Archives for posts with tag: Labor

It is often noted that change takes time, specifically that it takes about 17 years for research findings to be consistently adopted as practice.  We see that issue frequently in obstetrics, where it often takes longer.  For instance, even though high quality research has shown for more than 20 years that routine episiotomies cause the very tears they were initially hypothesized to prevent, in many hospitals, episiotomy rates remain above 30%, with rates at some institutions being much higher (read more on episiotomy here).

In considering VBAC, however, we can see that change can occur almost instantaneously–in one direction.  The American College of Obstetricians and Gynecologists (ACOG) began recommending restricted use of episiotomy in 2006–more than a decade after research showed the risks of routine use–and many practitioners still aren’t on board.  But when ACOG changed its recommendations regarding vaginal birth after cesarean (VBAC), the practice came to a screeching halt.

ACOG has offered a series of recomendations on VBACs, beginning with Committee Opinions in 1988 and 1994, with Practice Bulletins following in 1995 (#1), 1998 (#2), 1999 (#5), 2004 (#54), and 2010 (#115).  Dr. Hilary Gerber put together an excellent slide show explaining the changes in each set of recommendations, which you can view here.

For most of the twentieth century, when lifesaving cesareans became a real option in hospital births, the common wisdom was “once a cesarean, always a cesarean,” a statement made professionally in 1916 at the New York Association of Obstetricians & Gynecologists.  However, for the next 60 years, cesareans were so rare to begin with that the number of women undergoing repeat procedures was small.  The overall cesarean rate in 1965 was under 5%.  As primary cesareans became more common in the late 1970s and through the 80s, more and more women also underwent repeat cesareans, and by 1990 the overall c-section rate was almost 23%.  At the same time, surgical techniques advanced to make VBACs safer, and in 1990 about 20% of women who had a prior cesarean had a VBAC.

In 1994, ACOG issued a Committee Opinion that said that in the absence of contraindications (primarily classical incision in prior cesarean), women should be encouraged to undergo trial of labor after cesarean (TOLAC) rather than automatically being scheduled for a repeat cesarean.  We know now that most women, especially those with only one prior cesarean, are good candidates for VBAC, and it is estimated that 70% of women undergoing TOLAC can have successful VBACs, but the next year, the VBAC rate was only 27%.  While this was definitely an increase, it hardly indicated that all of the most appropriate candidates for TOLAC were actually going into labor.  The VBAC rate peaked in 1996 at 28.3% and then began to decrease, driven by an article by Michael McMahon et al that linked TOLAC to an increase in maternal complications.

In 1999, ACOG released new, more restrictive recommendations, in part as a response to the McMahon article.  Chief among the changes was what became known as the “immediately available standard”:

VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

This recommendation was Level C evidence, meaning it was based on clinical opinion, not research trials.  Level A evidence, the level with the highest quality research to back it, still stated in the same bulletin that most women with prior cesareans were good candidates for TOLAC.

The problem with the immediately available standard is that most smaller hospitals can’t meet it.  They may not have an anesthesiologist in house 24/7 or enough OBs that there is necessarily one standing by on the ward, ready to perform surgery.  Even large hospitals may not meet this standard if they cannot guarantee that the available doctors will not be busy with other patients.  The standard was not specifically defined, and rather than be concerned that they weren’t meeting it, many hospitals simply stopped offering TOLACs, requiring patients who had previous cesareans to schedule a repeat surgery.

Here’s what happened:

cesarean VBAC graph

The line that ends at the top is the overall cesarean rate.  The line that ends in the middle is the primary cesarean rate, and the line that ends at the bottom is the VBAC rate.  In the mid 1990s, the VBAC rate was higher than the overall cesarean rate, but within a year of the 1999 guidelines, VBAC rates were down to what they had been in 1993, the year before less restrictive guidelines were initially recommended.  But it didn’t stop there.  The rate just kept decreasing.

in 2010, ACOG again issued less restrictive guidelines for VBAC.  Dr. Richard Waldman, ACOG’s president at the time, said,

Given the onerous medical liability climate for ob-gyns, interpretation of ACOG’s earlier guidelines led many hospitals to discontinue VBACs altogether. Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.

The new guidelines stated not only that most women with a prior cesarean were good candidates for VBAC, but that many women with two prior cesareans were as well.

Here’s what happened:

primarycesvbactbl

The rates rose a tiny amount, and remain about half of what they were in 1990.

In 2014, AGOC issued a consensus statement about preventing primary cesareans.  This publication pointed out some of the risks of cesarean over vaginal birth, including a tripling of risk of maternal death.  While some hospitals and doctors have gradually become more receptive to VBAC and have lifted out-and-out bans, some hospitals have instituted new bans since the 2010 and 2014 guidelines were released.

Many providers do not support VBAC and do not present benefits and risks in a way that allows women to make informed decisions.  The website My OB Said What? is full of quotes from doctors misrepresenting VBAC risks:

Attempting a VBAC is comparable in risk to standing your older child out in the middle of a busy highway and hoping she doesn’t get hit by a semi. Maybe the odds of her being hit are low, but you wouldn’t take that risk with your other child, so I don’t understand why you’re willing to risk your unborn baby’s life.

I don’t know where you got the *delusion* that you could VBAC, there was a law that was passed against VBAC’ing after more than one cesarean.

A VBAC is like *jumping off a bridge* in which mortality is close to 90% with a uterine rupture!

When citing risk of “uterine rupture,” many physicians include scar separation in the totals.  Just to clarify, there is a difference between genuine uterine rupture, which is a genuine emergency, and a cesarean scar opening, which is not:

In contrast to frank uterine rupture, uterine scar dehiscence involves the disruption and separation of a preexisting uterine scar. Uterine scar dehiscence is a more common event than uterine rupture and seldom results in major maternal or fetal complications.

So let’s review:

  • When VBACs were recommended as safe in 1994, the rate slowly crept up, reaching over 28% in 1996.
  • The rate began to go down in 1997 in response to a single article, even before recommendations were issued by ACOG.
  • When the “immediately available” standard was introduced in 1999, the rate plunged to its pre-1994 level within a year.
  • 10 years after the “immediately available” standard (level C) was introduced, the rate was 8.4%, even though the Level A recommendations still said that most women were good candidates for TOLAC.
  • Two years after less restrictive standards were introduced in 2010, the VBAC rate had inched up less than 2 percentage points, to 10.2%.  Many hospitals have continued their de facto VBAC bans, some hospitals have introduced new bans, and many physicians still refuse to perform VBACs.

The problem is (as others have also pointed out), why are hospitals not ready to perform an emergency cesarean?  Isn’t that the whole reason to birth in a hospital–that they are prepared for emergencies?  Uterine rupture is not unique to VBAC–it can happen as a result of  any number of complications, including labor inductions.  A hospital that is not equipped to support a TOLAC is not set up to support birth emergencies.

VBACfacts.com has a list of VBAC myths and corresponding correct information.  here is my favorite:

Myth:  If your hospital doesn’t offer VBAC, you have to have a repeat cesarean.

As Howard Minkoff MD said at the 2010 NIH VBAC Conference, “Autonomy is an unrestricted negative right which means a woman, a person, anybody, has a right to refuse any surgery at any time.” ACOG affirms that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.”

If your hospital does not support VBAC, ask them why they are not properly equipped and staffed to perform emergency cesareans.  Then go elsewhere.

 

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.

Image

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:

Image

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.

Medical practice has many issues around informed consent, with many procedures being routinely performed with no shared decision making process, no informed consent, or no permission at all.  Rebecca Dekker of Evidence Based Birth wrote than in her training as a nurse,

I was taught to say, ‘I am going to listen to your lung sounds now.’ My instructors told me that the patient would be less likely to refuse if I simply stated what I was doing, instead of asking permission. I practiced that way– and even taught nursing students that way– for several years. (emphasis mine)

This seems relatively innocuous when it involves listening to lung sounds, but has more onerous implications for pregnancy and childbirth.  Training to make statements is training for practitioners to say, “I am going to cut an episiotomy now” or “I need to do a cesarean.”  It may be true that the procedure is a good idea, but it is not acceptable to tell a woman that you are going to do something to her body.  A woman needs to have to opportunity not only to consent to a procedure, but also to refuse it.

Lithotomy-Now-300x230

Sometimes practitioners do not even say what they are going to do–they just do it.  Sometimes they tell the woman after it has been done, as in this case from My OB Said What?:

‘I gave you an episiotomy.’ – OB to mother after birth. Nothing was mentioned about an episiotomy being needed during the birth, and when the mother screamed in pain when the OB touched her, both the OB and the L&D nurse insisted the OB was just ‘stretching’ her.

Or this one

‘We will go ahead and schedule your cesarean section now.’ —OB to mother with two prior cesareans, at the mother’s 10 week prenatal appointment, after the mother indicated that she wanted to have a VBAC.

Sometimes the practitioner doesn’t tell tell woman anything, and she finds out what happened by reading her chart or talking about her case with a different practitioner, as in this report from Cookieparty at Community Baby Center:

I remember my OB saying he was stitching me and I was like oh I must have torn. He didn’t even tell me he did [an episiotomy], I found out later that day or the next day I think, when one of the nurses was tending to it. [It] pissed me off!

Instruction on “Patient Rights” from The Birth Place of UCLA Medical Center make it sound that their belief is that women do not have the right to refuse what health practitioners want to do in any case.  Their responsibility is to follow the rules and cooperate (emphasis mine):

Patient Responsibilities
As a patient, you have the responsibility to:

  • Treat those who are treating you with respect and courtesy.
  • Be considerate of the rights of other patients and hospital personnel.
  • Observe the medical center’s rules and regulations, including the Visitor and No Smoking policies.
  • Be as accurate and complete as possible when providing information about your medical history and present condition, including your level of pain.
  • Cooperate fully with the instructions given to you by those providing your care.
  • Fulfill the financial obligations of your health care, know your insurance benefits and eligibility requirements, and inform the hospital of changes in your benefits.
  • Provide a copy of your Advance Directive (Durable Power of Attorney for Healthcare) if you have one.

In their Committee Opinion “Elective Surgery and Patient Choice,” the American College of Obstetricians and Gynecologists (ACOG) says that OBGYNs may perform unnecessary surgeries upon a woman’s request, including cesareans, as long as the woman is adequately informed of the risks and alternatives and the OBGYN believes the surgery is not an undue health threat:

Performing cesarean delivery on maternal request should be limited to cases in which the physician judges that it is sufficiently safe, given the specifics of the woman’s pregnancy and setting, and has had the opportunity for thorough and thoughtful conversation with the patient.

In their Committee Opinion “Maternal Decision Making, Ethics, and the Law,” ACOG points out

  • Appellate courts have held…that a pregnant woman’s decisions regarding medical treatment should take precedence regardless of the presumed fetal consequences of those decisions.
  • [M]ost ethicists also agree that a pregnant woman’s informed refusal of medical intervention ought to prevail as long as she has the ability to make medical decisions
  • [I]n the vast majority of cases, the interests of the pregnant woman and fetus actually converge.
  • Because an intervention on a fetus must be performed through the body of a pregnant woman, an assertion of fetal rights must be reconciled with the ethical and legal obligations toward pregnant women as women, persons in their own right….Regardless of what is believed about fetal personhood, claims about fetal rights require an assessment of the rights of pregnant women, whose personhood within the legal and moral community is indisputable.

Two of the main conclusions of this committee opinion are

  • Coercive and punitive legal approaches to pregnant women who refuse medical advice fail to recognize that all competent adults are entitled to informed consent and bodily integrity.
  • Court-ordered interventions in cases of informed refusal, as well as punishment of pregnant women for their behavior that may put a fetus at risk, neglect the fact that medical knowledge and predictions of outcomes in obstetrics have limitations.

However, the obstetric community continues to bully women into acquiescing to procedures that the obstetric team wishes to perform, and women are still persecuted for refusing procedures both legally and socially, even when these procedures are not evidence based.

Even when medical professionals do explain risks and benefits to a procedure, they often expect a woman to draw the same conclusion that they do regarding what should be done.  The flip side of informed consent, however, is informed refusal.  Women not only have the right to know what their options are, they have the right to choose the option they believe is right, regardless of what their health practitioner believes.

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:

big_baby_17961

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.

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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