The Gibson Report ~ False Association btw routine use of c-EFM to prevent cerebral palsy in babies, pelvic floor damage in moms & protect OBs from lawsuits ~ Part 2 (of 3)

by faithgibson on March 7, 2019

in Cesarean Politics, OB Interventions: Dubious or Detrimental

Part 2 (of 3)  word count 3500

Gibson Report #1 – continued ~ 2019

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Are ‘elective’ Cesareans an effective strategy for ‘saving’ the childbearing woman’s pelvic floor?

~ “A Scar is Born Every 39 Seconds~

Headline for an April 15, 1998 ad in Ob.Gyn.News. The statistics (that a ‘scar’ is born 39 seconds) refers to the number of Cesareans performed in 1995, when the rate was merely 20%. The ad was promoting a skin product specially formulated to treat surgical incisions in post-Cesarean mothers.

Imagine what the ‘per second’ rate of new CS scars is 21 years later in 2019, with a 32.9 % rate?


 

What you see is not necessarily what you get

There are many published studies that refute the notion that Cesarean surgery effectively reduces or eliminates what used to be called “females troubles” — pelvic floor problems that include incontinence, uterine prolapse and related issues.

However, nothing I could say about the false strategy of using ‘elective’ Cesareans to prevent ‘female troubles’ could possibly be more informative or  authoritative than the following two excerpts.

The first is from “Elective C-section Revisited” by Sacramento obstetrician Dr. Elaine Waetjen (Ob.Gyn.News; August 1, 2002, Vol 36, No 15):

The prophylactic use of elective cesarean section to prevent pelvic organ prolapse and urinary incontinence is gaining increased attention

Dr Benson Harer, Jr, past president of the American College of Obstetricians and Gynecologists, stated publicly last year that women should have the right to choose a cesarean delivery. 

“….why shouldn’t we offer prophylactic C-section to prevent this problem later in life?”

The answer is that the evidence does not support this approachPreventive strategies should cause no more harm than the disease or problem that they are trying to prevent. Ideally, they should:

    • incorporate some kind of screening to identify people at risk
    • they should be cost effective
    • based on very good evidence of benefit 

Elective C-section to preserve pelvic floor function fails on all these measures. 

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 {to the baby} 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 {i.e. infertility}.

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. (*Cesarean Birth Associated with Adult Asthma — ObGynNews, 6/15/01, Vol  36, N0. 12)

…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 prolapse or incontinence, we should be examining what we can do in our management of vaginal deliveries to protect pelvic floor function”.

The second excerpt is from Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery? published in Medscape Ob/Gyn & Women’s Health; 9/16/02

Dr Peter Bernstein, MD, MPH; Associate Professor of Clinical Obstetrics & Gynecology and Women’s Health, Dept of Obstetrics and Gynecology, Albert Einstein College of Medicine / Montefiore Medical Center, and Medical Director, Obstetrics & Gynecology , Comprehensive Family Care Center / Montefiore Medical Group, Bronx, New York

One argument often cited in favor of elective cesarean delivery is prevention of pelvic floor damage, which can occur with vaginal delivery. Stress urinary incontinence, pelvic organ prolapse, and anal incontinence have been associated with vaginal delivery.

But these adverse side effects may be more of the result of how current obstetrics manages the second stage of labor

    • Use of episiotomy and forceps has been demonstrated to be associated with anal incontinence in numerous studies.

Perhaps also vaginal delivery in the dorsal lithotomy position 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

Nonetheless, the  prevention of pelvic floor injury by routine elective cesarean delivery is not an appropriate solution. Rather, more research into the management of the second stage of labor is clearly necessary. Moreover, cesarean delivery does not guarantee protection against pelvic floor dysfunction, given the reports of similar rates of urinary incontinence in nulliparous woman as in parous women [2]

A potentially more persuasive argument in favor of elective cesarean delivery is based on the potential for fetal risks before and during vaginal delivery, including intrapartum death, intrapartum acquired hypoxic ischemic encephalopathy, and stillbirth at term before the onset of labor.

What is not clear, however, is how many cesareans would have to be performed to avert these disastrous events and what the cost would be in terms of maternal morbidity and mortality in order to prevent a single untoward fetal outcome.

To suggest that performing an elective cesarean delivery in a low-risk patient will avert intrapartum fetal injury is very misleading. These outcomes are rate, even in higher-risk women.

Indeed, they are so rare in women without any identifiable risk factors that an absurd number of cesarean deliveries would need to be performed to avert even one of these poor outcomes. Thus, resorting to cesarean delivery would not be appropriate standard procedure.

Although cesarean delivery has clearly become safer over the past 50 years with advances in antibiotics, anesthesia and thromboprophylaxis, it is still not without risks. Woman undergoing cesarean delivery have greater blood loss and risk of damage to internal organs. The mortality risk of under going an elective cesarean delivery with no emergency present has recently been reported almost 3 times the risk of vaginal delivery. [3]

In addition, risks to the fetus associated with cesarean delivery range from lacerations [a cut in the baby’s face or head when the surgeon makes the incision into the uterus] to respiratory distress syndrome and transient tachypnea of the newborn. Although these are typically manageable, their cost will be multiplied many times over if more elective cesareans are performed.

One of the most significant risks of cesarean delivery is the need for a subsequent cesarean delivery.  …  A repeat cesarean delivery carries significantly more risk in terms of placenta previa, placenta accreta, uterine rupture, injury to internal organs during surgery excessive blood loss, need for hysterectomy and maternal death.

These risks rise with each subsequent repeat cesarean delivery. Risk of [placenta] accreta and previa increases with each subsequent cesarean delivery, reaching a risk of > 60% in women with 4 or more cesarean deliveries. [4] In addition, the incidence of emergency peripartum hysterectomy for abnormal placentation seems to be rising as a result of the increase rates of cesarean delivery.

A move toward routine elective cesarean delivery may also have significant costs in terms of lost opportunities for bonding between mother and newborn. A woman who has had a cesarean may be less able to care for her child and may have a more difficult time breastfeeding

…..  Although this impact may be small for the individual patient, again, its costs multiplied over a large population may be great, based on the accumulating evidence for the benefits of successful long-term breastfeeding.

Arguments made by proponents of elective cesarean that it should only be provided to women who intend to have only 1 or 2 children fall flat, given that the rates of unintended pregnancy in the US approach 50%. And what of the woman who changes her mind 10 years later and chooses to have another child after having had 2 prior cesareans?

There may be no legal liability to the physician who performed the patient’s first cesarean section when the patient winds up with a hysterectomy or worse, but that does not clear that physician of responsibility for performing a surgical procedure of unclear benefit upon a patient’s request.

Some argue that, from an ethical point of view, allowing a patient to choose to deliver by cesarean is not substantially different from allowing her to choose to undergo cosmetic surgery.

But cesarean is very different. The benefits of elective cesarean relative to vaginal delivery are not established and the risks are substantial, especially given the potential for future repeat cesareans.

That women are seeking elective cesarean deliveries is probably more significant in that it indicates the failure of modern medicine and society at large, in the sense that women may fear the experience of labor and birth attendants may fear the legal risks of allowing appropriate women to have a trial of labor.

Modern management of labor should be reassessed to address the concerns raised by proponents of elective cesarean delivery. If elective cesarean becomes an acceptable alternative, we may never be able to undo the practice.

Excerpts from “Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?” by clinical professor of obstetrics and gynecology, Dr Peter Bernstein, MD, MPH;  9/16/02

A Failed Medical Experiment: EFM & Cesarean as the obstetrical Standard of Care:

To translate all these professional studies and journal articles into plain English, fifty years of continuous electronic fetal monitoring for all laboring women, in conjunction with the emergency use of cesarean section at the slightly suspicion EFM tracing, is a failed medical experiment.

This undeclared experiment was based on the hypothesis that continuous electronic monitor of all labor patients would prevent morbidity and mortality for mothers and babies and reduce financial burdens on individuals, institutions and taxpaying public by virtually eliminating the incredibly expensive care required for children with CP and permanent neurological damage.

These have always been extremely worthy goals, and I personally hope we can figure out how to achieve them, the sooner the better. But when it comes to c-EFM, the scientific literature does not provide the desired “proof of theory” so desired by hospital chains and the obstetrical profession because universal use of c-EFM does not achieve its own goals.

Instead of helping childbearing parents and society, its routine use results in expensive iatrogenic complications that primarily affect the childbearing woman, in particular, an increased rate of morbidity and mortality that is painful if not tragic for families and extraordinarily expensive for society.

All this is a direct result of the higher Cesarean section rate and its propensity for spawning complications during the surgery itself, immediately post-op and/or serious delayed and downstream problems for both mothers and babies.

Cesarean Surgery – the “gift” that keeps on giving!

Cesarean surgery is the gift that keeps on giving, not only at the time the operation is performed, but in all future pregnancies. Unfortunately for 6% of post-Cesarean mothers, a downstream complication of their Cesarean surgery is infertility as a result of a post-operative infection.

Life-threatening complications of this surgery can result in the need for blood transfusions, unplanned emergency hysterectomy for uncontrollable hemorrhage and days or even weeks in the ICU.

The postpartum recovery period is longer, harder, more painful and in some cases of prolonged post-op pain, exposes new breastfeeding mothers to opioid addiction as a result of the needed narcotic medication. In other instances, the problem is post-operative infections that have to be treated with IV antibiotics and may require new mothers to be readmitted to the hospital.

Obviously, none of this is conducive to bonding with one’s new newborn or learning how to care for and meet its needs, something that may be a make-it-or-break-it issue for post-op mothers trying to breastfeed for the first time.

Then there is the long shadow that a previous C-section casts over all subsequent pregnancies. This begins with the risks of possible uterine rupture of the Cesarean scar either before or during labor. That is the primary source of controversy over a vaginal birth after Cesarean (VBAC), as many doctors, hospitals and medical malpractice insurers do not want to risk being sued in these cases. As a result they either decide not to  “do” VBACs, or hospital policies (often based on liability insurance contracts) won’t allow them to do so.

This sets up previous-Cesarean mothers for additional, often unwanted (and certainly not medically necessary) major surgeries by requiring that all future babies be delivered by repeat C-section. This exposes her to all the aforementioned risks, over and over again, and dramatically increases the likelihood of the placenta-related complications described below.

The most devastating and potentially deadly of the many delayed and downstream complications of Cesarean surgery is the propensity to develop abnormal placental implantation in future pregnancies, a risk that increases exponentially with each subsequent Cesarean delivery.

Even the very best of circumstances — the least invasive category of placenta accreta — can be life-threatening. Luckily. the majority of these new mothers come through without requiring blood transfusions, major surgery, or admission to the ICU.

But when the placenta grows into the uterine muscle (placenta increta), or worse yet, grows completely through the wall of the uterus (percreta) and attaches itself to other abdominal organs (usually bladder or bowel), it requires a highly risky preterm Cesarean-hysterectomy. This dire but mostly preventable emergency is fatal 7-10% of the time.

Unfortunately, the delayed and downstream complications associated with Cesarean surgery make any policies or practices that increased the C-section rate counterproductive in the extreme.

Vocabulary Review for types and levels of abnormal Placental attachments:

  • Placenta Previa is when the placenta implants at the bottom of the uterus. Depending on how close to the cervix, there are 4 levels of previa: (a) low-implantation (b) marginal (c) partial and (d) complete, which covers the cervix completely and makes vaginal birth impossible.
    In addition to the previa, the placenta may also grow abnormally deep into the uterus, which means the mother-to-be has both a previa and a perceta. The most serious levels of previa (c & d) or any level of accreta-percreta requires Cesarean delivery.
  • Placenta accreta is when the placenta grows abnormally into the superficial lining of uterus and is the least serious level of invasion
  • Placenta increta is when it grows into the uterine muscle
  • Placenta Percreta is when it grows through the uterine wall and attaches to other abdominal organs.
    These are life threatening complications that frequently require an emergency hysterectomy to stop the bleeding and has a 7 to 10% maternal mortality rate.

What is the word for promising one thing & doing the exact opposite?

Now we come to the well-documented facts about the current national standard for obstetrical care in the US, which is organized around the universal use of c-EFM. There is no question that the frequent use of emergent C-section based on EFM tracing that are ‘non-reassuring’ increases our national Cesarean rate. In fact, “non-reassuring fetal heart tones” is the second most frequent diagnosis for Cesareans performed on first-time mothers.

Yet the raison d’etre for EFM — reducing the instance of cerebral palsy and other neurological disabilities — is NOT happening. What surely is happening is a decades-long medically-unnecessary increase in Cesarean surgery and its many intra-operative, post-op, delayed and downstream complications that remains an everyday reality for the four million laboring women (3.5 million of whom are healthy and have normal pregnancies).

These women will find themselves immobilized in their labor beds while they remain hooked up to continuous electronic monitoring equipment. This is almost always followed by a cascade of obstetrical interventions — IVs and epidurals for pain, automatic blood pressure cuff, pulse oximeter, foley catheter and far too often, the need for vacuum extraction or Cesarean delivery.

As if this is not problem enough, this “standard care ” predictably doubles or triples the cost of normal childbirth.

How could such a discordant practice have been perpetuated for the last 50-plus years? How come no one else had noticed?

Hospitals economics & the Nancy Reagan “Just Say No” policy

The professional journal publications quoted in this post and many other peer-reviewed articles clearly convey the obvious — the routine use of continuous EFM on low and moderate risk women is NOT a science-based practice AND has never been able to do what was advertised– eliminate or greatly reduce the rate of CP and other neurological pathologies of the newborn.

Nonetheless, the obstetrical profession and hospitals have masterfully ignored everything they don’t want to hear, decade after decade after decade, as they swept new studies under the rug to join all the earlier studies– something not to be talked about, and certain not to be acted on!

The R2D2 of EFM!

In spite of the many complications associated with the universal EFM for healthy women with normal pregnancies, and well-established fact that c-EFM is not associated with better outcomes, the practice continues unabated in the 3,400 hospitals in the U.S. that provide obstetrical services.

EFM is now the single most frequently used medical procedure in the US, which is to say that the use a $15,000 electronic monitor system has ourstriped every other medical device or procedure in America.

The official estimate is that 85 to 93 % of all childbearing women are hooked up to continuous EFM equipment during their entire labor. [citation L2M Survey 2002 & 2005; Martin et al 2003]

Many health insurance carriers reimburse hospitals $400 an hour for intrapartum continuous electronic monitoring. According to doctors and hospitals, this is the cheapest and best way to protect them from multi-million dollar malpractice suit for a damaged baby, and like one’s American Express card, you shouldn’t go anywhere without it!

The April 2011 article quoted in Part 1 acknowledges the lack of a scientific basis for c-EFM, but at the same time, they went on to say some version of:

“ya, but we have to keep using universal EFM because there are too few nurses to use use IA”

This means that hospitals in the US have systematically chosen NOT to hire enough L&D nurses to use the ‘alternative’ to EFM — a simpler but equally-effective monitoring method of known as Intermittent auscultation (IA). {full explanation and description of how it works follows in Part 3}

As noted, many hospitals bill health insurance companies and the federal Medicaid program up to $400 an hour for each labor patient who is hooked up to c-EFM. Each hospital is reimbursed many thousands of dollars for an average labor (8-10 hrs = $3200-$4,000), multiplied by 3 to 12 labor patients in the unit at any one time (i.e. generating from $10,000 to $40,000 per shift).

L&D nurses certainly are NOT getting paid $400 an hour (average RN pay in US is btw $28 and $45 an hr).  Obviously hospitals in the US find it a whole lot more profitable NOT to hire enough L&D nurses to monitor (i.e. the active verb, not the machine!) the unborn baby using a hand-held Doppler and Intermittent Auscultation (IA) protocols.

While “auscultation” is a strange and hard-to-pronounce word, IA itself is a simple and straightforward screening process that collects essentially the same 4-points of information on the fetal heart rate and rhythm as EFM to determine the health status of the fetus at each specific point in time as either ‘reassuring’ or ‘NOT reassuring’. The use of low-level technologies similar to IA that are regularly used during labor include a blood pressure cuff and thermometer to repeatedly check on the well-being of the mother.

In the case of intermittent auscultation of an unborn baby, the birth attendants or nursing staff are listening for four data point listed below and will use them, just as they would information about the mother’s BP or temp, to determine if everything is normal or if there is a problem that needs to be medically evaluated. These four data points for fetal well-being are:

  • normal baseline  (y/n)
  • normal variability (y/n)
  • the presence of reassuring Accelerations (y/n)
  • the absence of pathological Decelerations (y/n)

This screening process is repeated many times during labor, usually every 30 minutes during 1st stage and every 15 minutes or more often during 2nd (pushing) stage.

Whether this data is gathered by EFM or IA,  the ‘screening’ process uses the same binary data (yes/no) of four specific markers that provide a clinical picture of normal vs not normal. This tells the primary birth attendant (OB or midwife) and/or L&D staff whether additional evaluation is indicated or if emergent interventions is necessary.

These four point of information as provided by IA on fetal wellbeing allows the unborn baby to be monitored without the many complications, expense, increase C-section rate and maternal mortality associated with c-EFM.

The dilemma that c-EFM poses to obstetricians is humorously described in this brief tongue-in-cheek editorial by Dr. Drosman to his fellow obstetricians.

Why the C-section rate is rising by Dr. Steven Drosman, MD, obstetrician-gynecologist in San Diego, CA; Editorial ~ Medical Economics, Oct 2000 ~

“Probably  the biggest C-section motivator, however is fear of a lawsuit. The rational is simple: At worst, you’ll be criticized for performing a C-section but you can be roasted for delaying one!

When a patient is hooked up to a fetal monitor, it initiates an unholy trinity — the anxious patient, the hovering nurse and the paranoid physician. The tension escalates as monitoring devices are added: the fetal scalp electrode, the fetal pulse oximeter, and intrauterine pressure catheter.  Add some more Pitocin to the mix, and the action begins.

The labor and delivery nurse watches the monitor and observes decreased variability and persistent late decelerations. The obstetrician is notified, wipes the perspiration from his forehead and pops a handful of antacids.

The patient and her family are informed of the potential crisis, and the can of worms has been opened. More likely than not this “electronically compromised” fetus will be delivered by emergency C-section, with perfect Apgar scores.

Continue to Part 3 (of 3)

The False Association btw the routine use of efm to prevent Cerebral Palsy in babies, pelvic floor damage in mothers & protect OBs from lawsuits

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