The Wrong Use of Obstetrics: Introduction ~ currently being edited 01-23-2025

by faithgibson on January 21, 2025

in Contemporary Childbirth Politics

Originally posted 2021
The Wrong Use of Obstetrics:

The most Profound Change
in normal Childbirth Practices
in the history of the human species!

An academic and synoptic version for
educational and legal purposes

Part I ~ Introduction and Overview ~

Author’s Note:  The following historical information is not meant to denigrate or undermine the contemporary practice of obstetrics. It’s not my intention to diminish the enormous value of the obstetrical profession’s contribution to making childbirth safer for women with high-risk pregnancies, those who develop complications, experience an obstetrical emergency, need an operative delivery, or require ongoing treatments for women’s reproductive issues.

Part I ~ Introduction and Overview ~ 01-22-2025

Author’s Note:  The following historical information is not meant to denigrate or undermine the contemporary practice of obstetrics. It’s not my intention to diminish the enormous value of the obstetrical profession’s contribution to making childbirth safer for women with high risk pregnancies, those who develop complications, experience an obstetrical emergency, need an operative delivery, or require on-going treatments for women’s reproductive issues.

Speaking as a former L&D and ER nurse, professional midwife, and spokesperson for many childbearing parents and midwives, we are all profoundly grateful for the life-saving skills of American obstetricians and their ability to assuage unnecessary suffering.

As a young bride, I personally benefited greatly from the art and science of modern obstetrics. Without the diagnostic and surgical abilities of a wonderfully compassionate obstetrician-gynecologist, I would not have a family of three healthy, now adult, children and two wonderful grandsons. My eldest grandson recently graduated from medical school and is an ER physician. So  I continue to be profoundly grateful the obstetrical profession and want to see to it live up to its potential and thrive.

Nonetheless, I take extreme issue with the current American obstetrical standard of care for healthy women with normal pregnancies. That standard frequently encourages and advocates the use of obstetrical interference under the false flag of “greater safety” that promotes the routine use of obstetrical interventions, often as a hedge against possible malpractice litigation, while turning a blind eye to the many well-documented dangers associated with intervening in the spontaneous labor and normal birth in healthy labor patients. [Loudon, 2000 #1].

As noted above, obstetrics is a surgical specialty developed to intervene in high risk pregnancies and childbirth-related emergencies. Nowhere else in the American healthcare system (or those in other developed countries) does a surgical specialty provide primary care to a large population of healthy people.  Since the 1950s, approximately four million babies have been born every year in the United States.

Obviously, the biology of American women must be functioning pretty well, but unfortunately “pretty well” isn’t very good, since the US has the highest rate of maternal deaths compared to all other wealthy industrialized countries.

We rank 128th out of 183 countries in the ratio of maternal deaths to live births. Our is the highest maternal mortality rates in the developed world, one of the highest Cesarean surgery rates, and the economic cost of having a baby that is two to three times greater than the rest of the developed world.

High cost and poor results are nothing to be proud of!

Obstetrics can and should be a noble profession. In those places where it currently is not, it needs to open itself up to the kind of historical, statistical, and evidence-based information widely available and make the appropriate “adjustments” and policy changes described in these “Wrong Use of Obstetrics” essays. As a wife, mother, former ER and L&D nurse and professional midwife, I can tell you with certainty that more of what isn’t working is not going to work.

After 125 years of promoting of the wrong use of obstetrics by systemizing and institutionalizing it as the American standard of care for all childbearing women, I can also say with certainty that the ever-increasing rates for inducing labor ever earlier in term pregnancies (i.e. before the baby’s due date), in concert with our already over-the-moon C-section, scandalous maternal mortality rate and sky-rocketing hospital bills for normal birth that have begun to rival those for an organ transplant are all a wrong use of obstetrics and not a workable plan for a better future or affordable healthcare system.

Obstetricians currently deny any professional responsibility for providing direct support or guidance to laboring women who prefer to avoid standard interventions. With very rare exceptions, they are not willing to be personally present or even make sure that one-on-one physiologically-based midwifery care is available to these mothers.

This lack of responsibility by the obstetrical profession for the mother’s experiences during active labor, something that can make the difference between a normal vaginal birth or Cesarean surgery, is clearly identified as “how it’s supposed to be” by the American Journal of Obstetrics and Gynecology: Macer, J. A. 1992:166:1690-7. 

“It is no longer feasible for individual physicians who have invested 12 years in training at a cost of hundreds of thousands of dollars to dedicate extended periods to observing one normal woman in labor.”

Notice how this obstetrician-author does not talk about “helping” or “supporting” a woman in labor, only his own passive act of standing by and “observing” her, which he and all other obstetricians seen as a relative waste of the obstetrician’s 12 years of training and hundreds of thousands of dollars in medical school costs.

Long-ago origins of our dysfunctionalized obstetrical system

Beginning in the early 20th century, the American obstetrical profession defined so-called “normal childbirth” to be a dysfunctional and therefore dangerous aspect of female biology that risked the lives of both mother and unborn baby. Even if both survived what they called “the ordeal” of childbirth, both mothers and babies might still have suffered permanent and debilitating harm.

Historically, a small number of very influential American obstetricians (Drs. J.W. Williams, DeLee, Ziegler, etc) insisted that the only way to make childbearing reasonably safe in the United States was for the care provided during normal childbirth to become the exclusive domain of the new surgical specialty of obstetrics.

Management of hospitalized obstetrical patients involved the use of several medical inventions and invasive surgical procedures. On admission to the hospital’s “white-only” labor ward. Only hospital personal were permitted the “surgically sterile” environment of the obstetrical ward, so hospital policy required labor patients be isolated from husbands and family members. However, every labor patient was given repeated injections of the Twilight Sleep drug scopolamine mixed with morphine, which was the chemical equivalent of a reversable lobotomy.  Since all labor patients were medicated with the amnesic-hallucinogenic drug scopolamine, all patients were confined to their beds.

When the baby was about to be born, these about-to-be new mothers were moved by stretcher to an obstetrical-equipped operating room. Then the mother was “put her to sleep” under a general anesthetic and the “delivery” conducted as a series of surgical procedures. This frequently started by the doctor using a pair of sterile scissors to cut an episiotomy (incision into the skin at the base of her vagina).

The obstetrical forceps were used to extract the baby from its mother’s unconscious body. After the handing the newborn over to the nurse, the woman’s obstetrician, or in teaching hospitals, an intern, resident, or medical student, would reach a gloved hand up into the unconscious mother’s vagina and into her uterus and detach the placenta from the uterine wall with his fingertips, and pull it out in his hand. The surgical procedure of obstetrical delivery ended with suturing of the episiotomy incision.    [#1].

Thankfully, the obstetrical profession has abandoned many of its most dangerous and painful practices. But things are not as different in the 21st Century as many childbearing women and virtually all midwives had hoped. Many of the most outspoken obstetricians are openly hostile to the practice of midwifery in general and the choice by some families to give birth in an out-of-hospital setting (home or free-standing birth center).

A significant percentage of obstetricians continue to routinely and unnecessarily medicalizing normal childbirth in low-risk pregnancies by hospitalizing and electively inducing labor in healthy women with no medical indications on or before their baby’s due date. The newly hospitalized labor patient is immediately and continuously hooked up to an electronic fetal monitor during normal labor, an IV drip is started, and the drug Pitocin is added to the patient’s IV yo “speed things up”. This is “business as usual” in the obstetrical department of American hospitals.

Over the last two decades the Cesarean rate for healthy low-risk women with a single baby in a head down position of 25%. A high level of intervention is the norm in more than 90% of births in the US [#2 Listening to Mothers surveys I, II, & III; ChildbirthConnection.org]

Hospital policy is to immediately hook the about-to-be new mother up to the continuous electronic fetal monitor (EFM) sitting right next to her hospital bed. Except for using the bathroom, the majority of hospitalized patients find themselves lying in bed for almost all of their labor. Unfortunately the most unnatural and painful position for the laboring woman lying down and/or staying relatively still. In fact, this is so intolerable for most laboring women that they eventually ask for pain medication or epidural anesthesia.

All this is this in stark contrast to the “right use of gravity”, in which laboring women are upright, moving about, unencumbered by IV lines and EFM cables as they walk around the room or stand in the shower.

The connection between labor interventions and unplanned unexpected Cesarean surgery

In 2023, the cesarean delivery rate in the United States was 32.3%.This means that 32.3% of live births were delivered by C-section. 

Unfortunately, there is a direct correlation between the use of obstetrical interventions in the pregnancies and labors of healthy women and a statistically significant increase in the Cesarean surgery rate. The particular intervention most associated with an increased rate of surgical deliveries is the routine use of continuous electronic fetal monitoring (EFM).

Continuious EFM has become the universal obstetrical standard with 85% of all labor patients are hooked up to the fetal monitor. Unfortunately, this has nothing to do with the individual needs of the moment or any actual risk.

Likewise, there is a very direct and specific correlation between higher rates of Cesareans and our disproportionally higher rates of maternal morbidity and mortality. The United States has the very highest MMR of all wealthy countries, a stark statistic that has been true for the last 125 years — all of the 20th Century and the first quarter of the 21st century.

Historical influences on modern obstetrics that drives high C-section rate in US

Historically the problem is that American obstetricians took over the practice of midwifery (i.e. attending healthy women having normal births) in early 1900s without any understanding or respect for the principles, practices and technical skills of physiological management.

The foundation for normal physiological labor starts with a mother-to-be who is upright and mobile — walking around, physically active, eating and drinking at will. Unfortunately, the very first thing that happens when a laboring woman is admitted to a hospital labor room is that she is put in bed. Normal progressive labor is directly associated with maternal mobility, a variety of positions, and unrestricted mobility. That means NOT lying in bed hooked up to medical paraphernalia!

A normal un-intervened with labor uses non-drug ways to cope with labor pains. This includes “patience with Nature”, the “right use of gravity” and not imposing arbitrary time limits as long as the mother and unborn baby are stable and healthy.

For a variety of complicated historical, economic and political reasons, along with a big helping gender-prejudice and unbridled misogyny, the obstetrical profession has never acknowledged the greater safety and other proven benefits ofphysiologically-managed childbirth nor had any interest in adopting physiologically-based care during labor and birth as its standard of care. [#1].

The profession also didn’t factor in the dangers introduced by medical interference and invasive surgical procedures, [#3 – complications placenta extraction]. These interventions were particularly lethal before the availability of antibiotics. Until the 1940s, 40% of all maternal deaths were the result of sepsis – often called septicemia or “blood poisoning”. [#] More than a hundred years have passed, and the obstetrical profession as a whole still doesn’t really understand or appreciate the normal biology of spontaneous childbirth in healthy women. As a result, it also doesn’t see why midwifery care, whether provided by a physician or a midwife, in or out-of-hospital, is the evidenced-based scientific standard for the non-interventive support of normal labor and birth in a healthy population.

Instead the obstetrical profession insists that the routine/pre-emptive use of obstetrical interventions makes childbirth safer for healthy childbearing women, while the scientific studies all report a higher rate of serious morbidity and mortality are associated with unnecessary obstetrical interference. Risky intervention to be avoided include, but are not limited to, elective pre-term induction in healthy women with normal pregnancies, the routine use of continuous EFM on low-risk women (current reported rate is 85% of all labor patients are hooked up to a continuous EFM system) and elective use of Cesarean surgery.

Unfortunately for the obstetrical profession and the women who are harmed or die as a result of their intemperate use of invasive obstetrical interventions, the professions’ assertion of greater safety is not upheld by scientific literature. Quite the opposite, as the US continues to have the highest maternal mortality rates (MMR) of any developed country, ranking 127th out of 183 countries in maternal deaths.

In addition, the US also has one of the highest Cesarean surgeries which is linked to higher rates of maternal mortality and very high rate of maternal morbidity. For each C-section performed in the US, 70 new mothers who will suffer from a serious and sometimes life-threatening complication of their childbirth. One of these complication includes a 13-fold increase in emergency hysterectomies within 14 days of having had Cesarean surgery. This is drastic and life-altering surgery compared to a normal vaginal birth.

Despite these dismal statistics, the obstetrical community insists that normal childbirth is significantly safer when healthy women labor in highly medicalized obstetrical departments. Nonetheless, the accuracy of this claim can easily be determined by publicly available statistics. If interventive obstetrics for healthy women was as safe as claimed by the obstetrical profession, those statistics for maternal mortality and morbidity in the US would be the lowest in the world and we would have bragging right to a remarkably cost-effective maternity care system. But obviously, that is not the case.

Instead, childbirth services in the US are two to three-fold more expensive than other developed countries, with an extremely poor return for our money. While we pride ourselves for being #1 in everything, ranking 128th in maternal mortality is nothing to be proud of.  The cost of having a baby in the US is orders-of-magnitude greater than the rest of the developed world, and yet our mother and babies are not having better outcomes.

Sad to say but plenty of “third world” countries are a much safest place to have a baby. The list of these third world countries that put the US to shame include:

Belarus, Poland, Norway, Italy, Israel, Finland,
Czech Republic, Greece, Denmark and Iceland.

None of these countries is remarkably wealthy or innovative; none have a world-famous healthcare system, and yet they have much safer maternity care systems.

A mother-to-be in America would be safer giving birth in Tajikistan, Russia, Iran, Bahrain, Kuwait, Kazakhstan, Bulgaria, Bosnia-Herzegovina, Estonia, Qatar, and Croatia than in the US.

Obstetrics Can and Should Be a Noble Profession

Obstetrics can and should be a noble profession. In those places where it currently is not, it needs to open itself up to the kind of historical, statistical, and evidence-based information found in thousands of published studies over the last 50 years, and other reliable sources included in this essay but widely available elsewhere. This would help them to make the appropriate “adjustments” and policy changes.

As a wife, mother, former ER and L&D nurse and three decades as a professional midwife providing out-of-hospital care, I can say with absolute certainty that more of what isn’t working won’t work either!

For the last 120 years the wrong use of obstetrics has promoted, systemized and institutionalized obstetrical intervention as the American standard of care for all childbearing women, including the 75% of childbearing women who are healthy and have normal pregnancies. Contemporary obstetrics in the US suffers from the twin evils of a scandalously high maternal mortality rate and sky-rocketing hospital bills for normal birth that have begun to rival those for an organ transplant (over $100,000).

All of this is a wrong use of obstetrics.

A paper published in the American Journal of Obstetrics & Gynecology, March, 2017 [#4] DOI: 10.1016/j.ajog.2016.12.033;] begins by saying:

Obstetrical care in the United States is unnecessarily costly.

Birth is one of the most common reasons for healthcare use in the United States and one of the top expenditures for payers every year.

When compared with other OECD countries, the US spends substantially more money per birth without better outcomes.

When these excessive, unproductive and pernicious costs for obstetrical services are traced back to their source, the single unifying factor that glues this Gordian knot together and generates an annual expenditure of $1.600,000,000,000 (1.6 billion!) is the universal use of continuous electronic fetal monitoring on 85% of hospitalized labor patients and the doubled or even tripled rate of unplanned Cesarean performed during as a result of electric fetal monitor print out that is said to be “non-reassuring”.

This triggers a high level of obstetrical anxiety that in our litigious society that is best assuaged by the famous obstetrical maximin “when in doubt, cut it out”. Every OB is primed at every minute to race off to the OR and do an emergency C-section so he won’t have to worry about a possible lawsuit.

I could quote any one of a thousand published studies over the last 46 years on the use of continuous EFM on healthy low-risk patients. A very large body of scientific literature goes all the way back to 1976, when the very first prospective clinical trial by Haverkamp et al was published. It compared the continuous use of EFM to auscultation during the labors of healthy women. Auscultation (aus-cul-ta-tion) describes intermittently listening to the fetal heart rate (FHR) with a fetoscope or hand-held Doppler every 30 minutes in first stage and every 15 minutes during pushing, more frequently if there is any reason to worry.

The conclusions by the authors of Haverkamp et al were:

“ ……  no differences in the infant outcomes in any measured category between the electronically monitored group and the auscultated group.

The cesarean section rate was markedly increased in the monitored group (16.5 vs. 6.8 per cent in the auscultated patients).

The presumptive benefits of electronic fetal monitoring for improving fetal outcome were not found in this study.”

The conclusions of the Haverkamp study is chilling for two reasons. First, the authors found absolutely no difference in outcomes for babies — exactly same ratio of normal outcomes for newborn babies in each arm of the study

Second, women monitored by continuous EFM had a statistically-significant higher C-section rate; despite the so-called “rescue” nature of their Cesarean surgery, there still was NO difference in the rate of normal outcomes for their newborns.

However, mothers in the C-section group had dramatically increased rates of complications associated with surgical delivery. These fall into the three categories of (a) immediate (b) delayed and (c) downstream.

Immediate surgical complications included uncontrolled bleeding (hemorrhage) during surgery that required blood transfusions and in extreme circumstances, an emergency hysterectomy. Other complication include pulmonary embolism, and/or admission the ICU for as long as four weeks.

Delayed complication of abdominal surgery includes thrombosis (blood clots) or thrombophlebitis (inflamed blood vessels) in deep legs veins, need for pain medications that make the new mother sleepy and/or interfere with breastfeeding and enjoyment of her newborn; hospital-acquired MERSA infections in the surgical wound that are resistant to antibiotics; progressive necrotizing fasciitis that in extreme cases requies amputation of all four limbs (the result of restricted blood flow that is a side effect of drugs needed to keep the patient alive); rehospitalization within 14 days due to uncontrollable vaginal bleeding, serious wound infections, a bowel obstruction and other health issues.

Downstream complications of Cesarean include post-op adhesions, a potentially fatal post-op bowel obstruction caused by adhesions; secondary infertility (6%), slightly increased risk of fetal demise; abnormal placental implantation that requires a Cesarean delivery and hysterectomy,  ,

@@@@@@@@@@@ new edit above and older version below

Speaking as a former L&D and ER nurse, professional midwife, and spokesperson for many childbearing parents and midwives, we are all profoundly grateful for the life-saving skills of American obstetricians and their ability to assuage unnecessary suffering.

As a young bride, I personally benefited greatly from the modern art and science of obstetrics and Gynecology. Without the diagnostic and surgical abilities of a wonderfully compassionate obstetrician-gynecologist, I would not have a family of three healthy, now adult, children and two wonderful grandsons. My eldest grandson recently graduated from medical school and is an ER physician. So  I continue to be profoundly grateful to the obstetrical profession and want to see that it lives up to its potential, for its own sake and the well-being of all its patients.

Nonetheless, I do take extreme issue with the current American obstetrical standard of care for healthy women with normal pregnancies, which unfortunately is at odds with the actual physical, psychological, and social needs of healthy childbearing women and their families. Instead of supporting the normal biological process of labor and birth (such making “right use of gravity” to help the baby come down and be born naturally) labor beds in obstetrics departments are full of women in hospital beds who are hooked up to IV bottles, electronic fetal monitor straps around their pregnant belly, a catheter in their, and other kinds of wires and cords from blood pressure and pulse-oximetry machines.

They are a demonstration of the “wrong use of gravity” — the very opposite of a realistic relationship with the actual Laws of Gravity. What realistically does help a baby to be born spontaneously and without medical or surgical interference.

The standard frequently promotes the routine use of obstetrical interventions (often as a hedge against possible malpractice litigation) while it turns a blind eye to the many well-documented dangers associated with intervening in spontaneous labors and normal births in healthy labor patients who do not need or want such interference. [Loudon, 2000 #1].

Very Different Ideas about the Risks of Childbirth and Proper Role of Obstetrics in America

As noted above, obstetrics is a surgical specialty that was specifically developed to intervene in high-risk pregnancies and childbirth-related emergencies. Nowhere else in the American healthcare system (or those of other developed countries) does a surgical specialty provide primary care to a large population of healthy people.  Since the 1950s, approximately four million babies have been born every year in the United States. Obviously, the biology of American women must be functioning pretty well.

Beginning in the early 20th century, the American obstetrical profession defined “normal childbirth” to be a very dangerous aspect of female biology that risked the life of both mother and unborn baby. Even if both survived what at that time was often referred to as “the ordeal of childbirth”, both mothers and babies might still have suffered permanent and debilitating harm.

Historically, a small number of very influential American obstetricians insisted that the only way to make childbearing reasonably safe in the United States was for the care provided during normal childbirth to become the exclusive domain of the new surgical specialty of obstetrics. It seems that no one thought to, or dared to ask the obvious and pertinent question “Why would a healthy discipline that provided care to a healthy population (approximately 77 to 85% of its patients) be a SURGICAL specialty?

As a result of this confusing and confounding definition of “obstetrics,” the management of hospitalized obstetrical patients perversely triggered the use of multiple medical inventions and invasive surgical procedures that heretofore were only used to treat very serious complications of childbearing.

Before the passage of the “Civil Rights Act of 1965″ and the subsequent desegregation of public facilities, the hospital’s nursing staff assigned to its “white-only” labor ward“ were required to wear a hospital-issued surgical gown, cap, mask, and shoe covers. This was because the L&D unit was considered to be “surgically sterile environment” as were all the other operating rooms and staff dressing rooms.

The happenstance of this hospital policy also meant that all labor patients had to labor in a sterile isolation unit that was part of the surgical department. This prevented any contact between the labor patient and her husband or family members during the many hours of labor (as long as 3 days), the surgical “delivery”, and standard post-anesthesia recovery period.

While the concept of “informed consent” was first legally recognized in the United States in 1914, many decades passed before hospitals in the southern parts of the United States grudgingly “allowed” some categories of patients — mainly adult males with a good regal representation — to have a say in how they were treated and be allowed to refuse medical care recommended by an MD.  However, lots of people still believed that “the doctor knows best“. 

When it comes to the reproductive “rights” of adult women, there still is an incredible number of people, especially highly opinionated men, who are constantly trying to control the reproductive decisions of women and even eliminate the legal ability of childbearing women to control their own bodies and it reproductive process.  

It didn’t actually  become a legal factor in medical care and hospital procedures the 1970s,

— that is, be uniformally implemented in The last but most pernicious vestig of resistance was in relation to reproductive care to women. 

each and very labor patient, whether she agreed or not,  was

@@@@@@@@@@@@@@@@@@@@ above not finished, below is change of topic

immediately injected with the Twilight Sleep drug scopolamine mixed with morphine. This powerful mixture of the amnesic-hallucinogenic drug scopolamine and narcotic morphine was repeated every 2 to 3 hours. The effect was the equivalent of a reversible chemical lobotomy.

As a result, all labor patients in the ward had to be repeatedly medicated with these drugs and confined to their beds at all times. The use of bedpans eliminated the need for them to get up to use the bathroom.  Some labor patients had a powerful paradoxical reaction to this powerful drug cocktail and became so agitated the tried to climb over the bed rails. To prevent these potential escape artists from falling out of bed and getting hurt or really escaping from the labor ward, the nurses used four-point restraints. These were very large leather wrist and ankle cuffs that we borrowed from the psychic unit and attached to their wrists and ankles. Then the straps were attached to each of the four corners of their bed.

When the baby was about to be born, these about-to-be new mothers were moved by stretcher to an obstetrical-equipped operating room. Then the mother was “put her to sleep” under a general anesthetic and the “delivery” conduct as a series of surgical procedures. This frequently started by the doctor using a pair of sterile scissors to cut an episiotomy (incision into the skin at the base of her vagina).

The obstetrical forceps were used to extract the baby from its mother’s unconscious body. After the handing the newborn over to the nurse, the woman’s obstetrician, or in teaching hospitals, an intern, resident, or medical student, would reach a gloved hand up into the unconscious mother’s vagina and into her uterus and detach the placenta from the uterine wall with his fingertips, and pull it out in his hand.

The surgical procedure of obstetrical delivery ended with suturing of the episiotomy incision.    [#1].Thankfully the profession of obstetrics has abandoned the majority of its dangerous and painful practices. But things are not as different in the 21st Century as most childbearing women of virtually all midwives had hoped. Many of the most outspoken obstetricians are openly hostile to the practice of midwifery and the choice by some families to give birth in an out-of-hospital setting.

A significant percentage of obstetricians continue to routinely and unnecessarily medicalize normal childbirth. Once hospitalized this includes having an IV drip started, often with the drug Pitocin added to “speed things up”.

routinely scheduling maternity patients with low-risk pregnancies be inducted before or on their baby’s due date., the labor patient is hooked up to nearly universal use of during normal labors in American hospitals. Over the last two decades the Cesarean rate for healthy low-risk women with a single baby in a head down position of 25%. A high level of intervention is the norm in more than 90% of births in the US [#2 Listening to Mothers surveys I, II, & III; ChildbirthConnection.org]

Hospital policy is to immediately hook the about-to-be new mother up to the continuous electronic fetal monitor (EFM) that sitting right next to her hospital bed. Except for using the bathroom, the majority of hospitalized patients find themselves lying in bed for almost all of their labor. Unfortunately the most unnatural and painful position for the laboring woman in lying in bed and staying relatively still. In fact, its so intolerable that most labor patients find asking for pain medication or epidural anesthesia.

All this is this is in stark contrast to the “right use of gravity”, in which laboring women are upright, moving about, unencumbered by IV lines and EFM cables as they walking around the room or stand in the shower.

Unfortunately, there is a direct correlation between the use of obstetrical interventions in the pregnancies and births of healthy women and a statistically significant increase in the Cesarean surgery rate. The particular intervention most associated with increased rate of surgical deliveries is the routine use of continuous electronic fetal monitoring (EFM) as a universal obstetrical standard that is disassociated from individual need or actual risk, and the elective induction of labor in healthy women with no medical indications or needs.

Likewise, there is a very direct and specific correlation between higher rates of Cesareans and our disproportionally higher rates of maternal morbidity and mortality. The United States has the very highest MMR of all wealthy countries.

Historically the problem is that American obstetricians took over the practice of midwifery (i.e. attending healthy women having normal births) in early 1900s without any understanding or respect for the principles, practices and technical skills of physiological management, such as the importance of upright positions, maternal mobility, non-drug ways to cope with labor pains, patience with Nature, the right use of gravity and not imposing arbitrary time limits when the mother and unborn baby are stable and healthy. For a variety of complicated historical, economic and political reasons, the obstetrical profession didn’t appreciate the greater safety and other benefits afforded by physiological methods [#1].

The profession also didn’t factor in the dangers introduced by medical interference and invasive surgical procedures, [#3 – complications of placenta extraction]. These interventions were particularly lethal before the availability of antibiotics. Until the 1940s, 40% of all maternal deaths were the result of sepsis – often called septicemia or “blood poisoning”. [#]

More than a hundred years have passed, and yet the obstetrical profession as a whole still doesn’t really understand or appreciate the normal biology of spontaneous childbirth in healthy women. As a result, it also doesn’t see why midwifery care, whether provided by a physician or a midwife, is the scientifically appropriate standard for the non-interventive support of normal labor and birth in a healthy population.

Instead, it continues to publicly proclaim that the routine use of obstetrical interventions makes childbirth safer for healthy childbearing women. This includes but is not limited to elective pre-term induction in healthy women with normal pregnancies, using continuous EFM on low-risk women and casual use of Cesarean surgery. Their assertion of greater safety is not upheld by scientific literature. Quite the opposite, as the US continues to have the highest maternal mortality rates (MMR) of any developed country, ranking 127th out of 183 countries in maternal deaths.

In addition, the US also has one of the highest Cesarean surgeries which is linked to higher rates of maternal mortality and very high rate of maternal morbidity. For each C-section performed in the US, 70 new mothers suffer from a serious, sometimes life-threatening complication of their childbirth. This can include an emergency hysterectomy within 14 days of a C-section. This is a 13-fold increase for this life-altering surgery compared to the rate for normal vaginal birth.

Despite these dismal statistics, the obstetrical community insists that normal childbirth is significantly safer when healthy women labor in highly medicalized obstetrical departments. However, the accuracy of this claim can be easily determined by publicly available statistics. If interventive obstetrics for healthy women was as safe as claimed by the obstetrical profession, those statistics for maternal mortality and morbidity in the US would be the lowest in the world and we would have bragging right to a remarkably cost-effective maternity care system. Obviously, that is not the case.

Instead, childbirth services is the US are two to three-fold more expensive than other developed countries, with an extremely poor return for our money. While we pride ourselves for being #1 in everything, ranking 128th in maternal mortality is nothing to be proud of.  While the cost of having a baby in the US is orders-of-magnitude greater than the rest of the developed world, and our mother and babies are not enjoying an orders-of-magnitude better outcome.

The safest place to have a baby is Belarus, followed by Poland, Norway, Italy, Israel, Finland, Czech Republic, Greece, Denmark and Iceland. None of these countries is remarkably wealthy or innovative; none have a world-famous healthcare system, and yet they have the best maternity care outcomes. A mother-to-be in America would be safer giving birth in Tajikistan, Russia, Iran, Bahrain, Kuwait, Kazakhstan, Bulgaria, Bosnia-Herzegovina, Estonia, Qatar, and Croatia than in the US.

Obstetrics can and should be a noble profession; in those places where it currently is not, it needs to open itself up to the kind of historical, statistical, and evidence-based information distilled in this series of essays (but widely available elsewhere) and make the appropriate “adjustments” and policy changes. As a wife, mother, former ER and L&D nurse and long-time professional midwife, I can say with certainty that more of what isn’t working won’t work either!

For the last 120 years the wrong use of obstetrics has promoted, systemized and institutionalized obstetrical intervention as the American standard of care for all childbearing women, including the 75% of childbearing women who are healthy and have normal pregnancies. Contemporary obstetrics in the US suffers from the twin evils of a scandalously high maternal mortality rate and sky-rocketing hospital bills for normal birth that have begun to rival those for an organ transplant (over $100,000).  All of this is a wrong use of obstetrics.

A paper published in the American Journal of Obstetrics & Gynecology, March, 2017 [#4] DOI: 10.1016/j.ajog.2016.12.033;] begins by saying:

Obstetrical care in the United States is unnecessarily costly.

Birth is one of the most common reasons for healthcare use in the United States and one of the top expenditures for payers every year.

When compared with other OECD countries, the US spends substantially more money per birth without better outcomes.

When these excessive, unproductive and pernicious costs for obstetrical services are traced back to their source, the single unifying factor the keeps this Gordian knot glued together and generating an annual expenditure of $1.600,000,000,000 (1.6 billion!) and that is the universal use of continuous electronic fetal monitoring on all hospitalized labor patients.

I could quote any one of a thousand studies of EFM on healthy low-risk patients published over the last 46 years. This body of scientific literature goes all the way back to the very first prospective clinical trial by Havenkamp et al published in 1976: “

“There were no differences in the infant outcomes in any measured category between the electronically monitored group and the auscultated group.

The cesarean section rate was markedly increased in the monitored group (16.5 vs. 6.8 per cent in the auscultated patients).

The presumptive benefits of electronic fetal monitoring for improving fetal outcome were not found in this study.”

All the other EFM vs. auscultation (i.e. listening with hand-held Doppler) studies say the same thing, that is, they just reiterate what the 1976 finding of Haverkamp et all.  A more contemporary obstetrician makes this crystal clear in April 2011 article in The Female Patient titled “Heart Rate Monitoring Update”.

  “Intrapartum fetal heart rate monitoring is the most common obstetric procedure performed in the United States” {1}:

“Despite the widespread use of EFM, there has been no decrease in cerebral palsy.

… a meta-analysis of randomized control trials has shown that EFM has no effect in perinatal mortality or pediatric neurologic morbidity. {2}

However, EFM is associated with an increase in the rate of operative vaginal and cesarean deliveries.” {??}

Electronic fetal monitoring technology is expensive to purchase and maintain, to update its operating systems every year or two and upgrade outdated technology. It is expensive in staff time and cyber storage of extensive EFM tracing, which sometimes are as long as 48 or more hours for just one pregnant patient, multiplied by thousands of patients year after year. Some years ago, a hospital in the SF Bay area was billing insurance companies and the federal Medicaid program $400 for each hour of a patient’s use of continuous EFM. The billing system as changed since then and I don’t know what the current charges are.

But the unproductive and really pernicious costs associated with the universal use of continuous EFM are triggered each time it produces a “non-reassuring” EFM tracing. This results in an immediate and dramatic increase in invasive procedures – putting the mother on oxygen, stopping her Pitocin IV and when those measure does not immediately correct the problem, cutting an episiotomy and doing a vacuum extraction or emergent Cesarean to “rescue” the baby.

The second most frequent reason cited for doing a C-section on a first-time mother is “Non-reassuring EFM tracing”. Mind you, this is not due to diagnosed “fetal distress”, just that the tracing was not “reassuring” to the obstetrical staff or the obstetrician. These emergency extraction of babies with less-than-perfect EFM tracings routinely come out with Apgar of 8, 9 or 10, which is to say, they never were in distress.

This is particularly an issue for hospitals with “central monitoring systems” in which doctors and nurses sit at a desk in the hall outside the labor rooms and watch a bank of fetal monitoring screens. They are, in essence, “monitoring the electronic monitors” by watching the real time display of EFM trancing for mothers in several different labor rooms at once. While it might seem that this high-tech surveillance would make things super safer for mothers and babies, it turns out to be just the opposite. The CS rate is even higher in hospitals that use central monitoring systems than individual bedside EFM monitoring.

Universal use of EFM on healthy women associated with dramatic increase in operative deliveries, Cesarean surgeries, and maternal morbidities and mortality

But the biggest direct and indirect costs associated with the use of EFM on healthy mothers is a dramatic increase in maternal morbidity and mortality associated operative deliveries, particularly Cesarean deliveries. Each of these invasive procedures has a host of immediate and delayed complications. While episiotomy is obviously not “major” surgery, that distinction is lost on mothers who had their perineum cut with a pair of scissors and then sutured. They will quickly tell you that episiotomy is an excruciatingly painful intervention that hurts every time they sit down.  The post-op pain lasts for weeks, and for a few unfortunate women, negatively affects their sex life ever afterwards.

Last but not least are the twin controversies of post-Cesarean pregnancies, the much higher surgical risks of an electively scheduled repeat Cesarean vs. the risks of a “VBAC” – Vaginal Birth After Cesarean — with its rare but real risk of uterine rupture.  Note that neither of these serious risks would exist if the mother-to-be hadn’t had the original C-section.

The most dangerous and expensive complications are those that accompany Cesarean surgery, whether it is a first C-section or repeat surgery. This includes intra-operative emergencies, blood transfusions, admission to the ICU and post-op complications that includes pain, infection, pulmonary embolisms, continued bleeding, and infection and sometimes death

 

[Note ~ Two recent online stories of a repeat CS in a young mom at Cedars Sini Hospital in LA who died in the recovery room of an undetected post-op hemorrhage; also the post-operative death of Kira Johnson ten hour after her obstetrician failed to adequately respond to a hemorrhage caused by his unintentional severing of an artery as he rushed to finish her Cesarean in 17-minutes] A repeat Cesarean generally takes 45 minutes to an hour.

Delayed and downstream complications of Cesarean surgery include a 6% post-Cesarean infertility rate and slightly increased rate (aprox. 1:1,000) of fetal demise in future pregnancies due to placental-related problems. However, the really disturbing, often heartbreaking and break-the-bank expensive issues come from potentially fatal complications in future pregnancies. This includes abnormal placental implantation issues such as placenta accreta and percreta. Unfortunately, the more Cesareans a woman has, the higher the likelihood and severity of abnormal placental implantation.

The ‘safest’ C-section is the first C-section; after that Cesarean is slightly more dangerous. This is the result of abdominal adhesions that form during the first 24 hour after every Cesarean, starting with the first and getting more pronounced with each additional surgery. Abdominal adhesions are created by small but persistent amounts of bleeding (oozing) from tiny blood vessels that were cut as a part of the surgery and continue to ooze even after the surgeon closes the incision.

This clotting blood slowly creates elastic bands of tissue that sort of glue abdominal organs together like a big cobweb. This greatly increase the surgical difficulty in all ‘repeat’ C-sections.  In these repeat C-sections, the surgeon has to dissect (i.e. surgically separate) the bands that between the mother’s uterus and her bladder, fallopian tubes, ovaries, and intestines. Obviously, this takes much longer than the first C-section. Also, sometimes the oozing blood from many places at once can reduce the ability of the mother’s blood to clot normally. This can result in very difficult to control intra-operative hemorrhage and sometimes become so acute that emergency hysterectomy is required during the surgery or the next 14 days.

Post-CS abnormal placenta implantation – accreta, increta, and percreta

For unexplained reasons, women who have had a previous Cesarean are at high risk for an abnormal or invasive growth of the placenta in a subsequent pregnancy. This connection between previous Cesarean surgery and abnormal placental implantation in subsequent pregnancies is an established fact, but no one knows why this happens, just that something inexplicable causes the placenta to grow too deeply into the uterus in this cohort of mothers.

The first kind of “adherent” placenta is called an “accreta”; it attached more deeply to the inside surface of uterus than is normal. This frequently causes excessive bleeding but usually can be resolved without surgical intervention. A placenta increta grows into the uterine muscle that forms the walls of the uterus and requires surgical separation; this frequently causes an intraoperative hemorrhage and need for blood transfusions. A placenta percreta is the most pervasive of the three, as it grows completely through the wall of the uterus and attaches itself to the adjacent abdominal organs, usually the bladder or intestines.

The only ‘treatment’ for the most invasive types of placental abnormality – the kind that grow deeply into the uterine muscle or through the uterine wall to other organs — is a Cesarean hysterectomy. In addition to ending the woman’s reproductive life, surgery for placenta percerta requires many pints of transfused blood and routine admission to the ICU for immediate post-operative care. If complications are present or develop, the new mother may be in the ICU for several weeks.

Caption: A specially built and equipped operating room for performing Cesarean-hysterectomies for mothers with placenta percreta. It includes high-tech interventionalist radiology equipment as well as 14 specially train hospital staff and no doubt costs as much as a kidney transplant.

But in spite of being in one the very best hospitals in America, with an experienced OR staff, two obstetrical surgeons and a bevy of highly competent specialists (usually a hematologist and/or urological surgeon), this post-Cesarean complication is fatal for 7% to 10% of these new mothers. Citation ~ Personal attendance at a Society of Maternal-Fetal Medicine conference; session on placenta percreta by Dr. Richard Por(?? Unsure spelling) 2000

The way to prevent all these expensive tragedies is prevent unnecessary Cesarean surgeries. The biggest contributor to unnecessary Cesareans is the universal use of continuous electronic fetal monitoring (EFM) as the obstetrical standard of care for all laboring women including the 70-to 80% of women who are healthy and low rick. EFM adds the unnecessary risk of iatrogenic

Intermittent Auscultation (aus-cul-ta-tion) vs. Continuous EFM

The way to prevent unnecessary Cesarean surgeries and their cascade of complications is the “right use continuous EFM”. Electronic fetal monitoring was developed to monitor the unborn babies of pregnant women with serious medical complications, high risk pregnancies and obstetrical emergencies that might be harmful for the fetus. While the right use of EFM is to be supported, its “wrong use” of EFM in the labors of healthy women with normal pregnancies is to be prevented and considered an unnecessary and unsafe procedure, such as giving antibiotics or blood transfusions to patients who don’t have infectious disease or recent blood loss.

Not using EFM doesn’t mean that no one is monitoring the unborn baby during labor. It just changes “monitor” from a noun that refers to an electronic machine to an active verb – something being done in real time by a live person, in this case, a nurse or midwife! “Fetal monitoring” as a verb describes the use of a much more traditional but equally effective and safer method for tracking the wellbeing of unborn babies during active labor without tethering the mother to her hospital bed and without increasing the Cesarean rate, and associated increase in maternal deaths from it’s immediate, delayed and downstream complications.

It’s known as “intermittent auscultation (or IA) and had been used throughout the 20th century. This describes using a hand-held ultrasound Doppler or acoustical fetoscope to listen to the unborn baby’s heart rate and rhythm for one minute or longer on a regular schedule, depending on the phase and stage of labor — more frequently as the labor gets more active, the contractions get longer and closer together and the mother’s enters the 2nd or “pushing” stage of labor.

However, IA has been dramatically improved in the last couple of decades, helped along by easy access to affordable hand-held Dopplers and development of a more comprehensive method. The upgraded protocols of comprehensive intermittent auscultation (CIA) assess and record the same four critical markers of fetal wellbeing that are monitored and recorded by EFM. This criterion includes a:

  • normal baseline (bpm) of 110 to 150
  • moderate heart rate variability
  • presence of normal accelerations
  • absence of pathological decelerations

This is accomplished by counting the fetal heart rate (FHR) in 5-second increments over the course of a full minute or more, using clock with sweep second hand or a quartz time piece that stops briefly after each “tick” (which is easiest). Data collected from twelve or more 5-second samples as noted in the four criteria of fetal wellness listed above is charted and assessed for the presence or absence of “reassuring characteristics”, with interventions initiated if needed.

 Link to information about modernized auscultation 

A consensus of the scientific literature for nearly half a century has concluded that auscultation is the better, safer and more cost-effective method for intrapartum fetal monitoring. Auscultation provides an equally good outcome for newborn babies and substantially better and safer outcomes for mothers. The reason is obvious — CIA dramatically reduces number of risky and expensive Cesareans and even more expensive, even more risky, and sometimes even fatal post-Cesarean complications as identified and described earlier.

Keep in mind that hundreds of scientific researchers over the last 4 -plus decades, in addition to many individual obstetricians, have consistently and repeated concluded that the routine use of EFM on healthy women with low-risk pregnancies provide no benefit to either mother or baby. Nonetheless the use of EFM continues to be associated with a statistically significant increase in the number of medically unnecessary Cesarean surgeries and its many dangerous consequences and yet continues to be used universally in the obstetrical department of every hospital.

This obvious disconnect between documented scientific facts and a biased reaction to them is best described as a preference for “alternative facts”. This reminds me of Congressional hearing on the dangers of tobacco use held in the US Congress in the 1990s. When asked if they thought cigarettes smoking represented any kind health hazard to smokers, each of dozen tobacco company executive stood up one by one and said, under oath, “NO”. Like the scientific facts that established beyond question the dangers of smoking cigarettes, and the dangers of EFM are also a matter of easily-accessed public records.  For example:

“Intrapartum fetal heart rate monitoring is the most common obstetric procedure performed in the United States” {1}:

… widespread use of EFM, there has been no decrease in cerebral palsy. … a meta-analysis of randomized control trials has shown that EFM has no effect in perinatal mortality or pediatric neurologic morbidity.2

However, EFM is associated with an increase in the rate of operative vaginal and cesarean deliveries.1” [Female Patient, 2011]

 

As for the money issue, this same article (The Female Patient, Heart Rate Monitoring Update, April 2011) gives a so-called “reason” for not using AI despite it far better safety record:

 

Although intermittent fetal auscultation {IA} may be a theoretical option in low-risk patients, nursing staffing limitations make this impractical … ”

Let me “unpack” this statement starting with that last word “impractical”, which is actually referring to a money problem for hospitals. They just don’t want to hire more nurses or nurse-midwives at $40-to-$80 an hour to provide one-on-one bedside monitoring with a hand-held Doppler. It’s as simple as that. The increased cost associated with the use of auscultation has no economic “silver lining” as it costs more but without generating in any more revenue.

However, having nurses sit in front of bank of monitor screens watching the real time EFM tracing for several labor rooms at once takes many less people. In addition, the higher rate of Cesarean in hospitals with centralized systems turns out to be good for obstetrical surgeons and good for the hospital business. Not only dose Cesareans surgery generate larger much reimbursements from insurers and the federal government, as well as longer hospital stays, but it almost guarantees return business as previous CS patients need a repeat Cesarean. While it is abhorrent to contemplate, doctors and hospitals benefit economically from the very expensive surgeries associated with placenta percreta and other life-threatening post-cesarean complications.

To do more of what isn’t working – i.e. more of the wrong use of obstetrics — is not a workable plan for more affordable healthcare system in the US or a better future for healthy childbearing women.

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URL for info on auscultation: http://faithgibson.org/ia-addendum-to-false-association-routine-efm-prevention-cp_march2019/

EFM reference #4 ~ Fetal Monitoring: Creating a Culture of Safety with Informed Choice;
Lisa Heelan, MSN, FNP-BC* doi: 10.1891/1058-1243.22.3.156 PMCID: PMC4010242 PMID:

J Perinat Educ. 2013 Summer; 22(3): 156–165. 24868127 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4010242/

@@@ Negative Assessment of obstetrical intervention by doctors compared to midwifery care provided by midwives  @@@

~ “We have had a small but convincing demonstration by the Frontier Nursing Service of Kentucky of what the well-trained midwife can do in America. …. The midwives travel from case to case on horseback through the isolated mountainous regions of the State. There is a hospital at a central point, with a well-trained obstetrician in charge, and the very complicated cases are transferred to it for delivery”. [1937-A]^136

~ “In their first report they stated that they have delivered over 1000 women with only two deaths — one from heart disease, the other from kidney disease. During 1931 there were 400 deliveries with no deaths. Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company, after analyzing the work of the Frontier Nurses’ midwifery service in rural Kentucky, made the following statement on May 9, 1932:

~ “The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe. If such service were available to the women of the country generally, there would be a savings of 10,000 mothers’ lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life.”

~ “What are the advantages of such a system? It makes it economically possible for each women to obtain expert delivery care, because expert midwife is less expensive than an expert obstetrician. Midwives have small practices and time to wait; they are expected to wait; this what they are paid for and there they are in no hurry to terminate labor by ill-advised operative haste.” [1937-A] {*}

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MOVE to ???  Now is the time to say good-bye to Dr. J. Whitridge Williams’ 1914 “Plan” for electively hospitalizing, drugging and massively intervening in the labors and births of healthy, wealthy childbearing women as “paying customers” and start a new “2021 Plan”.

This is a real problem that calls for a real solution!

 

Political aside for California LM readers:  Instead of the obstetrical profession fixing this problem, the attention of CMA and ACOG and considerable money is being spent on blocking any legislation that would authorize an independent midwifery board.

 

But the real story here is the wrong use of obstetrics. That is the story we need to get published widely in many different venues — online, Facebook, ProPublica, Mfry Today, Sac Bee, SF Chron, LA Times, New Yorker, other newspapers and venues. A change in the power dynamics will require a dramatically different strategy, one in which mothers and midwives put obstetrics on the defensive and ultimate, on the run so they have to defend themselves, rather than just insisting to the public and MBC that midwives are “baby killers” and use their money and overwhelming political influence to block legislation that would incorporate midwifery care into the mainstream healthcare system.

 

Childbearing women must have positive view of obstetrical care so they will be willing to receive obstetrical care or hospitalization when necessary. But unfortunately, the truth (which I would never say in public) is that the wrong use of obstetrics is killing American mothers, and this has been the ‘norm’ since the early 1900s. One credible expert puts the historical death toll at a combined cost of 70,000 mothers and babies annually from 1900 to 1945 (when the antibiotic penicillin first became available). {see reference for Dr. Louis Dublin, President of the American Public Health Association and the Third Vice-president and Statistician of the Metropolitan Life Insurance Company at the end of this document}

 

Nonetheless midwives are professionally obligated to refrain from saying anything that would discourage or deter a childbearing woman who had an obstetrical complication from seeking out the necessary and timely obstetrical care.

 

The public discourse about normal childbirth in the US has to be “corrected”, that is, reversed from

 

  • an inherently anti-midwifery/pro-obstetrics to  anti-wrong use of obstetrics

 

  • to promoting the:

    Right Use of Obstetrics The Art and Science of Physiologically-based Childbirth Practices Independent Midwifery Profession as a normal part of the maternity care system

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