Procrustean Obstetrics: Narrowing the Range of Normalcy

Procrustes took in lodgers on the road to Athens, but they had to fit his proffered bed.  If the prospective lodgers were too short, he stretched them, and if they were too tall, he cut as many inches as necessary from their legs. As a result, according to Encyclopedia Brittanica, “The ‘bed of Procrustes,’ or ‘Procrustean bed,’ has become proverbial for arbitrarily—and perhaps ruthlessly—forcing someone or something to fit into an unnatural scheme or pattern.”

Enter American Obstetrics.

Human beings generally are within  a range of normalcy.  As such, we do not expect everyone to be exactly the same height or weight.  We don’t say that everyone should have exactly the same blood sugar reading, and we accept a range of blood pressure readings as healthy.  A woman could be 5 feet or 6 feet tall–we might think that one woman was short and the other tall, but we probably wouldn’t consider either to be abnormal–certainly not to the point that we would medically intervene to change her.  There is an average, to be sure, but there is a range around that average that is considered “normal.”

But that range, in the mind of an obstetrician, may become very, very small.

A friend of mine, pregnant with twins, had one twin who was substantially smaller than the other.  As the pregnancy came close to 36 weeks gestation, the OB ran some tests to see if the smaller twin was suffering from intrauterine growth restriction.  The numbers came back within the normal range, but the doctor didn’t like them because they were on the low side of normal.  She told my friend that a cesarean was necessary, and as a result, the larger twin, not ready to be born, spent a week in the NICU with respiratory problems.

The length of a normal, healthy pregnancy can vary by as much as 5 weeks, but new definitions recommended by the American College of Obstetricians and Gynecologists (ACOG) have narrowed the definition of  normal gestation to a 2 week window.  Only babies born at 39-41 weeks are “term”:

Recommended Classification of Deliveries From 37 Weeks of Gestation

• Early term: 37 0/7 weeks through 38 6/7 weeks
• Full term: 39 0/7 weeks through 40 6/7 weeks
• Late term: 41 0/7 weeks through 41 6/7 weeks
• Postterm: 42 0/7 weeks and beyond

As Linda Hunter observes, accurately calculating a due date from the first day of the last menstrual period (LMP)  depends on “the woman’s accurate recall of her LMP; the regularity of her cycles; the presence of early or light bleeding; and other factors, such as oral contraceptive use or breastfeeding that could influence ovulation timing.  There can also be some variation in the actual timing of ovulation, even in the presence of a seemingly normal 28-day menstrual cycle.”  And many women do not have 28 day cycles, though the due date is generally calculated the same way regardless.

Ultrasound screening is generally more accurate at estimating gestational age than using the LMP, but this method also has limits.  Hunter reminds us that screening is only reliably accurate if done in the first trimester.  In addition, she says, “Ultrasound’s accuracy depends greatly on the skill of the person performing the examination and the quality of the images, not to mention the size of the patient and the fetal position.”  She notes that ultrasound dating is useful because many women’s due dates are estimated too early under the LMP method, and thus many women undergo unnecessary inductions for “postdate” pregnancies (late term or post term, according to the new definitions) that are actually still well within the “term” range.

Even within the two week window, many OBs push for induction as soon as a woman reaches 39 weeks.  The average pregnancy length has become shorter and the range of gestational age at birth narrower as induction has more frequently been used to force women’s bodies to conform to obstetrical definitions of term.  In the past decade, the average length of pregnancy has decreased from 40 to 39 weeks, in part because of scheduled inductions and cesareans to make women’s pregnancies fit an increasingly narrow definition of “normal.”

Perhaps the most egregious narrowing of the normal window comes from Friedman’s curve.  Friedman observed the labors of women in the 1950s, and came up with a”normal” trajectory for a labor to progress (click to enlarge):

As Rebecca Dekker at Evidence Based Birth explains, Friedman’s curve is now obsolete.  Women are no longer heavily sedated in labor.  Their size is different, their nutrition is different, their lifestyles are different, and most women labor much longer now than they did during the time of Friedman’s observations.  Here is a graph that shows Friedman’s curve against the typical labors of contemporary women (click to enlarge):

Despite the historical changes, many OBs cling to Friedman’s curve as the definition of “normal” labor, and give women Pitocin and other drugs to try to make an uncomplicated labor conform to Friedman’s curve.  If the woman’s body still does not conform, she may wind up with a cesarean for “failure to progress,” even though her labor was progressing fine.

A debate has now arisen over diagnosis of gestational diabetes (and I’m sure this debate will continue).  New standards proposed would lead to nearly 20% of pregnant women being diagnosed with gestational diabetes.  Although the NIH issued a consensus statement that the old standards should remain for now, some doctors are now concerned by blood sugar readings that were considered perfectly normal by everyone just a few years ago.  It should be noted that women experience many negative effects with a diagnosis of gestational diabetes, including “constant worry and anxiety over their baby, self-blame and guilt, and more medicalization throughout the prenatal care and delivery,” all of which, like gestational diabetes itself, can lead to negative health consequences.

The narrowing range of obstetric normalcy mirrors other areas in which women are expected to conform to a narrow standard–and literally to cut their bodies to conform:

There are many ways to be a human being and to grow one.  In the words of Dr. Anne Marie Jukic,

[N]atural variability may be greater than we have previously thought, and if that is true, clinicians may want to keep that in mind when trying to decide whether to intervene on a pregnancy.

Women do not need to be cut open because their bodies do not follow a line on a graph.  They do not need to be shamed and blamed for numbers a doctor doesn’t like.  They do not need to be given medications to force their functions to fit a preconceived idea of what is normal.  Perhaps instead someone could observe the woman and her fetus and see if both appeared to be healthy and developing well, and intervene only when an actual problem arose.

Fitting into a Procrustean version of obstetrics that dictates increasingly narrow ranges of normal does not benefit women or babies–and rejecting such a model would allow more women to emerge from pregnancy and birth physically and psychologically intact.

Public Service Post: The Bishop Score

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:

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:

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:

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.

Avoid an Unnecesarean

It would be hard to find anyone who doesn’t think the cesarean rate is too high.  The World Health Organization says that a 15% rate “is not a target to be achieved but rather a threshold not to be exceeded.”  Healthy People 2020 goals (see section MICH-7) target reductions in primary cesareans and increases in vaginal birth after cesarean (VBAC) as two primary goals in maternity care. In some situations, the benefits of a cesarean far outweigh the risks, but when the surgery is not needed, it has the small but significant potential to cause severe complications for the woman and her baby, and also affects the woman’s subsequent pregnancies.

Cesareans have many advantages for doctors.  The payment for attending a cesarean is equal to or greater than attending a vaginal birth.  While even a fast vaginal birth generally takes at least several hours from the time the woman arrives at the hospital,  performing a cesarean takes about an hour.  Cesareans are not risk-free, but the outcomes are predictable.  And scheduling a cesarean is particularly lucrative and convenient for doctors because they can avoid conflicts with office hours and family/leisure time.

Dr. Jonathan Weinstein of Frisco Women’s Health, whose cesarean rate is under 15%, offers the helpful list, Top Ten Signs Your Doctor is Planning to Perform an Unnecessary Cesarean Section on You:

1. Arrives to L&D immediately after office hours and says, “I just don’t think this baby is going to fit”
2. Third Trimester, Routine Office Visit, “I think this is going to be a big baby you should just have a C/S” – Did you know? ACOG has very specific guidelines for when it is appropriate to offer a patient an elective C/S for MACROSOMIA (fancy word for large baby). ‘Prophylactic (elective) cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 gms (11 pounds) in women without diabetes and greater than 4,500 gms (9.9 pounds) in women with diabetes.
3. “We should induce at 39 weeks your baby is getting too big” – Did you know? According to ACOG, ‘Induction of labor at least doubles the risk of cesarean delivery without reducing shoulder dystocia (rare situation where baby’s shoulder can get stuck at delivery) or newborn morbidity(complications). Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.’
4. Performs routine ultrasounds at end of pregnancy to see how big your baby is. Did you know? Ultrasounds at the end of the pregnancy can be 1-2 pounds off. Ask some VBAC patients who were talked into a C/S for this, then had a vaginal delivery of a bigger baby the next time.
5. “You have a positive herpes titer (or history of herpes); the baby will get it if you deliver vaginally.” Try some Valtrex for the last month of the pregnancy that is pretty much standard of care now. It prevents outbreaks and allows for a normal vaginal delivery.
6. “Your baby is breech you need to have a C/S” Ever heard of or performed an External Cephalic Version? It really does work.
7. “You have pushed for 2 hours” (with an epidural that prevents you from feeling anything so you are probably not pushing effectively; this is evident on exam because the baby’s head is still perfectly round, but you do not need to know that) it’s just not going to come out.”
8. “I scheduled you for an induction at 39 weeks, it is just soooo… much more convenient for you!” (and so much higher risk of ending in a C/S, especially if you are not dilated when you start the induction). At least 80% of my VBAC patients were induced the previous pregnancy. For whose convenience was the induction?
9. First Visit (7 weeks), “Congratulations you are having twins. I will go ahead and schedule your C/S at 38 weeks, but don’t worry if you go in to labor early I will cut you right away!” Translation, “I am scared out of my mind for you to deliver your babies vaginally because I am not trained on what to do when the second baby is coming, plus it pays more to cut you open. Oh yeah, I don’t have that great a rapport with you because I only spend 2 minutes (fundal height, heart beat and ‘I’ll see you next time’) with you each visit, so I am afraid I will be sued for trying to do the right thing.” (note from Human with Uterus: planned cesarean for twins is not evidence based.)
10. First Pelvic Exam in Office (7 weeks), “Hmm, your pelvis is pretty narrow”
11. Bonus Tip: 38-week visit, “Your blood pressure is a little up today you are probably developing preeclampsia or toxemia. That can cause you to have a SEIZURE! The treatment is to deliver the baby. You need a Cesarean Section this is the quickest way to resolve it. Let’s get you up to L&D NOW!” Translation – Preeclampsia or Pregnancy Induced High Blood Pressure is a pain in the butt. If I induce you, it could take 24 hours or more and then I would have to manage your blood pressure, and put you on Magnesium. This is way too inconvenient. Do not worry you can try to have the baby vaginally next time. Yeah right!

For more information on cesarean/induction for “big baby,” see this post from Evidence Based Birth.

Despite reports that cesareans are performed at maternal request, only about 1% of primary cesareans were requested by the woman.  As a woman cannot perform a cesarean on herself, the skyrocketing rate must be driven by providers.  Providers also say that high cesarean rates are driven by liability concerns. A connection between liability environments and cesarean rates exists, but the effects are small.  A natural experiment in Texas, which underwent tort reform, showed that reductions in liability did not lead to corresponding changes in cesarean rates–cesarean rates went up at roughly the same rate as they did in the rest of the country.  Texas cesarean rates are currently 35.3%, higher than the national average.

We might also generally question the ethics of performing a surgery that is in the best interest of the doctor, not the woman and her child.  When a doctor recommends a risky procedure such as major abdominal surgery, women should always ask for references to evidence (meaning documents they can read, not off-the-cuff statistics).  A woman’s care should be a process of shared decision making, not following someone else’s orders.  A woman’s humanity demands nothing less.

Cesareans Are Us: Mississippi

I am a big fan of Jill Arnold’s cesareanrates.com, and I encourage you to visit.  Here is Jill’s report on Mississippi cesarean rates.

River Oaks Hospital, which is just outside of Jackson, has the highest cesarean rate in the state of Mississippi:  57.2%.  Just for reference, the national rate is 32.8%,  the average for Mississippi is 38.3%, and the World Heath Organization says that 15% is a “threshold not to be exceeded” because maternal and infant health do not improve when rates rise higher.  To be fair, River Oaks handles many high risk cases from around the state, but the WHO threshold is supposed to cover even high risk populations.  A rate nearly four times the maximum threshold seems excessive.

According to March of Dimes Peristats, the VBAC rate in Hinds County (where River Oaks is located) was 4.3% in 2010, meaning that among women who have already had at least one cesarean, only 4.3% who had another baby in 2010 birthed vaginally.  According to the Jackson chapter of the International Cesarean Awareness Network, River Oaks does “allow” VBAC, though there were fewer than 200 VBACs in the entire state in 2010.

So let’s look at what happens at River Oaks.  The homepage for their Labor and Delivery Center features three links: planning a pregnancy, healthful pregnancy and cesarean.  Hmm….  Here is their list of possible reasons a woman would need a cesarean at their hospital (followed by my commentary):

There are several conditions which may make a cesarean delivery more likely. These include, but are not limited to:

• Abnormal fetal heart rate. The fetal heart rate during labor is a good sign of how well the fetus is handling the contractions of labor. The heart rate is monitored during labor…If the fetal heart rate shows there may be a problem, immediate action can be taken… A cesarean delivery may be necessary.

We know from my past post on Florida that fetal monitoring is not recommended for a normal labor, and that the evidence suggests that fetal monitoring does not lead to better outcomes for infants but does lead to higher cesarean rates.  In normal labors, the best evidence suggests that the baby’s heart rate be monitored by intermittent oscillation (using a hand-held Doppler at regular intervals).

• Abnormal position of the fetus during birth. The normal position for the fetus during birth is head-down, facing the mother’s back. However, sometimes a fetus is not in the right position, making delivery more difficult through the birth canal.

It is true that head down facing back is the most common position and that other positions tend to make births more difficult.  However, according to ACOG committee opinion, a skilled practitioner can deliver some breech babies vaginally (a sideways baby who won’t turn has to be delivered by cesarean).  Unfortunately, many practitioners do not have the skills for safe vaginal breech delivery.   A posterior (“sunny side up”) baby can  be delivered vaginally and does not require unique obstetrical skill.  Breech and posterior babies can often be turned, and posterior babies especially often turn themselves late in pregnancy or during labor, making a planned cesarean  unnecessary.

• Labor that fails to progress or does not progress normally

“Normal labor” has changed.  Many doctors rely on the outdated Friedman’s curve, developed in 1954.  It  does not fit with the  labor progression of contemporary women, who labor under different conditions (e.g. not heavily sedated).  “Active labor” used to be diagnosed at 3 cm of cervical dilation; current thought is a woman should reach 6 cm before being considered in “active labor.” However, many hospitals and many individual physicians still cling to the outdated norms. As women now labor more slowly, this leads to many cesareans for “failure to progress.”

• Baby is too large to be delivered vaginally

The medical term for a large baby is “macrosomia,”  but the condition is often called simply “big baby,” which always sounds to me like the character in Toy Story 3:

Hopefully, most macrosomic babies don’t look like that.  In any case, practice guidelines

do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb)

Yes, you read that right.  ELEVEN POUNDS.  Rebecca Dekker at Evidence Based Birth has some great information on macrosomia.

• Placental complications (such as placenta previa, in which the placenta blocks the cervix and presents the risk of becoming detached from the uterus too soon). Premature detachment from the fetus is known as abruption.

Placenta previa is a situation in which cesarean is life saving for women and babies.  Please, if you have have placenta previa, follow your doctor’s advice regarding cesarean (but do not go on bed rest).  Abruption may or may not require cesarean, but it is absolutely reasonable that it be considered.  The placenta, however, separates from the uterine wall, not the fetus.  These people scare me.

• Certain maternal medical conditions (such as diabetes, high blood pressure, or human immunodeficiency virus [HIV] infection)

Sometimes conditions like high blood pressure can mean that the baby needs to be delivered early to preserve the life and health of either the baby or the pregnant woman.  In these cases, an induction can often be tried first.  The choice of induction vs. cesarean for a maternal or fetal medical condition should always be made with the full informed consent of the woman.  I have no idea if that’s the case at River Oaks, but given their cesarean rate, I doubt it.

• Active herpes lesions in the mother’s vagina or cervix

Yes, if the infection is active, cesarean is a good choice.  The chance of herpes transmission to the infant during vaginal delivery is up to 50%.  However, if the woman has been receiving prenatal care, the herpes infection can be treated in advance, which should allow for vaginal delivery in most cases.

• Twins or other multiples

I have posted on vaginal birth vs. cesarean for twin delivery.  A new, high-quality study shows that planned cesarean does not improve outcomes for twins as long as Twin A is head down.  In response, the chief of obstetrics as Mass General wrote an opinion piece saying that doctors should plan cesareans for twins anyway.  That appears to be the River Oaks philosophy.

• Previous cesarean delivery

According to ACOG’s practice bulletin on VBAC, the vast majority of women with one prior cesarean are appropriate candidates for VBAC, as are some women with two prior cesareans.  Probability of successful VBAC ranges from 60-80%.  ACOG says that risks and benefits should be discussed, counseling on VBAC should be documented in the medical record, and the ultimate decision should lie with the woman.  According to the River Oaks website,

A woman may or may not be able to have a vaginal birth with a future pregnancy, called a vaginal birth after cesarean (VBAC). Depending on the type of uterine incision used for the cesarean birth, the scar may not be strong enough to hold together during labor contractions.

Who knows what kind of uterine incisions the docs there are using, because apparently the only way to get a VBAC is to come in pushing and have the baby before they can cut you.

• There may be other reasons for your doctor to recommend a cesarean delivery.

Perhaps it is 4:30 on Friday.

There is more non-evidence-based care featured on their website, including this video featuring babies who bottlefeed and do not room-in with their mothers (fine if that’s what the woman wants, but not a message that promotes best practices).

River Oaks does not appear to be the place to have a baby if you want a vaginal birth and evidence based care.  But you can go make them some money if you want.

Note: this is my second piece on a hospital with the highest cesarean rate within a state.  You can read the post on Florida here.

Forceps in Birth: Woman as Test Animal

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.

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.

Low Tech, Low Cost, and Easy to Use–Will it Have a Chance?

An Argentinian Car Mechanic, Jorge Odón, has devised a way to help birth a stuck baby based on a nifty trick for getting a cork out of a bottle, which you can see in this video:

You really have to watch the video to understand how it would work–otherwise the description sounds like you are putting a bag over the baby’s head, and we all know where that leads.  Here’s a picture of the Odón Device:

Yes, it looks like you are putting the baby in a blender.  Seriously, watch the cork video and it will make much more sense.  Although the video will not explain why a baby in the process of being born is wearing a striped romper.

Anyone who has read this blog knows that I am not in favor of “devices,”  and many devices concocted for use in birth seem like something out of a horror movie (the one in the link even generated a petition).  What intrigues me about this one is that it has the potential to replace dangerous devices (or surgery) that may be necessary in many cases.  The Odón, if it actually works, could replace the use of forceps and vacuum extractors, both of which carry significant risks, including incontinence, tissue and nerve damage, and pelvic prolapse for the woman and skull fracture, cranial bleeding, and seizures for the baby.  Because of the risks involved in instrumental delivery, and because many U.S. doctors no longer have sufficient practice to do instrumental deliveries safely, cesareans are a more common solution to slow progress or a stuck baby in second stage labor.  As Atul Gawande notes in his excellent New Yorker article ,

Forceps have virtually disappeared from the delivery wards, even though several studies have compared forceps delivery to Cesarean section and found no advantage for Cesarean section. (A few found that mothers actually did better with forceps.)

It seems women and babies may be likely to do even better with the Odón Device, though it has not been widely tested yet, and it has specifically not been tested on women with confirmed obstructed labor (the condition for which the device is designed).  A New York Times article explains the perspective of Dr. Meraldi of the Word Health Organization (WHO):

About 10 percent of the 137 million births worldwide each year have potentially serious complications… About 5.6 million babies are stillborn or die quickly, and about 260,000 women die in childbirth. Obstructed labor, which can occur when a baby’s head is too large or an exhausted mother’s contractions stop, is a major factor.  In wealthy countries, fetal distress results in a rush to the operating room. In poor, rural clinics…if the baby doesn’t come out, the woman is on her own.  Although more testing is planned on the Odón Device, doctors said it appeared to be safe for midwives with minimal training to use.

The device is estimated to cost about $50 to make.

Doctors have readily adapted–and refused to give up–high-tech, costly processes that do not work or cause unnecessary harm, such as fetal monitoring, prophylactic cesarean for twin births, and elective induction.  At the same time, doctors have  actively resisted low or non-technical processes that are both helpful and low-cost or free, such as freedom of movement in labor, doulas, and water for pain relief.

It remains to be seen

1. if the new device is safe and effective
2. and if it is, whether U.S. physicians will be willing to give up lucrative surgeries for a $50 device that can be used by a layperson and is based on a parlor trick
3. or if it will be enthusiastically embraced and used on all birthing women whether they need it or not.

Let’s hope that women (and their babies) are ultimately the ones who benefit.

Elective Inductions: Be Thankful not to Have One

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

Healthy Babies and their Human Mothers

There is some debate in the blogosphere about whether or not women should care about anything in their birth experience other than a healthy baby.

You can read posts that indicate that a healthy baby should be privileged to the exclusion of other concerns here (read the responses), here, and here.

While it appears that people say “all that matters is a healthy baby” to women all the time, not as many want to go public with that sentiment.  Women who have been told that “all that matters is a healthy baby,” however, have some feelings about that idea, and so do advocates for women.  You can read posts that indicate that there are important things to value in birth in addition to a healthy baby here, here, here, here, here, here, here, here, and here.  If you google “healthy baby all that matters,” you can get more than 4 million other responses.

The statement that “all that matters is a healthy baby” dehumanizes women and suggests that they are nothing more than a conduit for birth.  While nearly all birthing women want nothing more than a healthy baby, it is disingenuous to imply that women cannot have healthy babies and be treated with dignity and have their own health valued at the same time.  And if a woman has an unhealthy baby, the woman’s health is still important.  The White Ribbon Alliance advocates for respectful maternity care as a human right.

view a larger version of the poster here

The WRA points out that violations of these rights happens in rich countries and poor countries and that women remember their childbirth experiences for a lifetime.  A healthy baby is very, very important.  So is a healthy mother–and mental health is as important as physical health to a woman’s ability to care for herself AND a newborn after birth.

 

Update: For information and analysis of the Rinat Dray forced cesarean case, see VBAC vs. Forced Cesarean: Facts, Opinion, and Informed Consent

Your Way–as Long as it’s Our Way: Florida

Jill Arnold is updating the stats at CesareanRates.com, and according to her new tables, South Miami Hospital has the highest cesarean rate in Florida: 62%.  This is nearly double the national average and 4 times the “threshold not be exceeded” identified by the World Health Organization.  Let’s investigate.

Women have babies at the hospital’s Center for Women and Infants.  Their patient brochure begins, “The philosophy toward childbirth at South Miami Hospital encourages your individuality and supports family involvement.”  Such a statement indicates that the woman can call the shots in her own birth–an admirable goal as long as she is given evidence-based information to make choices.  Except it turns out that she doesn’t actually have a lot of choices.  Nor are routine hospital practices based on evidence.

For instance, here are some example from the “Frequently Asked Questions” page (all emphasis and commentary is mine):

3 Q:  Will I be able to walk or use my birthing ball when I am in labor?
A:  We encourage you to discuss this with your physician as you will want to be familiar with your doctor’s practices.

Um…what are the doctor’s birth ball practices?  Should the woman expect to have to share?

6. Q:  Will I be able to eat in labor? How soon will I be able to eat after the baby is born?
A:  While in labor, it is recommended that you have only ice chips. The presence of food in the stomach may cause nausea and vomiting. In the event you should need anesthesia for your labor, vomiting could cause aspiration of food to the lungs, a condition that is dangerous to you. If you deliver vaginally, you will be able to eat once your recovery is complete.  (…)

“It is recommended” by whom?  There is no evidence base for denying women access to food and drink in labor.  A Cochrane review on the subject notes that depriving women of food and drink leads to longer and more painful labors and concludes, “women should be free to eat and drink in labour, or not, as they wish.”  And when would “recovery be complete”?  Isn’t common wisdom that it takes about 6 weeks to recover from a vaginal birth?  That’s a long time to survive on ice chips.

9. Q:  What is a fetal monitor? Do you have wireless monitors in the labor rooms?
A:  The fetal monitor is used to determine the baby’s well-being prior to birth.  It provides a continuous printed record for the evaluation of uterine activity and the baby’s heart response.  Your obstetrician may decide to use an external or internal monitor. Baptist Hospital does have wireless monitors. These monitors are used when appropriate and available.

Continuous monitoring has been shown to raise the risk of cesarean without producing superior maternal or infant outcomes and it is not recommended for low risk women–not even an initial test strip.  In addition, if the wireless monitor is not available, the woman’s movement would be restricted, which would also go against evidence based practice.  Internal monitoring can be painful and introduces risk of infection.  According to Rebecca Dekker at Evidence Based Birth, “evidence clearly demonstrates that the best option for most women and babies is intermittent auscultation” (meaning using a handheld doppler at intervals throughout labor).  Note that the best practice is not mentioned as an option.  Whoops.

11. Q:  Do you have a Jacuzzi?
A:  Use of the Jacuzzi is based on room availability. In early labor, some patients enjoy relaxing in the Jacuzzi. Use of the Jacuzzi will depend on many circumstances revolving around your labor. Your physician will need to approve its use.

It’s interesting that the question is “do you have a Jacuzzi,” but the answer is about all the reasons a woman won’t be able to use one, even though there is a strong evidence base for laboring in water.

It’s also interesting that a physician would need to approve women’s evidence based requests, while the hospital will require women to follow non-evidence based routines.  This does not seem particularly encouraging of individuality.  Or of health.

Women are told they to be admitted at 3 centimeters’ dilation because that is when they are in active labor, even though the most current recommendations state that women should not be considered in active labor until 5-6 cm.  Early hospital admission tends to lead to unnecessary cascades of  intervention that increase birth costs and can lead to cesarean.

Even regarding non-medical issues, South Miami places limits on what women (or their families) can do.  For instance, their video and photography guidelines have some practical information–tripods shouldn’t be used because they get in the way; doctors and nurses should give their permission before being photographed or video recorded.  But the guidelines, which state that “the birth of a baby is an exciting time” also state that no one is actually allowed to photograph or videotape the birth:

1. For vaginal births, videotaping and photographing are permitted, but only after the birth, and when the baby is dried, cleaned and alert.
2. Videotaping is not allowed during a C-section delivery. Photographs may be taken only after the baby is dried, cleaned and alert.

Since a baby should go skin-to-skin with the mother directly after birth and remain with her there for about an hour, it may be a long time before anyone can get a picture of the baby.  Unless South Miami is not following evidence based recommendations about skin-to-skin contact.  Hmm…

We require labels on food packaging to give nutritional information.  It seems we might benefit from hospital labeling to get health information.  If a woman chooses to abide by non-evidence based practice, that is her right.  But it is disingenuous for a hospital to proclaim that it supports a woman’s individuality in childbirth–as long as her individuality fits their mold.

 

You can read the second in this series, an analysis of  the Mississippi hospital with the highest cesarean rate, here.

Female while Human: the (un)Privileged Body

Merriam Webster defines privilege as a right or benefit that is given to some people and not to others.  One privilege given to men in our society is the assumption that their reproductive capacities are normal and that women’s are deviant.

Society generally considers viewing female reproductive bodies as normal as somehow privileging women.  This is not to say that there are not plenty of men and women in our society who appreciate that women’s bodies can menstruate, carry a fetus, give birth, and lactate.  But it is also considered perfectly acceptable to discriminate against women for these functions or to behave as if women’s normal reproductive functions are an abnormal inconvenience or a “choice.”

For instance, a common argument in conservative circles is that women and men have similar earnings if you control for things such as childbearing.  Women “choose” to have children, and thus the time they take for childbearing is a choice, and thus it makes sense to pay them less because they work less.  Men do not bear children, and if women also do not, their salaries are similar to those of their male counterparts.  However, this ignores that men retain their salary privilege whether they reproduce or not.  Women who reproduce are the only ones who face a pay gap.

If it were considered normal to get pregnant, birth babies, breastfeed, and actively engage in childrearing, then the assumption in the workplace would be that all adults would spend some time doing these things, and workplace policies would be designed around that assumption.  Instead, workplaces are often designed around the assumption that not only will workers not get pregnant, birth babies, breastfeed, and actively engage in childrearing, but that someone else will do that for them.  This is only possible to assume if one views the normal human body as the male version.

There is a case going before the Supreme Court of the United States in which a pregnant woman working for UPS was not given accommodations needed to maintain the health of her pregnant body (in her case, being given light physical duty for the first half of her pregnancy).  People who were not pregnant could get accommodations to maintain the health of their non-pregnant bodies–it was only workers who needed health accommodations associated  with pregnancy who were denied.  UPS argued that their policy was “pregnancy blind”–that they were not discriminating because they simply treated all workers as if they were not and could never be pregnant–even if they were pregnant.  This assumes that the normal human body is never pregnant.

In a recent “Faith and Reason” lecture at Patrick Henry College (a college for devout Christians who were homeschooled), Stephen Baskerville complains that women have made “demands for access to workplaces, universities, the military, and other previously male venues” and that women’s presence in these institutions is “accompanied with equally strident demands to engage there in female-only activities, such as pregnancy or breastfeeding.”*

Baskerville’s argument assumes that it is right and just for institutions to be for male bodies only.   His idea is that the female reproductive body is not normal, so that structuring an institution to adapt to normal states of being of the female reproductive body is somehow discriminating against men.   His argument is equivalent to stating that peeing while standing is male-only activity and therefore it is discriminatory against women to have urinals in bathrooms.

Women are commonly shamed for having lactating bodies in public (on a light note, here are a few situations that I agree would be bad for lactating/nursing publicly ).  A healthy body will lactate after birthing and for as long as an infant gets nourishment at the breast.  It is a normal–if temporary–state for a the postpartum body.  Yet the right of a woman to her lactating body is so controversial that there have had to be numerous laws passed stating that the normal lactating body must be accommodated in public, including making time for lactation in the workplace.  It is generally expected that humans will take time to do other normal human functions, such as eat or pee.  We generally accommodate ordinary human functions in public spaces and institutions.

It is  an ordinary human function to menstruate, be pregnant, give birth, or lactate–that is, if you consider a woman to be human.

Update: Here is the first follow-up to this post: The (un)Privileged Body: Pregnancy and the ACA

*Baskerville says this as part of a larger argument about sexual harassment.  You can read a great takedown of the whole lecture here.