typically is accompanied by a loud maternal groan.
There’s also no need for women to routinely try pushing for a count to 10. When allowed to push on their own, they tend to push about three to five times each contraction, and they tend to push for about 4-6 seconds…the so-called 2-hour rule needn’t be followed in all cases. This obstetrical practice, which is of unknown origin and dates to the early 1900s, is arbitrary, and if the fetus and mother are in good shape at the second stage, it’s not necessary to intervene surgically at 2 hours. (19)
“Right use of gravity”, vertical positions offer most room for birth –MR pelvimetry study:
“Upright birthing positions provide significantly more room for delivery in terms of pelvic dimensions, compared with lying supine” “At the sagittal outlet, both the hand-to-knee and squatting positions provided significantly more room than the supine position. Similarly, the hand-to-knee and squatting positions provided more room for delivery at the interspinous diameter compared with the supine position. The intertuberous diameter was wider in the squatting position than the supine position.
These differences are statistically significant and confirm the advantages of birthing positions long practiced in other cultures. … 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 (18)
Vacuum, Forceps Raises Injury Risk:
“The risks of both maternal and fetal injury are increased with the sequential use of vacuum extraction and forceps for assisted vaginal delivery” “A …study of more than 33,000 birth using Washington state birth certificate data found increased risks of intracranial hemorrhage, facial nerve injury, maternal lacerations and postpartum hemorrhage with combined assisted vaginal deliveries”
Stats per 1,000 Normal birth forceps Vacuum Both
Brain bleed 0.6 1.4 2.8 7.8
Facial Nerve Injury 0.4 6.8 1.7 13.3
Fourth Degree Lac 0.9 2.4 2.4 4.2
Combined total for all complications of NSVD 1.9
Total for all complication of forceps alone 10.6
Total for all Vacuum complications alone 6.9
Total for all complication both instruments 25.3
No stats were given for maternal hemorrhage, neonatal seizures and depressed 5-minute Apgar scores associated with operative deliveries but this would be in addition to those listed (20)
Forceps double risk of incontinence: “A woman whose baby is delivered with forceps has almost twice the chance of postpartum [bowel] incontinence than a woman who delivers vaginally, results of a multicenter study suggest”. (21)
Forceps, perineal tears raise anal incontinence risk 5 times:
“Forceps delivery and third- or fourth-degree perineal tears both significantly increase the risk for long-term anal incontinence in primiparous women” … “In addition, women who had third- or fourth-degree perineal tears [associated with episiotomies] during delivery were at nearly fivefold greater risk, … The women were interviewed at 2 weeks, 3 months, and 1 year.
At 2 weeks, incontinence [of stool] was higher in both the patients delivered by vacuum (17%) and forceps (35%) than among those who delivered spontaneously (7%). By 3 months, the forceps group remained at increased risk (21%). Those proportions had not changed significantly at 1 year, with continued anal incontinence reported by 2% of the spontaneous delivery patients, 4% of the vacuum group, and 20% of the forceps patients. There was no apparent relationship between anal incontinence and birth weight or length of the second stage of labor, forceps delivery also increases the risk for persistent urinary incontinence.” (22)
Episiotomies still favored by private physicians – more common in whites, privately insured:
“Routine episiotomies are falling out of favor in response to a growing body of evidence that they are medically unjustified but white women, those with private insurance and those with private practitioners are still disproportionately receiving that the popular press has called the “unkindest cut.”
“Episiotomy was at one time almost universally performed in vaginal births in the US but has been increasingly called into question. Some studies have linked episiotomy with increased perineal damage, postpartum pain, blood loss and infection. A number of studies … found a decline in the percentage of episiotomies from 56% in 1979 to 31% in 1997. … findings that black women were at considerably lower risk …than white women. Spontaneous vaginal deliveries less likely to be associated with an episiotomy, while forceps delivery and 4th degree lacerations were positively associated…”
“Even more striking however was the difference in the episiotomy rate between [medical] residents … and private practitioners … [who] performed episiotomies in 65.7% of vaginal deliveries. “This analysis demonstrates the persistence of high rates of episiotomy use among private practitioners, despite current evidence-based literature that support restricted use…” (23
Risk of bad perineal tear higher with midline episiotomy – long term pain:
“The greatest risk factors for 3rd degree perineal tears during vaginal delivery are midline episiotomy, forceps delivery, and oxytocin use…”
“Although 3rd degree perineal tears are rare … they can eventually lead to long-term pain and incontinence. Of the 242 women with underwent episiotomy, 9.1% had 3rd degree tears, compared with 1.7% of women who didn’t have episiotomy. Among women who had forceps deliveries, 9.3% suffered 3rd degree tears, compared to 2.9% who had spontaneous deliveries. Tears were also more frequent with oxytocin use, occurring in 5.6% … and 2.3% of the women who didn’t. (24)
Episiotomy scars have increased failure rates – subsequent vaginal delivery;
“Scars resulting from episiotomies were nearly twice as likely to fail during a subsequent delivery as scars that resulted from a spontaneous laceration during vaginal delivery…” … “Of the 130 women with episiotomy scars, 62 lacerated [greater than 50%] during their second delivery. Of the 40 women with scars from spontaneous lacerations, 14 lacerated ….” (25)
Prolonged resolution of shoulder dystocia is well tolerated, not tied to fetal academia, cautioned NOT to clamp/cut nucal cord:
“A moderate delay in childbirth for the sake of resolving shoulder dystocia is not associated with clinically significant increases in umbilical artery academia” “Few data address the question of safe time thresholds for resolving shoulder dystocia; however, some authors have arbitrarily placed the limit at around 2-3 minutes. On the basis of this study and other data in recent years, “statement of an arbitrary time limit is inappropriate,” Dr. Stallings said in an interview. The results suggest that if the fetus is healthy, it will likely be able to tolerate a prolongation of delivery by 4-5 minutes. “It should not be the clinician’s first impulse to increase the forces applied in a rushed attempt to deliver the fetus within an arbitrary 2-minute time limit,” ..”drops in fetal pH levels after the onset of shoulder dystocia probably occur much more gradually than physicians have generally assumed, challenging the notion that shoulder dystocia requires a crash or rushed delivery.
Nor was there a significant correlation between longer times to dystocia resolution and decreasing 5-minute Apgar scores. Of the 8,282 vaginal deliveries studied, there were 134 cases of shoulder dystocia, representing an incidence of 1.7%. the mean birth weight for infants with dystocia was 4,504 g [10#]. The average head-to-body interval was 3 minutes, ranging from 30 seconds to 8 minutes. In a subgroup of 43 cases, there was a nuchal cord present at delivery, but this was not believed to be associated with adverse outcomes. Only one infant had an Apgar score of less than 3; no infant had a 10-minute Apgar score of less than 4.
A few studies suggest that outcomes following dystocia, even in the case of nuchal cord, depend on whether the cord is clamped and divided. [ a reason not to cut the cord before the birth – use summersault maneuver for nucal cord instead] “We speculate that, even in the face of shoulder dystocia with a nuchal cord, some cord circulation may continue, and that severing the cord may contribute to fetal hypoxia and hypotension during the time it takes to resolve the dystocia.” …” therefore, advise “caution regarding the clamping and cutting of the nuchal cord prior to the initiation of maneuvers.” (26)
Experts say Cesarean Section Rates Are Headed ‘Sky-High’ – Fewer VBACs cited as one factor [ACOG ‘no vaginal breech’ policy]
Cesarean section rates are headed up, up and away. According to the CDC, the VBAC rate …dropped from 28% in 1996 to 20% in 2000. “I suspect that the cesarean section rate is probably going to double by the next generation,” “speakers cited multiple contributing factors — the American College of Obstetrics and Gynecologists’ recent recommendation that vaginal birth after cesarean section (VBAC) be attempted only if physicians are “immediately available” to provide emergency care.” “That’s already having a chilling effect.”
“the recent ACOG practice bulletin recommending against planned vaginal delivery of singleton breech presentations will cause a bump in C-section rates. …three quarters of such cases are already managed by planned C-section. A bigger contributor … the patient choice issue, with a growing number of women opting for C-section to avoid perineal dysfunction after vaginal delivery..”
There is no mistaking ACOG’s intent …VBAC be restricted to setting where physicians are ‘immediately available’ ….”I don’t think ‘immediately’ means your in your office 6 blocks away or you’re at home. I think it means your backside is in the hospital.” Denver ob.gyn in private practice, said that the ‘immediately available’ criterion has put physicians like him in a bind.
“the real issue now is whether you’re willing to have an obstetrics practice where you’re going to devote a person to staying in the hospital all the time. If you don’t have a [medical] resident staff to help you, and you’re a practitioner who’s totally in control of your patients all the time and responsible to them, I’m going to predict for you – as I can now see happening in Denver — that the C-section rate is going to go sky-high,” he said.
Rural obstetricians cited another problem: Even though many of them would like to offer their patients VBAC, they typically can’t get an anesthesiologist or nurse anesthetist to stay in the hospital. And this precludes VBAC because of the now-unacceptable medicolegal risk. (28) [Note the risk to the mother is the same as it has always been — which is to say low for spontaneous labor. However, the focus of this concern is not the mother’s risk at the time of the labor or future pregnancies to her and her next baby as a direct result of a medically unnecessary repeat cesarean but instead on the physician’s malpractice risk defined as ‘now’ unacceptably high as a direct result of legal standard created by ACOG]
Turning to the recent change in practice regarding singleton breech….
… cited a highly publicized study by the Term Breech trial Collaborative Group as its basis …. led to ACOG’s recommendation in December against planned vaginal delivery.
The study has flaws rendering it vulnerable to criticism [Note that some of the ‘breech’ deaths in the vaginal breech cohort were of unrelated causes] None the less, the speaker agreed that once it was published, the fate of planned vaginal delivery of … breech was sealed. There had already been increasing concern among ob.gyn leaders regarding younger American’s obstetrician’ lack of experience with the procedure [love that word ‘procedure’ when they mean normal birth!] “People have been doing cesarean deliveries for breeches because they wanted to avoid medicolegal issues This study was the icing on the cake. It was what everyone was waiting for,” [Note the idea of a ‘study’ that was expected to uphold the afore mentioned conclusions] Today, a highly motivated woman seeking vaginal breech delivery may with difficulty be able to find an obstetrician experienced in the procedure [!] and willing to take the medicolegal risk. “I guarantee that in another generation they’re not going to be able to find anyone to do it,” Dr Gibbs said. (28)
Trial of Labor, Repeat C-S Equally Hazardous – Bladder and bowel injuries;
Women who chose elective repeat Cesarean section and those who failed vaginal birth after Cesarean were at similar risk for major operative bladder and bowel injuries…The study, which included 14,309 women with a prior Cesarean, showed that both groups had “approximately the same risk of operative injury….A total of 64 cases of bowel and bladder injury were reported. [one out of every 223 surgeries or approximately 5 per 1,000] (29)
Perinatal Death Risk in Term VBAC Pegged at 1:1,000, Risk was twice as high as that seen in other multiparous women;
The absolute risk of perinatal death due to any cause for a healthy singleton fetus in cephalic presentation at term in a woman attempting vaginal birth after a prior cesarean section is similar to the risk in nulliparous women. That risk—about 1 fetal death per 1,000 deliveries (for healthy first time mother) —was based on findings from a study of more than 300,000
The risk of perinatal death due to uterine rupture specifically was eight times higher in women attempting VBAC—1 death per 2,000 deliveries—compared with the risk in nulliparous women or in other multiparous women. …
… study did not include figures on the number of inductions that were performed. A previously published study .. showed that, compared with women undergoing repeat elective C-section, those attempting VBAC with spontaneous labor were at three times the risk of uterine rupture. Women who were induced had 4.9 times the risk if prostaglandins weren’t used, and their risk increased almost 15 times if prostaglandins were used. This is the first large study of VBAC risks in otherwise uncomplicated pregnancies at term, he said. The perinatal death rate with VBAC due to mechanical causes including uterine rupture (4.5%) was a little lower in this study than has been reported by other investigators, perhaps because the current study excluded preterm births (30)
Trial of Labor (VBAC) Proves Cost Effective After C- Section
“A trial of labor was more cost effective than elective repeat cesarean delivery in a historical cohort analysis of 204 women “ …”The mean overall cost of care for the 65 women who had a repeat elective cesarean was $1,538 higher than that of the 104 women who had a successful vaginal birth after cesarean section (VBAC). Among the 35 women who failed VBAC, the mean cost was $323 more than that of the C-section group. ….. VBAC is cost effective as long as the success rate exceeds 18%,” And although the costs incurred when women fail an attempted VBAC are higher than those associated with elective repeat cesarean delivery, “our data would suggest that this difference is small.” There were no maternal or neonatal deaths and no hysterectomies. Three women undergoing oxytocin induction experienced uterine scar separation and were delivered operatively because of nonreassuring fetal heart rate tracing.
The study has limitations, … It represents only 1 year of data from one institution. Furthermore, there were no cases of catastrophic uterine rupture resulting in neurologic injury to the neonate. Such an occurrence typically would incur very high costs and could significantly influence overall cost efficacy. In a retrospective study of 2,233 patients who experienced a trial of labor after previous cesarean delivery, 77.4% of those women younger than 35 had successful vaginal deliveries. By contrast, the success rate for those older than 35 was 72.6%, (31)
Fetal Weight Does Not Help Predict VBAC Success; Using weight estimates to Determine who gets a Trial of Labor “Not Justified” – Induction vs. Spontaneous Labor;
Fetal weight estimates based on ultrasound are not useful in determining which women with a history of C-section due to cephalopelvic disproportion — should undergo a trial of labor…Contrary to widespread practice [!], estimating the size of the fetus and comparing it to that of the [previous] neonate should not be used as a risk factor …… studied the medial records of 1,176 women who attempted VBAC at 17 medical centers. “We could not identify a cut off that yielded an acceptable trade-off between sensitivity and specificity, Dr Pare said. And in the end, looking at fetal weight, weight difference between the [first] neonate and the current fetus “is no better than flipping a coin.” On the basis of this study, it appears that ultrasound at term to measure fetal weight and to determine who is eligible for a trial of labor “is not justified,” (32)
What does appear to be predictive of a women’s success at VBAC is whether labor is induced or spontaneous
“a second study presented at the meeting .. compared the medical records of 2,943 women who went into spontaneous labor with those of 803 who were induced. All the women underwent a trial of labor and had one previous C-section. Of the women who were induced, 38% were delivered by C-section compared with 24% of the women in the spontaneous labor group [63% normal birth rate for induction compared with 76% for spontaneous labor] In addition, early postpartum hemorrhage rates were 7.4% for those induced and 5% for spontaneous labor… rates of neonatal intensive care admission were 13% for induced and 9% for spontaneous labors…
Even when the data were adjusted for various risk factors, women who were induced had nearly double the risk of having a C-section, compared with those who delivered spontaneously. Although the incidence of uterine rupture was not large enough in absolute term to yield statistically significant differences, the rate in the induced group was about double that of spontaneous labor (0.7% vs. 0.3%). Uterine rupture was approximately twice as likely in the prostaglandin group, compared with the oxytocin group….(33)
Excerpts from an October 7th, 2002 article in Los Angeles Times, Giving Birth Their Way ~ Pregnant women who’ve had a previous C-section have a tough time persuading doctors to let them deliver vaginally
“Women who have had a caesarean section often want to deliver their next child vaginally–and many are physically capable of doing so. But across the nation, they’re increasingly denied that option.”
“Only 16.5% of U.S. women with prior caesarean sections had a vaginal birth last year, according to the National Center for Health Statistics, a 20% drop from the previous year. California’s rate, at 14.5%, is among the lowest in the nation and some local hospitals report current rates of less than 5%.”
“Statistics show that VBACs are successful in 80% of women who are considered good candidates for the procedure.”
“…. a 24-year-old Simi Valley woman, sought a vaginal birth earlier this year because of a difficult recovery after the caesarean birth of her first child. Although doctors said she was a good candidate for a vaginal delivery, she had to change physicians twice before finding one who supported her request.”
“Women’s health experts agree that VBAC can be a reasonably safe–even preferable–option. The American Academy of Obstetricians and
Gynecologists concluded in a 2000 report that the benefits of a vaginal birth after a caesarean outweigh the risks for many women. And the
federal government has set a goal of 37% VBAC deliveries as part of its Healthy People 2010 objectives, up from the 28% rate reported in 1998.”
“But safety, cost, convenience and malpractice concerns have sent the rates plunging, not increasing. The decline started in 1999 when the American College of Obstetricians and Gynecologists recommended that a doctor and an anesthesiologist be “immediately available” when a VBAC patient is in labor. Before 1999, a doctor and surgical team were advised to be “readily available,” widely interpreted to mean that they be within 30 minutes of the hospital.”
“There has been absolutely no change in the underlying scientific background on VBAC,” says Dr. John Aiken, an obstetrician at Northridge
Hospital Medical Center. “But because of this … requirement, the physician has to be on site. A lot of physicians don’t come in to the
hospital until their patient is fully dilated [ready to give birth]. So they can’t meet the criteria.”
Both hospital administrators and doctors say it’s too costly and inconvenient for a doctor to sit with a patient in labor (which may last many hours). “There really isn’t any incentive for the physician to do VBACs,” said Dr. Roger K. Freeman, an obstetrician at Long Beach Memorial Medical Center and chairman of the obstetricians task force on VBAC. “It’s more time-consuming, more worry. And they don’t get paid any more for it.”.. [the patient’s doctors] were blunt in denying her VBAC attempt. “One doctors said he wouldn’t be willing to wait during my labor.
“Some women, patient advocates and doctors are upset that non medical issues may lead to unnecessary surgery that has attendant risks of its own. The risk of infant death due to a uterine rupture during a VBAC is about 1 in 1,000, twice the rate among other laboring women, according to studies. Uterine rupture can cause permanent injuries in babies and lead to hysterectomies.”
“But women who have successful VBACs avoid the much longer recovery time and risks associated with C-sections. For the mother, those risks include infection, hemorrhage, blood clots, injuries to other organs and exposure to major anesthesia. The risks to the baby from C-sections are higher rates of respiratory disorders, fetal trauma and fetal death.”
“San Pedro woman who is expecting her second child, was surprised when her obstetrician balked at her request to try a vaginal birth.
“He came right out and said it was for liability reasons,” says Gang, who has hired a doula to help advocate for her during her labor. “Part
of me was a little offended at his honesty…. I want my doctor to do what is in my best interest.”
“To reduce possible complications, the American College of Obstetricians and Gynecologists recently admonished doctors to avoid using drugs that start or speed up labor in VBAC deliveries. Use of labor-inducing drugs, called prostaglandins, have doubled in the last decade (from 9.3% of all deliveries in 1990 to almost 20% in 2000). But the drugs dramatically increase the risk of a uterine rupture during VBAC, according to a study published last year in the New England Journal of Medicine.”
Commentary ~ A Critical Expert System Spins Out of Control,
with no oversight, no accountability
These reports – straight from the ‘horse’s mouth’ — make it clear that the unbridled enthusiasm of this expert system for its own ‘toys’ is irrational and marked by ‘cognitive dissidence’. When the obstetric profession is provided with corrective information, it consistently fails to take corrective action. Physiological management, such as ‘right use of gravity’ or ‘patience with nature’ is given only brief and occasional lip services and then functionally dismissed. Obstetrical researchers identify again and again the problems of aggressive ‘management’ and excessive or inappropriate application of technology. They acknowledge that a consistently interventionist style introduces unnecessary and unnatural dangers into normal childbearing but do not ‘practice what they preach’. Instead they publish research papers on the supposed dangers of “planned home birth” (or VBAC or breech) as a ploy to distract us from these facts.
In spite of these efforts to distract us, examples of obstetrical excess are everywhere. According to national birth certificate data more than 3 million births included the use of continuous electronic fetal monitoring in the year 2000. EFM is functionally universal in spite of being directly associated with escalating rates of Cesarean surgery with its known risks of maternal death. The widespread reliance on ultrasound to estimate fetal weight – wrong 50% of the time – to ‘dictate’ who will be ‘allowed’ to labor (another excuse of Cesarean surgery) is a prenatal example of the ever-creeping invasion of technological excess.. An ObGynNews article in this series identified a global risk factor of 25 for combined use of forceps and VE — compared to 1.9 for spontaneous birth. Other articles reported a doubling of maternal death with Cesarean surgery and a huge increase in placenta accreta and percreta in post Cesarean pregnancies (with many emergency hysterectomies and maternal fatalities).
As was the case for Dr. Semmelweis in the 1840s in regard to the iatragenic origin of puerpual sepsis (childbed fever) and my own experience in obstetrical nursing during the ‘knock’em out, drag’em out’ era of the 60s and 70s, the obstetrical profession still consistently fails to make the connection between the warnings carried in its own textbooks, journal articles and drug package inserts and the big and little problems associated with providing hospital-based obstetrical care to a healthy population. The data is there but its application is biased and used to promote interventionist obstetrics, with the ‘maternal choice’ Cesarean raised to the level of crown jewels.
For the entire last century, ‘good science’ (as contrasted with junk science) has amply documented preventable deaths and a high level of damage associated with medical, surgical and instrumental interventions. But the beat goes on and on, like a malevolent version of the Energizer Bunny. The obstetrical profession repeatedly fails to take corrective action until and unless they are adopting newer, “better” and usually more expensive or even more invasive procedures or products. The low-dose (or walking) epidural is the current “new trick”. Doctors ague over the best choice of drug for epidural administration and the specific dose or timing, but never acknowledge the natural wisdom and benefit of non-pharmaceutical pain management as the goal of good maternity care.
This constitutes the same “irrational exuberance” for the use of obstetrical technology that the dot.com mania applied to the technology stock market (which ended in the dot.bomb!). This is to be expected when there is absolutely no accountability and a total lack of oversight for critical expert systems. These failures result in the loss of “institutional memory”, which is then exchanged for institutionalized forgetfulness. It replaces a factual knowledge base for unsupported assumptions and paves the way for information to be come disinformation.
Instead of a “market correction” for the inflated opinions of interventionist medicine, the forces of organized medicine pick a select few, in fact, just one study that, with the right spin, can make a case for eliminating natural labor or normal birth in each category – breech, VBAC, home-based midwifery. Each particular study is defined as the ‘final word’ on the topic. Then the PR people call up the Associated Press and National Public Radio and claim to have an irrefutable and ‘scientifically sound’ case for eliminating all planned breech births, all planned VABC births and all planned home births. Most recently, the have begun to make the case for eliminating all ‘planned’ vaginal births. Will ‘natural’ conception be next? I bet those ‘assisted reproduction technology’ wizards hope we will exchange normal sex for cloning in a petre dish.
After setting the American public up so nicely with these ‘horrible problems’, the medical profession then provides us with the ‘final solution’. Of course, that always entails the ever wider application of reproductive technology, ever more ‘active’, more medical management of labor (oxytocin and epidural are now the standard) and more surgical or instrumental deliveries. Organized medicine is lying to the public through press releases that promote ever-higher levels of medical intervention as a way to circumvent the normal risks of childbearing. We have institutionalized fraud and disinformation, and substituted a propaganda machine for an educational one.
And should the US ever suffer a national disaster, an act of war or bio-terrorism, there will be no midwives, no understanding of physiological management and no doctors who will know how to manage a normal vaginal birth or deliver a breech baby vaginally. Without electricity for operating room lights and sterilizing surgical instruments, without the highly sophisticated equipment and skills of anesthesiology, without operating room scrub nurses and access to oceans of IV fluids, antibiotics and narcotic drugs – where will the laboring women of American be? In a parking lot triage line with the critically ill and injured, exposed to god know what, awaiting their turn for a “maternal choice” Cesarean because in exchanging “institutional memory” for institutionalized forgetfulness, we have forgotten that there even is a normal ‘birth canal’ and that human being have many ways to help a mother give birth naturally, without suffering and without either herself or her baby being damaged.
Being a part of the problem or part of the solution ~ the choice is ours
So how much worse does it have to get before we mobilize an effective response among “birth professionals” (practitioners, educators, consumer advocates, medical anthropologists, sociologists, breastfeeding and child development specialists, etc)?
In a media-defined world, how much longer can we afford to let organized medicine dominate and manipulate the media for its own ignoble purposes?
In a world that worships science, how much longer will the PhD scientists of American let organized medicine hold good science hostage, subjugating legitimate science to the economic advantage of special interests group (and the detriment of the public), and turn the worship of junk science to religion?
In a country that honors the “rule of law”, how much longer can we afford to let organized medicine manipulate the “malpractice” issue into an excuse for “not permitting” possibly problematic labors — VBAC, breech, post-term, big baby – and effectively forcing women into unwanted, unnecessary and potential lethal Cesarean surgeries? In legal theory, this kind of situation is known as “turning the (mother’s) shield into the (physician’s) sword”.
The logical conclusion to the current attack on ‘planned home birth’ is the first step to criminalizing both parents and practitioners. In the last 2 weeks, our local (and formerly homebirth-friendly) Kaiser RWC hospital has called the police on parents who wanted to go home immediately after the baby was born. A pregnant client having initial lab work done was told repeatedly by the OB that her home-based midwifery choice was irresponsible and that her baby could die and be permanently damaged and how could she live with herself.
You see, there is no “neutrality” here – we are either moving towards increasing suppression or working to bring about understanding and respect. Doing ‘nothing’ is to passively cooperate with the extinction of midwifery and all forms of natural labor and normal birth.
So what will it take to initiate an effective campaign to restore sanity and create an appropriate public awareness of the problem of run-away obstetrics, which has been using Arthur Anderson-type ‘creative accounting’ techniques to cover up the truth – interventionist obstetrics for healthy women with normal pregnancies is an ‘unsafe maternity practice’, in the same league as unsafe sex. The mind-set that brings that about is a ‘virus’ that infects our culture and destroys our critical thinking skills like a computer virus harms our hard drive.
The uncritical acceptance of an unscientific premise – interventionist obstetrics for normal maternity care — is the root of the problem.
Physiological management is the solution
Staffing our labor & delivery rooms with professional midwives is the solution.
Holding our doctors to the same standard — physiological management – when providing care to healthy women is the solution.
“Active management” of the media by midwives and proponent of physiological management is the solution.
Holding organized medicine responsible in a court of law and in the court of public opinion for its false and misleading claims is the solution.
Insisting that our national maternity care policies promote and protect physiological management is the solution.
Most crucial of all – admitting that we need to act now – that is the keystone to turning these otherwise insurmountable problems – stumbling block erected by special interest groups – into stepping stones that will lead us to an ‘sustainable’, cost-effective and mother-baby friendly maternity care system. Future generations (the wealth of our nation) depend on physically and emotionally healthy mothers for a ‘healthy start’. Maternity care systems need to meet the practical needs of all its stake holders, including doctors, hospitals and insurance companies, but most especially the mothers and babies it serves. The sooner we start, the better for all.
Go to www.eObGynNews.com to read these reports in full – log on as an “other healthcare provider”
