Archives for category: Labor

Rinat Dray was forced to have a cesarean in 2011 at Staten Island University Hospital.  Dray had two previous cesareans and chose a doctor who said he supported her desire for a VBAC and a hospital with (by American standards) a low cesarean rate and a good VBAC rate.  But once she arrived at the hospital in labor, according to Dray (as reported by the New York Times),

The doctor told her the baby would be in peril and her uterus would rupture if she did not [have a cesarean]; he told her that she would be committing the equivalent of child abuse and that her baby would be taken away from her.

She still refused the cesarean, and she was supported in her refusal by her husband and her mother.  The hospital strapped her down and wheeled her into surgery as she begged them to stop.  A note in her medical record by Dr. James Ducey says, “I have decided to override her refusal to have a C-section.”  During the surgery, the doctor punctured her bladder.  You can hear a podcast on RH Reality Check in which Dray discusses her case along with professionals in obstetrics, law, and ethics.

Dray is a Hasidic Jew, which likely means that she wants a large family.  While there are risks to vaginal birth after cesarean, in most cases there are even greater risks to having many cesareans.

In the podcast, Dr. Katharine Morrison, MD, FACOG (Director of Buffalo WomenServices, which I wrote about here) says that she reviewed the record and it did not appear that there was an emergency situation or that a cesarean was needed at all.  But even if a cesarean has appeared necessary to preserve the life or health of Dray or her baby, as Dr. Howard Minkoff, chairman of obstetrics at Maimonides Medical Center in Brooklyn, said in the NYT article, “I don’t have a right to put a knife in your belly ever.”

One would think that a case in which a psychologically stable woman refused surgery and was then strapped down, sliced open, and had her bladder perforated would be apparent to anyone as a horrendous breach of human rights.  (And actually, she was asking them to wait a little longer, not saying she would not agree if she felt a cesarean was truly necessary).

All one has to do to see where a woman falls in the human rights spectrum of many is to read the comments on the New York Times piece.

The comments fall into a number of categories, including some that unequivocally support Dray.

Many, however, unequivocally support the the doctors or the profession of obstetrics.  Here is Northstar5:

If this woman had 2 prior C-sections then the doctors are absolutely right that vaginal delivery was exceedingly risky. I almost laughed when I read that the woman is charging the doctors and hospital for “improperly substituting their judgment for that of the mother.” What?? That’s what they are supposed to do. They are doctors, she is not.

Some defend the doctors doing whatever they like to avoid risks of malpractice:

Attempting a vaginal birth after two c-sections is extremely dangerous and reckless. The physicians involved would likely have been sued regardless of the method of delivery, so I applaud them for at least saving a life in this case.

I’m not sure where the commenters get their medical information, but the doctor agreed in advance to attend Dray at a vaginal birth.  You can read the entire American College of Obstetricans and Gynecologists’ practice statement “Vaginal Birth After Previous Cesarean Delivery,” which specifically says, “women with two previous low transverse cesarean deliveries may be candidates for TOLAC [trial of labor after cesarean].”  I highly recommend that you visit Jennifer Kamel’s website VBACFacts.com and read “13 Myths about VBAC.”  Repeat cesarean and VBAC both have risks.  The newest ACOG obstetric care consensus statement on cesarean points out the risks of cesarean over vaginal birth.  Cesarean nearly quadruples the risk of maternal death, and risks of maternal morbidity and mortality go up with every cesarean.  This would be a particular concern for a woman who wanted a very large family, as many Hasidic women do.  Here is a consent form that clearly lays out the risks and benefits of repeat cesarean and VBAC.

Some commenters are completely on the side of the fetus–if the mother’s status is reduced to that of a container, so be it.  Here’s NYC Commuter:

In this case, the hospital and doctors have not one patient, but two. One is an adult who appears competent to make medical decisions. The other is a fetus, at term, who has no voice. The courts have repeatedly affirmed that the state has a duty to protect citizens that cannot protect themselves. If a fetus is believed to be “alive,” then an argument can be made that it must be protected as well. Pregnant women have been forced to receive imprisoned to prevent them from harming their fetuses (e.g. drug abusers), take medication (e.g. for treatable diseases), and even receive c-sections if the baby’s life is judged to be in direct jeopardy.

I have written about the ethics of privileging the well-being of a fetus over an adult woman many times, including here, here, and here.  ACOG also agrees that a woman should have the right to make her own decisions, even if it may negatively impact the fetus.  One recommendation from ACOG’s Committee Opinion, “Maternal Decision Making, Ethics, and the Law” says,

Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy.

In addition to wanting to protect the rights of physicians and fetuses over those of pregnant women, many commenters simply condemn Dray as selfish, selfish, selfish.  Here’s Beth Green:

What an incredibly selfish woman putting her unborn child in harms way. She got her several hours of trial-labor and no baby, so according to the standard of care she got a C-section and a healthy baby.

Some also posit that Dray is not only selfish but also psychologically compromised.  Here’s Dave:

This case is not about the “debate over C-sections.” This case is mostly about psychopathology, but there is a larger point. Rinat Dray’s actions harm us all. In her narcissism, she was willing to sacrifice her child to maintain her sense of control. This bears repeating – we are dealing with someone who would rather her child suffer than allow a section. So I’m sure she cannot put herself in the place of others, and she will not understand this, but she makes it all the more difficult to deliver babies in the US. Once all the OB/GYNs suffer these indignities and these lawsuits from those with personality disorders, who will deliver babies safely?

And here’s Reader:

A mother in labor who focuses more on her joy of delivery rather than trying to ensure that she delivers a healthy child who could be stuck with birth defects for up to an average of 7-8 decades thereafter is not rational, is selfish and needs to have her head examined.

What we get above all else if the “all that matters is a healthy baby” trope.  Here is NMY:

I have absolutely no sympathy for this woman at all. Her sense of entitlement is simply galling. She’s having a baby. The most important thing here is to ensure the delivery of a healthy baby, not to satisfy some preconceived notion that she should have a vaginal delivery.

Here’s Jen:

The OBGYNs can’t win. Now they are going to get sued for performing c-sections. It used to be they got sued for not doing the section soon enough. This lawsuit is absolutely ridiculous and I hope the physicians win. Do you want a c-section and a healthy baby or a VBAC and a dead baby? How can any mother refuse a c-section when the physician is telling you the health of your baby is at risk?

Here’s Stephen:

Sorry, but the health of the fetus should trump the intellectual desires of the mother….There are too many C-sections performed to be sure, but isn’t the point of labor and birth to deliver a healthy baby?

Here’s Lynn in DC:

She had this child in 2011 and all of her children are healthy so what’s the big harm here?

Aside from the fallacy of believing that Ms. Dray could not have both a respectful vaginal birth AND a healthy baby, a healthy baby is not all that matters.  A healthy mother matters too.  As in Ms. Dray’s case, having a perforated bladder and the trauma of being strapped down for a surgery that she actively refused did not result in a healthy mother.  Not being dead is not good enough.

 

 

 

Image The cesarean rate is Brazil has been high for a long time, and it is getting higher.  In private hospitals, almost all women deliver by cesarean; in public hospitals it’s about half.  According to Ricki Lake, who went to Brazil in the process of filming The Business of Being Born, “There was actually a joke circulating that the only way to have a natural birth in Rio was if your doctor got stuck in traffic.”  Brazil’s childbirth practices have come to attention recently because of Adelir Carmen Lemos de Góes, who on April 1, 2014, was taken by police to have a forced cesarean under court order.  Here’s an account of what happened from The Guardian:

…Brazilian mother Adelir Carmen Lemos de Góes was preparing for her third birth. Despite living in a country with one of the highest caesarean rates in the world (82% for those with private insurance and 50% for those without), she was looking forward to giving birth vaginally after previously having caesareans she felt were unnecessary.  However, in the midst of her labour, six armed police banged on her front door. Despite there being no question of reduced mental capacity, doctors had obtained a court order allowing them to perform a caesarean…Adelir was taken from her home, forcibly anaesthetised and operated on without consent.

Attorney Jill Filopovic writes,

A Brazilian court granted a prosecutor’s request for the appointment of a special guardian. And just in case it was unclear whose life gets prioritized when a woman has a c-section against her will, the judge specified that when there is a ‘conflict of interests of the mother with the child’s life … the interests of the child predominate over hers.’

Filopovic quotes Dr. Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo: 

In our culture, childbirth is something that is primitive, ugly, nasty, inconvenient….It’s part of Catholic culture that this experience of childbirth should come with humiliation.

The Atlantic subsequently ran a longer piece by Olga Khazan, “Why Most Brazilian Women Get C-Sections,” which, also points to a confluence of attitudes, practices, policies, and norms that lead to a trend toward universal cesarean.  Humiliation isn’t hard to come by in Brazilian obstetrics.  Khazan reports,

Many physicians’ attitudes toward childbirth weave together Brazil’s macho culture with traditional sexual mores….When women are in labor, some doctors say, ‘When you were doing it, you didn’t complain, but now that you’re here, you cry.’

Mariana Bahia, who participated in protests against forced cesarean, noted:

There’s no horizontality between patients and doctors.  Doctors are always above us.

And Paula Viana, head of a women’s rights organization, said,

We have a really serious problem in Brazil that the doctors over-cite evidence [of fetal distress].  They think they can interfere as they would like.

But much of what these various articles says about childbirth in Brazil is eerily similar to what happens in the United States.  Khazan quotes Maria do Carmo Leal, a researcher at the National Public Health School at the Oswaldo Cruz Foundation about birth practices in Brazil:

Here, when a woman is going to give birth, even natural birth, the first thing many hospitals do is tie her to the bed by putting an IV in her arm, so she can’t walk, can’t take a bath, can’t hug her husband. The use of drugs to accelerate contractions is very common, as are episiotomies.  What you get is a lot of pain, and a horror of childbirth. This makes a cesarean a dream for many women.

In the United States, Pitocin induction and augmentation are ubiquitous , and episiotomies, though less common than in Brazil, are still greatly overused.  Almost all U.S. hospitals use IV hydration as a matter of policy (rather than allowing women to eat and drink as they please, which is the evidence based recommendation).  And in the U.S., taking a bath in labor may be impossible, as many hospitals do not provide bathtubs out of a misguided fear of women attempting waterbirths. The website My OB Said What documents a seemingly endless stream of U.S. health professionals’ humiliating comments, such as referring to a pregnant women as a “little girls,” criticizing their weight, or belittling their pain.

Court ordered cesareans occur in the United States as well, as Erin Davenport documents in “Court Ordered Cesarean Sections: Why Courts Should Not Be Allowed to Use a Balancing Test.”  Davenport notes that forced cesareans are generally ordered because of concerns for fetal welfare–as in Brazil, U.S. courts often privilege the rights of the fetus over those of the pregnant woman.

Alissa Scheller created infographics on Huffington Post showing how states’ policies are used to persecute and prosecute pregnant in the name of fetal welfare.

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National Advocates for Pregnant Women, whose research supplied much of the information for the above graphic, documents the legal control of pregnant women that occurs in the name of fetal rights, such as prosecuting a woman for murder after a suicide attempt while pregnant (in this case, the baby–born by cesarean–was alive, but died a few days later).

While the cesarean rate in the United States is much lower than in Brazil, a third of U.S. births are by cesarean, more than double the “threshold not to be exceeded” identified by the World Health Organization.  Khazan notes the parallels between Brazil’s medical system and the the system in the U.S.–both incentivize cesareans:

With the higher price of the private system [in Brazil] comes better amenities and shorter wait times, but also all of the trappings of fee-for-service medical care. C-sections can be easily scheduled and quickly executed, so doctors schedule and bill as many as eight procedures a day rather than wait around for one or two natural births to wrap up.

As in Brazil, though some cesareans performed in the U.S. are certainly in the interest of maternal and/or fetal well-being, many are in the interest of the obstetrician’s well-being.  There is still a convenience factor; in addition, OB-GYN Dr. Peter Doelger said doctors and hospitals are protecting themselves by following protocols based a fear of litigation:

So you’re stuck with this situation where we’re doing things, not based on science.  [The increase in C-sections is] really based on protecting the institution and ourselves. And, you can’t blame them. Getting sued is a horrible thing for the physician, a horrible thing for the nurse, and a horrible thing for the institution.

And the woman?  Well as long as the baby is healthy, does she matter?

New recommendations from both the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) seem revolutionary.  Their new joint consensus statement advises abandoning the time restrictions on labor established by misguided adherence to Friedman’s Curve.  Here are some of the new recommendations, which are designed to lower the primary cesarean rate:

  • Allowing prolonged latent (early) phase labor.
  • Considering cervical dilation of 6 cm (instead of 4 cm) as the start of active phase labor.
  • Allowing more time for labor to progress in the active phase.
  • Allowing women to push for at least two hours if they have delivered before, three hours if it’s their first delivery, and even longer in some situations, for example, with an epidural.
  • Using techniques to assist with vaginal delivery, which is the preferred method when possible. This may include the use of forceps, for example.

Aside from being written as if an epidural is unusual (60%-80% of first time mothers have epidurals), these guidelines have amazing potential to lower the rate of cesareans by justifying longer time for women to labor and reducing obstetricians’ justifications for their “failure to wait.”

The question remains, however, whether these new guidelines really will change practice in any meaningful way.  Even the joint consensus statement from ACOG and SMFM says,

Changing the local culture and attitudes of obstetric care providers regarding the issues involved in cesarean delivery reduction also will be challenging.

They go on to note that systemic change (meaning things like changes in required hospital protocols) is likely to be essential for significant practice change to occur, and they also argue for tort reform (discussed below).

People often say that obstetricians perform cesareans because the reimbursement is higher, and there are studies that indicate that this is true.  Doctors, however, are not always paid more for cesareans, and when they are, the difference is often only a few hundred dollars–not chump change, but probably not the major motivator for those in one of the most highly paid medical specialties.  The increase in birth costs for cesareans is primarily for the hospital resources: the operating room, post-operative care, and a longer hospital stay for the woman and her baby.  Contrary to what some studies have found, according to a conversation I had with Alabama Medicaid officials, when Alabama changed its Medicaid reimbursement a few years ago to be the same for cesareans and vaginal births, officials were disappointed to find it did not reduce the cesarean rate.  Here is a graph based on CDC data from Jill Arnold’s CesareanRates.com:

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So what does drive high cesarean rates if it’s not all about the financial greed of physicians looking to make a couple hundred bucks through slice and dice obstetrics?

Some cite malpractice suits as a major motivator.  While malpractice premiums do appear to impact c-section rates, the effect is relatively small.  Rather than actual malpractice suits, according to Theresa Morris’ Cut it Out, it is  fear of them that drives OBs toward cesareans.  According to Childbirth Connection’s comprehensive report, Maternity Care and Libility, ACOG’s 2009 survey of OB practitioners reported that liability fears had led 29% of respondents to increase their use of cesarean and 26% to stop performing VBACs. Here’s another graph from Jill:

lawsuit csec

In his excellent New Yorker article on “how childbirth went industrial,” Atul Gawande points to the predictability and reliability of cesarean over vaginal birth, which makes doctors likely to choose cesarean over less invasive procedures (such as forceps deliveries) that may be risky in the hands of those without enough training, experience, or practice:

Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills….if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques….[O]bstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section….We have reached the point that, when there’s any question of delivery risk, the Cesarean is what clinicians turn to—it’s simply the most reliable option….Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth.

Yet c-sections also pose real risks, as this table from the joint consensus statement indicates:

Table 1. Risk of Adverse Maternal and Neonatal Outcomes by Mode of Delivery
Outcome Risk
Maternal Vaginal Delivery Cesarean Delivery
Overall severe morbidity and mortality*† 8.6% 9.2%*
0.9% 2.7%†
Maternal mortality‡ 3.6:100,000 13.3:100,000
Amniotic fluid embolism§ 3.3–7.7:100,000 15.8:100,000
Third-degree or fourth-degree perineal laceration|| 1.0–3.0% NA (scheduled delivery)
Placental abnormalities¶ Increased with prior cesarean delivery versus vaginal delivery, and risk continues to increase with each subsequent cesarean delivery.
Urinary incontinence# No difference between cesarean delivery and vaginal delivery at 2 years.
Postpartum depression|| No difference between cesarean delivery and vaginal delivery.
Neonatal Vaginal Delivery Cesarean Delivery
Laceration** NA 1.0–2.0%
Respiratory morbidity** < 1.0% 1.0–4.0% (without labor)
Shoulder dystocia 1.0–2.0% 0%
Abbreviations: CI, confidence interval; NA, not available; NICU, neonatal intensive care unit; OR, odds ratio; RR, relative risk.

(Note that cesarean’s near-quadrupling of maternal death risk is not causing a call to ban non-medically essential cesarean).

Another factor in physician preference for cesarean–one that is closely tied with money–is time.  As one prominent obstetrician once told me, the money itself isn’t the issue–what’s a couple hundred dollars to someone whose salary is well into six figures?  It’s time.  A cesarean takes 40 minutes.  A vaginal birth can drag on for hours and hours, and the timing is completely unpredictable.

This report on Maternity Care Payment Reform from the National Governors Association explains that the optimum timing possible with cesarean is personally convenient as well as financially lucrative–but not because of the payment for the cesarean itself:

[P]lanned cesarean deliveries have lower opportunity costs for obstetricians and facilities. For facilities, spontaneous vaginal deliveries may be more difficult to plan and manage compared to scheduled cesarean deliveries. With a planned cesarean delivery, hospitals can schedule operating room time and ideal hours for nursing staff. For providers, scheduling a cesarean birth ensures that they will be the ones to perform the delivery and they will not have to transfer care and associated payment to a colleague or be delayed from office or other hospital duties.11 In addition to securing reimbursement, having scheduled births allows providers more time to schedule billable procedures.

Even in vaginal births, the emphasis many obstetricians put on time is obvious.  Elective inductions allow for births to be scheduled at the physician’s convenience (and while this may sometimes be convenient for the pregnant woman also, you can bet that she does not get to pick a time that would be inconvenient for her doctor).  ACOG guidelines on labor induction and augmentation discuss the reduction in labor time that can occur with Pitocin administration in positive terms (without any indication that this is preferred by laboring women).

In my tours of hospital labor units, it has not been uncommon for every laboring woman on the board to have a Pitocin drip to “help them along.”  A friend of mine–one who was amenable to a highly medicalized birth and had an epidural in place–said her obstetrician walked into the room when she had dilated to 10 centimeters and said, “Okay, you have two hours to push this baby out and then I’m going to have to do a cesarean.”  This did not even meet old time guidelines, which indicated a three hour pushing time for first time mothers who had an epidural.

The website My OB Said What? is full of anecdotes about practitioners who value their own time over the normal progression of  labor.  A few examples:

Some doctors also feel a therapeutic mandate to “do something,” which is often counterproductive in a normal labor.  Obstetrician and ethicist Paul Burcher notes that a “therapeutic imperative” is essentially another term for “the inertia that prevents physicians from abandoning ineffective therapies because no better alternative yet exists.”  Burcher is writing about bed rest, but as with threatened miscarriage, the current “better alternative” in a normal labor is to do nothing at all.  As Dr. Burcher says,

It takes courage to do nothing, but when we have nothing of benefit to offer we must refrain from deluding ourselves and harming our patients.

Here’s hoping that ethics will trump time and money and lead to genuine change in practice.  But given the historic difficulties obstetricians have with implementing evidence based practice and the slow obstetric response to reducing (rather than increasing) intervention, given the average time it takes to put an innovation into routine practice, we may have at least 17 years to wait.

The Choosing Wisely campaign was begun in order to reduce unnecessary use of medicine and medical procedures.  Non-medically indicated use is unsafe for patients as well as being expensive.  Not only are there costs involved in the medicine or procedure itself, but there are also costs in treating side effects and other health consequences.

The American College of Obstetricians and Gynecologists (ACOG) has a list they made for the Choosing Wisely campaign, “Five Things Physicians and Patients Should Question.”  The top two items on the list are about elective induction of labor (these two items also made the American Academy of Family Physicians list).  The first warns against scheduling a delivery (cesarean or induction) before 39 weeks unless there is a clear medical indication.  Here is the text of the second:

Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable:  Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

This is similar to the information I provided in my posts on Pitocin and elective inductions.  Before 41 weeks, unless there is a clear medical indication, labor should begin on its own.  Note the caveat that if an elective induction is to occur, the cervix should be “favorable.”  A laywoman might ask what this means.  A favorable cervix is soft, effaced and dilated.  But really the standard that physicians use for determining whether a woman’s body is ready to labor is the Bishop score.

In 1955, Dr. Edward Bishop published a paper (subscription needed to get text) on elective induction of labor in which he looked at the likelihood of induction success based on several factors: fetal position, cervical softness, cervical effacement, cervical dilation, and the “station” of the fetus (how far it was engaged in the woman’s pelvis).  We might question the ethics of inducing labor without medical indication, but Dr. Bishop did find that if the baby was anterior and the cervix was soft,  higher levels of effacement, dilation and engagement made elective inductions likely to work and labors were more likely to be shorter.  This chart from Preparing for Birth sums it up:

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Bishop’s scoring system is still used and has some accuracy at predicting the likelihood of an induction’s success.  Some doctors use a simplified score that just looks at effacement, dilation, and station.

Here are some graphs from Intermountain Healthcare’s care process model on elective induction:

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You can see that higher Bishop scores lead to higher likelihood of a successful induction, and that the higher the score, the shorter the labor.

Nulliparous women (first time mothers) are especially likely to have cesareans when they have lower Bishop scores.  It is important to note, however, that even with a favorable Bishop score, nulliparous women are much more likely to have a cesarean than they would be if labor began on its own, and they are more likely to have operative deliveries (forceps or vacuum).

Dr. Gene Declercq of Boston University and colleagues run a wonderful site call Birth by the Numbers and produced this chart with data from Listening to Mothers III:

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This data does not imply that an induction cannot be successful, that no one should have an epidural, or that a cesarean might not be necessary for reasons having nothing to do with inductions or epidurals.  But the data do give credence to the idea of choosing wisely.  Taking Pitocin to start labor in an uncomplicated pregnancy before 41 weeks is akin to taking high blood pressure medicine when your blood pressure is normal (credit Debra Bingham).  The Bishop score may help to determine if the medicine will not hurt you, but why take it in the first place?  If you do want to go the induction route, however, your Bishop score is a tool to let you know how likely an elective induction is to lead to unnecessary major surgery.

All inductions should be done with full informed consent and should not be scheduled around a care provider’s office hours, vacation time, or child’s birthday party.  The well being of the pregnant woman and her fetus and the woman’s informed choice should be the only considerations.  A woman is a human being and not a vessel to be manipulated for the convenience of others.

When something goes wrong, we often seek someone to blame.  Sometime the culprit is obvious, as when someone hits you or rams into your car or knocks over your vase.  When things go wrong in a pregnancy, it can be harder to tell what happened.  But having someone to blame is comforting.  Assigning blame allows us to believe that avoiding the blameworthy person’s mistakes will spare us a similarly bad outcome.

Blaming Mothers

People are quick to blame women for any bad pregnancy outcome–miscarriage, preterm birth, still birth, baby with disabilities, baby with genetic disorders, low birthweight baby and on and on and on.  Any choice a pregnant or birthing mother makes, it seems, can be used against her.  A New York Times piece points out that

much of the language surrounding advice to pregnant women as well as warnings is “magical thinking” that suggests that women who do everything right will have healthy babies — and therefore, women who have babies with birth defects failed to do everything right.

Women are blamed for not following a doctor’s orders, even if those orders have no basis in evidence, such as bed rest to prevent preterm birth.

Women may be blamed for not following folk wisdom: some people strongly believe that a pregnant will miscarry if she lifts anything heavier than a frying pan or that her fetus will strangle on its umbilical cord if she raises her arms over her head.

Women may be blamed if they do follow a doctor’s orders if a bad outcome occurs.  Virginia Rutter notes the following case from Paltrow and Flavin’s 2013 article on the criminalization of pregnant women:

A Louisiana woman was charged with murder and spent approximately a year in jail before her counsel was able to show that what was deemed a murder of a fetus or newborn was actually a miscarriage that resulted from medication given to her by a health care provider.

Women may be blamed for choosing a provider or place of birth someone else feels is inadequate.  One mother who planned to birth at home with a registered midwife wrote,

If something does go wrong, with the birth, or otherwise, [my mother] is going to blame me forever, for my “selfishness.” If the baby grows up to have a learning disability or something (for whatever reason), my Mom [who had cesareans] is going to say that it’s all my fault for having a natural birth, that I damaged the baby’s brain.

In fact, blame may be heaped on women for things that others believe have the potential to cause poor pregnancy outcomes, even if the actual outcomes are just fine.  For instance, women are often pilloried for having so much as a sip of wine during pregnancy, even though the evidence of harm in to the human fetus from low to moderate alcohol use is nearly nonexistent.

Women may even be blamed for things that they no longer do, as was the case with Alicia Beltran, who was imprisoned for refusing medical drug treatment while pregnant because she no longer used drugs.

Blaming Providers 

Some OBs openly acknowledge that their colleagues find it difficult to change practice in response to new scientific information–or even old scientific information.  Some examples are recommending bed rest, performing routine episiotomies, and using Pitocin for elective induction of labor.  However, when a woman or her infant develops a complication from one of these routinely prescribed interventions, the physician is rarely blamed for the poor outcome.  In fact, the doctors are often lauded in such circumstances for doing “all they could.”

Doctors  claim that women demand potentially harmful procedures, such as elective inductions or cesareans. Ashley Roman, MD, a maternal fetal medicine specialist at NYU Medical Center said,  “I have definitely seen an increase in C-section requests, even when there is no real medical justification behind it.” But the Listening to Mothers III survey found, “Despite much media and professional attention to ‘maternal request’ cesareans, only 1% of respondents who had a planned initial, or ‘primary,’ cesarean did so with the understanding that there was no medical reason.”

ACOG actually sanctions elective cesareans (albeit reluctantly).  In a 2013 Committee Opinion on elective surgery, ACOG concludes, “Depending on the context, acceding to a request for a surgical option that is not traditionally recommended can be ethical.”  Though their 2013 Committee Opinion on maternal request cesarean says vaginal birth should be recommended, it provides parameters for performing an elective cesarean.

Doctors sometime behave as if they are helpless to say no in the face of maternal request for elective medical procedures, such as cesareans or early inductions.  The director of women’s services at one hospital with a high early induction rate said,

A lot of the problem was the fear among our physicians that if they didn’t do what the patient asked, they’d go find another doctor. It was a financial issue.

Women, however, report that physicians consistently offer elective inductions and cesareans.  On the Evidence Based Birth Facebook page, Megan posted, “I was ‘offered’ an induction at 39 weeks at every visit starting at 34 weeks.”  At The Bump, user Ilovemarfa wrote, “I was induced with my son when I went overdue by over a week and he was estimated to be about 10 lbs 5 oz. My doctor offered me a c section due I possible high birthweight…” Her baby weighed 8lbs 9 oz.  Note that a prophylactic cesarean is only supposed to be considered if the baby is estimated to weigh at least 11 pounds.

Physicians may act as if they are doing women a favor by offering elective procedures.  For instance Emily on Baby Gaga posted,

I’m due [in two weeks]. I went to the doctor today. Last week I wasn’t dilated, but now I am 3 cm. He said if I don’t have the baby by my next appointment, I could pick a day, and they would induce me. No medical reason.

Or the provider may state that the procedure will be done, without any discussion or informed consent process.  On the Evidence Based Birth Facebook page, Becca reported, “[My]care provider did routine 36 week ultrasounds. [I] was told I was going to have a ‘Texas sized baby’ and would be induced if labor didn’t start…before 40wks.”   Dana was told at 29 weeks that “All first time moms need an episiotomy.”

In their Committee Opinion on Maternal Decision making, ACOG recommends,

Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy.

Despite their acceptance of elective interventions and a professional ethics opinion stating that women’s decisions should be respected, physicians sometimes threaten or persecute women when they refuse interventions–whether they are evidence based or not.  At the blood-pressure-raising website My Ob Said What?, a woman who told her OB that she refused to schedule a routine C section for her twin pregnancy (not evidence based) reported that she was told,

If you do that, then we’ll have to get social services involved and believe me, you don’t want that, Cookie.”

Another said she was told,

If you don’t agree to the cesarean section, we will call Child Protective Services and they will take the baby away for someone to be a real parent.”

A woman in Florida “was ordered to stay in bed at Tallahassee Memorial Hospital and to undergo ‘any and all medical treatments’ her doctor, acting in the interests of the fetus, decided were necessary.”  She was not even allowed to ask for a second opinion (bed rest is not evidence based).

One woman pointed out that doctors are not “reported to social services for child endangerment every time they try to induce a baby who’s not ready to be born, just for their own convenience” but that “if a mother did something for her own convenience that landed her child in the hospital, there sure as hell would be…lots of tough questions, lots of shaming.”

As stated earlier, when bad outcomes happen because of a physician’s choices, people often praise the doctor’s heroic efforts, even if the dangerous situation was caused by the physician.

A prime example is use of Pitocin without medical indication (you can read more about Pitocin here and elective induction here).  Some doctors who want to rush a birth or generate a reason to perform a cesarean practice something called “Pit to distress.”  Nursing Birth has an in-depth explanation with examples, but the short version is as follows:

  • A doctor starts Pitocin to induce labor or augment it (speed it up).
  • The dose is raised until the woman is contracting strongly and regularly.
  • The doctor orders that the dose keep going up, even though the woman’s contractions are already strong (at least 3 in 10 minutes).
  • The uterus becomes “tachysystole,” meaning there are more than 5 contractions in 10 minutes.
  • In many cases, not enough oxygen gets to the fetus under these conditions, the fetus goes into distress, and the mother is rushed to the operating room for an emergency cesarean that “saves” her baby.

Many times, the woman has no idea that the physician ordered that her Pitocin dose be raised, so she doesn’t realize that the doctor caused the fetal distress.  All she knows is that the baby was in distress, and that her doctor saved the baby from a potentially terrible outcome.

Even when bad outcomes occur, lawsuits are not common.  Despite the hype around liability, it doesn’t seem to impact practice the way doctors say it does.  After tort reform passed in Texas, limiting physician liability, the cesarean rate continued to go up at more or less the same rate as the rest of the country.  As one obstetrical nurse said, though physicians and nurses fear lawsuits, “hospital staff are rarely criminally prosecuted for their actions or inactions.”

Blame, Fate and Social Control

Certainly there may be someone to blame when a pregnancy or birth has a bad outcome.  But there may not be.  Blaming a doctor is frightening–it encourages people to question someone they need to trust with their lives–and their babies’ lives.  Fate can be even scarier–no one controls fate.  And in looking someone to blame, it seems society is often more interested in the social control of pregnant women than in rooting out the real culprit.  There may be those who escape unscathed, but nobody wins in this blame game.

This post will tell a story about a birthing woman being used as a test animal for training in using obstetrical forceps.

Forceps can be an important tool, but learning to use them is difficult. Before the invention of the Chamberlen forceps in the 1600s, removing a stuck baby from the birth canal was a gruesome process, involving anything from surgical instruments to kitchen gadgets (usually the baby was already dead when the removal process began).

Few people got to use the Chamberlen forceps for a long time.  The family kept them highly secret, and while many babies and some mothers still died when these forceps were used, not all of them did. The Chamberlens must have seemed like miracle workers every time they were able to end an obstructed birth with a live mother and baby.

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Eventually the secret got out, and through the 1700s and 1800s, there were many redesigns of forceps to attempt to make them safer.  By the early part of the twentieth century, as birth moved increasingly into hospitals, about half of babies were delivered with the assistance of forceps.

Here is a graphic video depicting a successful and relatively gentle low-forceps delivery–if you are squeamish, you might skip watching.  (Note that in this birth there is no episiotomy and the doctor supports the woman’s perineum as the head emerges–this is not typical):

Developing expertise in safe forceps use can take years.  Modern day doctors are much more likely to turn to cesareans when problems arise in the birth process.  But many doctors do still receive rudimentary training in forceps use.  Training is usually done through simulation, but eventually it requires a birthing woman to train on. El Parto Nuestro says,

“Forceps training” are carried out without the woman’s consent and without medical indication, that is, during birth deliveries which are progressing normally without any kind of emergency that requires interventions. The absurd reason for this unnatural practice is just so the students can learn.

No woman in her right mind would consent to unnecessary use of a procedure with risks that include urinary and fecal incontinence and an infant with a fractured skull.  According to Dr. Atul Gawande, using forceps safely requires a high level of skill and expertise, which ‘means that the outcome is always uncertain, even for experienced surgeons.’ Thus, practice may be conducted on women who don’t understand what is going on and are perceived as not having the means to complain even if they do.  Such was the case of Nancy Narváez, a low-income immigrant woman in Barcelona.  According to this press release, Nancy and the friend who accompanied her

witnessed how different students tried one after the other to pull her baby out with the use of forceps, under the supervision of a tutor, who even screamed at one of them, “not like that, you could break the baby’s head!” Finally, the tutor had to pull Nancy’s baby out, who suffered severe craneal fracture, intracraneal bleeding, cortical-subcortical infarction and convulsions which required a [hospital] transfer…[The hospital] confirmed that the baby was also suffering from an epidural hematoma caused by obstetrical trauma during an instrumental birth delivery, hypotonia (lack of muscular tone) and ischemic infarction in the area of the craneal fracture. She was operated on to drain the hematoma. A [neonatology] report…verified that the ischemic injury had caused neurological motor damage to the right hand side of her body; for which she would need physiotherapy.  As to the mother, a large episiotomy was carried out on her to insert the forceps.

Poor and oppressed women’s bodies have often been used for medical testing and training without informed consent–or any consent at all.   For instance, fistula repair was perfected on unanesthetized enslaved women, and Depo Provera was tested on poor women in Atlanta before much was known about it at all.

Forceps can be a preferable alternative to either vacuum extractors or cesarean if the birth attendant is well trained in their use.  Simulations can give good practice on conducting forceps deliveries.  But if the training must ultimately be conducted on a living woman who does not need the intervention (because when forceps are needed, there’s usually an emergency that involves getting the baby out fast), at what expense are we doing this training?

Note: for a potential alternative to forceps that is currently in development, see this post.

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I have written previously about problems with Pitocin overuse (and about widespread overuse of other medical procedures in birth).  Now that the holidays are almost upon us, it seems wise to revisit the Pitocin issue.

Pitocin is a synthetic form of oxytocin, a natural hormone that promotes bonding and also causes cervical dilation and labor contractions.  Using Pitocin interferes with the body’s natural output of oxytocin, doesn’t effectively dilate the cervix, and prevents the body’s release of endorphins that naturally alleviate pain.  There are sometimes good reasons for inducing labor with Pitocin (for instance, if the baby must be born right away for health reasons).  In many cases, however, good reasons are not in the equation when the Pitocin comes out.

In 1990, fewer than 10% of women underwent labor induction.  Now, estimates indicate that up to 40% or more of labors may be induced.  As scheduled cesarean rates have also gone up dramatically in that same period (see this graph), we know that the proportion of women planning a vaginal birth who are induced has gone up even more.  If you doubt that large numbers of births are being scheduled, see this graph that shows that births are disproportionately on Tuesday-Friday, with an extraordinary dip on weekends.

Doctors like to indicate that elective inductions are primarily done at maternal request.  While some women definitely do request inductions, pregnant women cannot induce themselves with Pitocin.  Doctors seem to have no problem enforcing non-evidence-based practices that women don’t want, such as not eating in labor, but act as if they are helpless in the face of induction requests.

Some doctors also have selective memory when it comes to their own induction practices.  According to mothers, childbirth educators, and nurses, it is usually doctors who are encouraging inductions.  As one childbirth educator said,

[A]n increasing number [of women] are being encouraged by their physicians to have labor induced. Threats of “your baby is getting too big” or “your blood pressure is a bit high” or “going past your due date is dangerous” and seduction with “your baby is ready, let’s get on with it” are almost routine.

Even some doctors acknowledge that elective induction is often physician driven.  Dr. Vivien von Gruenigen writes,

Health care providers may request a patient to have an elective induction of labor and the “fee for service” model is a factor.  This routine is common for physicians in solo practice with needed time off call or impending vacation.  In addition, many physicians in group practice schedule elective inductions when they are on call for the purpose of financial gain.

Inductions are usually performed without true informed consent.  Pitocin is not FDA approved for elective induction of labor and carries a black box warning because it is a high alert medication (prone to errors in administration that lead to catastrophic consequences).  It appears that very few women are told that they are receiving a high alert medication that is being used “off label.”

One suggested consent form for elective induction includes the following for women to acknowledge:

  • An increased risk of the need for cesarean section (surgical abdominal birth)
  • I have also discussed the use of cervical “ripening agents” with my physician and I understand their separate risks of: a. Excessive stimulation of the uterus to the point that my fetus may become compromised and require emergency delivery, either vaginally or abdominally. b. I also understand that rarely the uterus may rupture under these circumstances, and cause death of my fetus and severe hemorrhage or death to myself.
  • An increased risk that instruments may be used to accomplish a vaginal delivery if necessary.
  • I also realize that if I have a cesarean birth, I am likely to require cesarean births for all of the children I may have in the future, and that each of these will incur the usual risks associated with cesarean section that I might have avoided had I had this birth vaginally.
  •  I acknowledge that there may be an increased risk for the need of blood transfusion, and I give my full consent to receive blood and blood products as necessary unless specifically stated here:

I have never met a lay woman who was aware of all of these risks, even if she had undergone an elective induction.

Marilyn Curl notes that elective deliveries spike before holidays–but that women do not always realize that the induction is elective:

Few doctors want to be pacing the halls on Thanksgiving or Christmas, waiting for a mother to deliver, so it’s not uncommon to see a surge of women with normal pregnancies being told that there might be an issue and that they should consider scheduling the delivery, coincidentally, right before a holiday.

Jill Arnold has a whole post about the pre-holiday induction phenomenon at The Unnecesarean.

Aside from  the health risks, there are many other disadvantages to a pre-holiday induction, namely that there are so many of them being done that the obstetric wards are likely to be overcrowded.  Robin Elise Weiss notes that

  • Trying to schedule an induction just before Christmas ensures a hugely busy and overworked staff because of everyone else doing the same thing.  I’ve personally seen women laboring in the halls or having very long wait for services like epidural anesthesia because of it.
  • When you have a baby in the week before Christmas (with lots of other women), you’ve also got a crowded postpartum floor.  This means longer waits for being seen by pediatricians, getting pain medicationss, etc.
  • Being in the hospital in a crowded induction season can mean that you have to share resources in the hospitals that are already spread thin, like the lactation consultant, breast pumps, birth certificate clerks, etc.

At a recent PCORI conference, consensus opinion was that elective induction of labor before 41 weeks was one of the most important issues facing perinatal care today.  As Deborah Bingham pointed out, we don’t give people with normal blood pressure medication for high blood pressure, because that would be dangerous; similarly, we should not be giving healthy pregnant women medication designed for rushing a birth in a medically dangerous situation.  And it certainly shouldn’t be done by tricking women into thinking an induction is necessary because of a big baby or other concern that is not an indication for induction.

Not even before Thanksgiving or Christmas.

Update: you may also want to read Public Service Post: The Bishop Score

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