Archives for posts with tag: shared decision making

American Heritage Dictionary (my personal favorite) defines treatment in a medical context as

a. The use of an agent, procedure, or regimen, such as a drug, surgery, or exercise, in an attempt to cure or mitigate a disease, condition, or injury.
b. The agent, procedure, or regimen so used.
Notice the terms cure and mitigate.
If we go back to the dictionary, cure is
a. A drug or course of medical treatment used to restore health: discovered a new cure for ulcers.
b. Restoration of health; recovery from disease: the likelihood of cure.
c. Something that corrects or relieves a harmful or disturbing situation:
and mitigate is
a. To make less severe or intense; moderate or alleviate.
Thus, we should expect that any medical treatment should make us better than we would be without it.  Yet reporting on a systematic review in JAMA,  the New York TImes recently ran a piece called “If Patients Only Knew How Often Treatments Could Harm Them.”
Perhaps in these cases, we might want to reconsider using the term “treatment.”
The JAMA review, “Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests,” concludes
The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.
But where are patients getting this information?  While some may see advertisements for a handful of drugs, for the most part, patients get information on “treatment” from their doctors.  A commentary on the review suggests limiting advertising and changing product labeling to be more transparent (big thumbs up from me on the second one in particular).  It also says that
[A] physician must first understand the risk herself (or himself) and must then communicate it effectively.  It is not clear that physicians do either of these things well.
Addressing OB care, the JAMA article notes that only 9% of women accurately identified the benefits of a trial of labor after cesarean (TOLAC) over an elective repeat cesarean (ERCS), and only 37% accurately identified risks of a TOLAC. Patients also incorrectly identified the benefits of a fetal abnormality scan (90% overestimated the benefits), and 57% could not accurately identify the risks of amniocentesis.
One of the original articles from the review, Trial of Labor After Repeat Cesarean: Are Patients Making an Informed Decision, states
Women in both groups [TOLAC or ERCS] were insufficiently informed about the risks and benefits of TOLAC and ERCS, particularly women in the ERCS group. Specifically, our patients were not familiar with
  • the chances of a successful TOLAC,
  • the effect of indication for previous cesarean section on success,
  • the risk of uterine rupture,
  • the increased length of recovery with ERCS versus TOLAC
  • the increased risk of maternal death, neonatal respiratory compromise, and neonatal intensive care unit admission with ERCS.

In addition, if our patient felt her provider had a preference, she was more likely to choose that mode of delivery, whereas when patients felt their providers were indifferent or if they were unaware of their providers’ preferences, 50% chose one mode and 50% chose the other.

 Note there is no indication that the women who did not feel the provider had a preference were making their own decisions based on accurate information.
Anecdotal evidence indicates that providers rarely provide accurate information–and sometime provide no information, simply saying, “Let’s schedule your cesarean.”  Some examples:
  • Jessica: I was told I need not waste my time trying to attempt a vaginal birth because it would be another long birth that would ultimately end in another section.
  • Jenerra: “I was always told by my doctors that because I had my first c-section that I would have to keep having them, even though my first c-section was the result of an induction gone wrong.”
  • Kiara: I do believe that [my primary cesarean] was the best outcome for everyone, but I knew that I didn’t want that
    experience again. When I discussed this with my OB, she said ‘Oh, we don’t do VBACs in this practice. When you get pregnant again, we’ll just schedule you like a hair appointment. Easy!’
  • Jamie: [My OB said], “You don’t want to VBAC. You don’t need to tear up your little bottom.”
The JAMA article, which is not focused on obstetric care in particular, does not address other common obstetric “treatments.” For instance, many physicians conduct ultrasounds routinely during pregnancy.  A friend of mine said her doctor never measured her fundal height, instead conducting an ultrasound at every appointment, even though there is no indication that having ANY ultrasounds improves pregnancy outcomes.   Other “treatments” for which women may not be adequately informed of benefits and risks include elective inductions,  Pitocin augmentation, and episiotomies, along with any number of other “treatments” offered in prenatal care, labor, and childbirth.
Women often believe they have no say in these procedures at all, as they are often presented as something that is going to occur rather than a choice that the woman can make.  Unfortunately, though ACOG offers excellent guidelines on informed consent, in practice informed consent is rarely more than a women signing a form that she has no time to read, and informed refusal is never on the table at all.  In fact some recent cases have indicated that in some cases doctors override a woman’s informed refusal, as in the case of Rinat Dray’s forced cesarean and Kelly X’s forced episiotomy.
The New York Times report on the JAMA review states:
This study, and others, indicate that patients would opt for less care if they had more information about what they may gain or risk with treatment. Shared decision-making in which there is an open patient-physician dialogue about benefits and harms, often augmented with use of treatment decision aids, like videos, would help patients get that information.
Unfortunately, shared decision making operates as a buzz phrase rather than a practice most of the time.  Perhaps this uninformed approach to “treatment” is why Marinah Valenzuela Farrell, a certified professional midwife, and president of the Midwives Alliance of North America notes in the New York Times series “Is Home Birth Ever a Safe Choice?” that hospitals carry their own risks.
They just don’t inform you about them.
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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.

 

There has been renewed interest in cesareans in the news (and on this blog) since the release of the ACOG/SMFM consensus statement on preventing primary cesareans in March.  When all health care providers are following best practices, rates of procedures should be relatively similar in patients with similar risk profiles.  This is not so for cesareans, where rates of the procedure in low risk births (singleton, cephalic fetus at term; woman with no health complications) can range from less than 5% to nearly 60% depending on the hospital.

Recently the Contra Costa Times ran a story about the issue in which they quoted Dr. Kirsten Salmeen (whose research interests indicate that she is interested in shared decision making models).  Here is the section of the story in which she comments on practice variation:

Why such profound variations? Should our standards of medical practice be so flexible?

The answer is “complicated” replies Dr. Kirsten Salmeen of the Maternal Fetal Medicine Division at UC San Francisco. She thinks variations in cesarean rates across the country are “likely due to a combination of factors.” That includes differences in patient populations and preferences, provider availability and coverage, hospital and provider culture, access to anesthesia and surgical obstetric services, and the prevailing medico-legal climate.

For example, Salmeen proposed that a difference in rate might depend upon the scope of available obstetrical services. In a hospital staffed with 24/7 obstetric coverage and resourced to provide a C-section when needed, a woman might be allowed more time for labor with a vaginal delivery. In contrast, that may not be as feasible with a solo or small-group provider who’d have to cancel scheduled clinic appointments with many patients in order to wait upon one patient’s labor.

While resource allocation can affect cesareans, in many countries, scant resources mean that women cannot get cesareans that they do need, which is one reason infant and maternal mortality rates are so high in developing nations where hospitals are not universally accessible by birthing women.  It seems preposterous that a lack of resources would lead to more cesareans–it’s how those resources are allocated.

The more important question in terms of shared decision making and informed consent is what women are told when a doctor performs a cesarean.  Are they given the real reasons as outlined by Dr. Salmeen:

  • Does an obstetrician in solo practice say, “Your labor is normal and you and the baby are doing fine but it looks like your birth is going to take several more hours, and I have patients waiting at the office, so is it okay if I just do a cesarean?”
  • Or perhaps in a state with high malpractice claims, the obstetrician says, “Your labor is normal and you and the baby are doing fine, but you had a brief indeterminate fetal heart rate tracing, and if your baby isn’t perfect, you could use that to sue me, so is it okay if I just do a cesarean?”
  • Or perhaps the obstetrician says, “Our culture here at this hospital is to do cesareans on women who don’t really need them, so let’s schedule yours now.”

Somehow, I think not.  Here is a video, intended to be humorous, in which the “OB” convinces a woman to have a cesarean, which “will be way easier” for him:

 

Unfortunately, the kinds of things the actor says are often not that far from things some obstetricians say in real life.

As Dr. Elliott Main (a generally great guy) points out, a doctor can convince pretty much any woman to have a cesarean.  Few women will refuse when a doctor tells them their baby is in danger.

That’s a much easier sell than needing to get back to the office.

 

What is an Episiotomy?

To attempt objectivity in definition, let’s start with the dictionary: episiotomy is “an incision into the perineum and vagina to allow sufficient clearance for birth.”  This means the vagina is cut open to make it bigger, ostensibly to make it easier for the baby to come out.  The cut goes in the direction of the anus.

There are two types of episiotomy: midline, in which the cut is made in a straight line toward the anus, and mediolateral, in which the cut is made at an angle toward one side of the anus.

episiotomy

In a review of the procedure, Cleary-Goldman and Robinson note that technically episiotomy refers to the cutting of the external genitalia, and perineotomy more accurately describes what is called episiotomy in American obstetrical practice.  If you are not squeamish, you can do a search on Google Images for episiotomy and see what they look like in photos rather than drawings.  I mean it about the not squeamish part.

A Short History

There is documentation of episiotomy being performed in the 1700s in particularly difficult and prolonged births.  There is also documentation in this era of using support and lubricants (such as hog lard) to prevent tearing of the perineum during birth.  Accounts in the preceding links differ, but episiotomies appear to have been introduced in the United States in the mid 1800s.  The combination of anesthesia, hospital birth, and routine use of forceps served to popularize episiotomies in the late 19th and early 20th centuries.

In 1918, advocating for episiotomy in a journal article, obstetrician Ralph Pomeroy wrote, “Why should we consider it other than reckless to allow the child’s head to be used as a battering ram?”  Obstetrician Joseph B. DeLee published a subsequent article on episiotomy in 1920 and claimed that episiotomy “preserves the integrity of the pelvic floor, forestalls uterine prolapse, rupture of the vaginal-vesico septum, and the long train of sequalae.”  Doctors also preferred the ease of sewing the straight incision of an episiotomy rather than a tear.

The speculations of  Pomeroy and DeLee were absorbed as truth, and episiotomy became routine procedure for physician-attended births, even though there was no actual evidence to support episiotomy’s effectiveness in preserving women’s pelvic function.  The procedure was not widely questioned or tested by anyone in mainstream obstetrics until the 1990s.

What Happens after Episiotomy?

Episiotomy has sometimes been referred to dismissively as a “little snip,” but like mackerel and pudding, the words vagina and snip should exist far, far away from one another.  Episiotomy can have serious health consequences, including

  • Bleeding
  • Tearing past the incision into the rectal tissues and anal sphincter
  • Perineal pain [short and long term]
  • Infection
  • Perineal hematoma (collection of blood in the perineal tissues)
  • Pain during sexual intercourse [short and long term]

Some women recover quickly from episiotomy and do not report lasting problems.  Some women even request an episiotomy to shorten second stage labor–after hours of pushing, anything to hasten the birth may seem a relief.

For many women, however, episiotomy (which, after all, is a deep cut into the genitals) is traumatic and has long-term effects.  In nearly all cases, an episiotomy is not necessary, meaning that these women suffer while accruing no medical benefit.

Evidence

(See here for a brief explanation of a randomized control trial.)

In 1992, a group of Canadian physicians published the results of a randomized control trial in Current Clinical Trials showing that there was “no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation.”  In addition, they found that almost all severe perineal trauma occurred among women who had median (midline) episiotomies, and that among women who had already had at least one vaginal birth, those who had episiotomies were much more likely to tear and needed more stitches on average than women who did not have episiotomies.

In 1993, a group of Argentine physicians published the results of a randomized control trial in the Lancet.  Their randomized control trial of 2606 women showed that routine episiotomy (rather than “selective” episiotomy) increased risk of severe perineal trauma.  Those in the routine group also showed higher rates of ” posterior perineal surgical repair, perineal pain, healing complications, and dehiscence.”  The study concluded that “[r]outine episiotomy should be abandoned.”

A 1995 study published in the Canadian  Medical Association Journal found that “Physicians with favo[rable] views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience.”  This study also found that the doctors who liked episiotomy had difficulty following study protocols about when to perform the procedure and were more likely to diagnose fetal distress and perform cesareans than their counterparts who did not have favorable views of episiotomy.

Some physicians still try to justify performing episiotomy to prevent tears, but tearing was shown to be preferable to episiotomy in a 2004 Scandinavian randomized control trial: “Avoiding episiotomy at tears presumed to be imminent increases the rate of intact perinea and the rate of only minor perineal trauma, reduces postpartum perineal pain and does not have any adverse effects on maternal or fetal morbidity.”

A 2012 Cochrane Review did not find significant differences between midline and mediolateral episiotomy–both were generally worse than avoiding an episiotomy altogether: “Women [who did not have episiotomies] experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days (reducing the risks by from 12% to 31%); with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth.”

Current American College of Obstetricians and Gynecologists (ACOG) guidelines note that “routine episiotomy does not prevent pelvic floor damage leading to incontinence” and recommend against routine use of episiotomy.  The guidelines note that median (midline) episiotomy is associated with anal sphincter injuries but that mediolateral episiotomy is “associated with difficulty of repair, greater blood loss, and, possibly, more early postpartum discomfort.”

The Royal College of Midwives (RCM, in the United Kingdom) offers the following evidence based reasons for episiotomy:

  • Aid the delivery of the presenting part when the perineum is tight and causing poor progress in the second stage of labour
  • Allow more space for operative or manipulative deliveries, such as forceps, shoulder dystocia or breech delivery (NICE, 2007; RCOG, 2005)
  • Prevent damage of the fetus during a face or breech presentation, or during instrumental delivery
  • Shorten the second stage of labour for fetal distress (Sleep, 1995) or maternal medical condition
  • Accommodate issues associated with female genital mutilation to the benefit of both mother and baby (Hakim, 2001).
  • Episiotomy is contraindicated when there is a high head. In these circumstances, descent will not be assisted.

Note that in the case of shoulder dystocia, the episiotomy is justified only to give the practitioner more room to perform necessary maneuvers.  Episiotomy does not, in itself, help with shoulder dystocia.  As the obstetrical nurse and midwife who blogs at Birth Sense explains:

Many physicians will openly admit that episiotomy does nothing to help facilitate the delivery of a baby with shoulder dystocia, because it is not a tissue problem, but a bone problem. The shoulder is stuck behind bone, and cutting the woman’s perineal tissue does not resolve the problem. Then why do it? Most physicians I’ve spoken with admit it is simply a matter of protecting themselves legally: by cutting a large episiotomy, they can show they’ve done everything they could possibly do to try to deliver the baby.

A recent study by Paris et al concluded episiotomy does not appear to reduce brachial plexus injuries (a rare paralysis associated with shoulder dsytocia):

There were a total of 94,842 births, 953 shoulder dystocias, and 102 brachial plexus injuries. The rate of episiotomy with shoulder dystocia dropped from 40% in 1999 to 4% in 2009 (P = .005) with no change in the rate of brachial plexus injuries per 1000 vaginal births.

Despite the evidence, shoulder dystocia is still commonly cited on popular consumer websites as a reason for episiotomy.

Overall, there are sometimes good reasons to perform episiotomy for the safety of the woman, the fetus, or both.  However, as Kim Gibbon of the RCM notes,

Consent is required for episiotomy, as it woud be for any surgical procedure. Women must be given a full explanation of the nature of the procedure and the situations under which its use will be proposed (Carroli and Belizan, 1999). Ideally, this should occur in the antenatal period so that the woman’s consent can be sought and documented at this stage. Further explanation should be given to the woman when a decision to use episiotomy is made to provide reassurance and confirm consent.

Current Practice

The Leapfrog Group has begun reporting episiotomy rates as one of its maternity care measures.  Unfortunately, reporting is voluntary at the hospital level, so there is only data for a limited number of hospitals (information on how to find the information on the Leapfrog site is at the bottom of the  page *).  Just looking at the data that is available shows enormous variations in practice.  For instance, among the four campuses in the Baptist Memorial Hospital system in Mississippi, rates range from a low of 1.5% at the De Soto campus to a high of 38.8% at the Golden Triangle campus.  Cesarean rates at all four campuses are similar (32% to 35%), so it appears that women who are not good candidates for vaginal birth (as well as a good number who are) have already been eliminated at all campuses.  Skin elasticity is unlikely to vary much by region, so why the variation in episiotomy rates?

A report on the evidence for episiotomy by the Agency for Healthcare Research and Quality (AHRQ) states,

Wide practice variations suggest that episiotomy use is heavily driven by local professional norms, experiences in training, and individual provider preference rather than variation in the physiology of vaginal birth.

Evidence indicates that many doctors have been slow to change practice regarding episiotomy, and that doctors who have not already changed may be increasingly reluctant to do so.  Like recommendations for bed rest, tradition or a “feel good” factor for the doctor may trump actual health outcomes.

Consistent with the findings of the Canadian study of physicians and their views on episiotomy (cited in the previous section), some hospitals with high rates of episiotomy are less likely to adhere to evidence-based maternity practice overall.  For instance, South Miami Hospital (of the Baptist Health South Florida network) has an episiotomy rate of 33.1%.  They also have the highest cesarean rate in the state (62%) and have not reached Leapfrog goals for early elective deliveries (induction or cesarean before 39 weeks for no medical reason).

The AHRQ report appears to give the most accurate reason for continued use of episiotomy at high rates: provider preference. One obstetrician quoted in the New York Times said that during her residency, “Fifty percent of the episiotomies I’ve done were because my supervising staff wanted to go back to bed.” According to this Times story, the quoted doctor has a colleague, who “‘loves epis’ and cuts them during almost every vaginal birth.”

Mothers’ reports from My Ob Said What? indicate that time is indeed  more important to some doctors than the integrity of women and their vaginas.  One mother reports questioning why her OB performed an episiotomy and was told, ““Why did I just do an episiotomy? I did an episiotomy because you would have been pushing for another 20 minutes!”  A friend of mine had an OB who told her, “Which do you think is easier for ME to sew up–a straight cut or a jagged tear?” (my friend switched practitioners).  A study by Webb and Culhane found that obstetrical procedures such as episiotomies increased at peak times in Philadelphia hospitals, to the detriment of women:

The fact that incidences of 3rd or 4th degree lacerations are high at roughly the same times that procedure use is high is consistent with what is known about the risks associated with episiotomy and vacuum/forceps use, and suggests that efforts to influence the timing of births through more liberal use of obstetric interventions may increase the morbidity associated with vaginal delivery.

Although rates of episiotomy have decreased drastically overall, some doctors do still perform them routinely, as this doctor indicated to a first-time mom who requested not to have one: “Well, we’ll see. I find that pretty much all of my first time mothers require an episiotomy.”

In addition, like the woman above, many women do not consent to episiotomies, but are cut anyway.  After one woman told her OB she did not want an episiotomy and preferred to tear (which is evidence based according to the Scandinavian study cited above), her OB told her, “I’m just giving you an episiotomy anyway.”  Another woman commented at the Chicago Tribune,

When I was pushing out my third child, my doula nudged my husband and told him that the OB was preparing to cut an episiotomy. The OB had not asked me if it was ok, and hadn’t even mentioned it. My husband piped up and said, “My wife doesn’t want an episiotomy.” He said that twice. The OB ignored him and injected me with the lidocaine. I finally clued in and shouted “I do not consent to an episiotomy” two times before the OB put her scissors down. Two times!! The kicker is that I didn’t tear. Not one bit. The episiotomy would have been completely unnecessary.

A 2005 comprehensive review in the Journal of the American Medical Association (JAMA) concurs with the above comment (emphasis mine):

The goals for quality of care must remain focused on both optimizing safety for the infant and minimizing harm to the mother. Given that focus, clinicians have the opportunity to forestall approximately 1 million episiotomies each year that are not improving outcomes for mothers.

While women sometimes successfully sue for episiotomies that are botched, as with cesarean (see this December 23, 2013 post), it is difficult to win a suit for an episiotomy performed without consent.  Generally, a doctor argues that the procedure was in the best interest of the fetus, and the woman’s rights cease to matter.

But women do matter.  Their pain matters.  Their sexual pleasure matters.  And most of all, their informed consent to what is done to their own bodies matters.  Practitioners may want to believe that they know better than their patients and can therefore slice and dice as they please.  They may believe that it is acceptable to sacrifice women’s bodily integrity to their own convenience.  Such a stance turns a woman into an object, a vessel who can be treated in any fashion as long as her body yields a healthy baby.  Women and those who love them must stand for a woman’s right to be human in childbirth — and always.

*To do a comparison of episiotomy rates at hospitals, click the Leapfrog Group link.  On the Leapfrog page, select “state” in the search by menu, select your state, and accept the terms of use.  On the next page, click the “Maternity Care” tab.  If there are any green bars in the “rate of episiotomy” column, click the blue question mark, and the rate will come up in a new window.

Dr. Paul Burcher has responded to my post “Is This OB Ethical” with a comment.  I would like to thank Dr. Burcher, and before I go on, here is the entire (verbatim) text of his comment:

This is Paul Burcher. You reference me in your blog, and I think you have made some incorrect pre-judgments about who I am. I am a practicing Ob/Gyn (true) and a PhD ethicist (also true) but I am no fan of Frank Chervenak’s position on home birth (if you google me you will see that I have collaborated extensively with, and defended midwives and home birth. I quoted Chervenak on a completely separate topic where I am with him–that talking with woman before labor, about labor, can reduce or eliminate misunderstandings and conflict. The “maybe” category that I wrote about is not a bait and switch as you suggest. As I wrote about in the Journal of Medical Ethics, how would you respond to a birth plan where the woman insists that no matter what happens in labor, and even if she requests it, that I must refuse her an epidural? As you know labor (and life) are fluid, and sometimes we don’t know “till we get there.” So maybe is maybe, and it means just that. The “non-starter” category is for me both real and small. I value patient autonomy, but it isn’t the only value in the room, and physicians also have values that must be respected by patients. If I say I can’t participate in what a patient requests, that is also my right. I rarely just say no, and I bend a lot even pushing beyond comfort zones at times.But physicians must be also be able to make rational and value laden choices–they must also be autonomous. These words don’t really express how it has played out in my practice, but I have 18 years in practice with almost no conflict with my patients, because I am respectful (and because I worked with midwives I have had strong-willed, conscientious women with alternative values as patients for much of this time).

I am honestly touched that Dr. Burcher cared enough to read and comment on my post, which I think gives much credence to what he says here about his respect for women.  If he didn’t care very much about his integrity and that of his practice, I’m sure he would not have bothered.  His “full biography” on the Albany Medical Center website states, “Dr. Paul Burcher specializes in general obstetrics and gynecology and women’s health. As an ethicist, he has a particular interest in the doctor/patient relationship and physician empathy.”  My post might have been more fair minded had I spent some more time researching his background.

For instance, I tied Burcher to Frank Chervenak because he begins his column by citing Chervenak’s idea of preventive ethics.  Dr. Chervenak’s attitude toward homebirth and midwifery is uninformed and patronizing, and because of the citation, I tarred Burcher with the same brush.  Burcher is not anti-homebirth, as evidenced by this piece about a woman who had a stillbirth while attended by unlicensed midwives.  This piece was co-written with Colleen Forbes, a licensed midwife (who is not a CNM, the kind of midwife who usually practices in hospitals–you can read a description of the various kinds of midwives here) and does not condemn homebirth.  He was also quoted in this piece in the New York TImes about the risks associated with episiotomies and the importance of women making informed decisions.  I think Burcher and I probably agree about many–even most–aspects of obstetric care.

I think some of the issues I have with Burcher’s column have more to do with audience than anything else.  In writing for other obstetricians, Burcher certainly had to appeal to them.  And defending the right of women to have birth plans and encouraging obstetricians to take them seriously is an important and noble undertaking.  I should have been less glib in my introduction and offered him more respect for his efforts.  I, on the other hand, am writing as a passionate advocate for women’s autonomy and agency, and my audience is those who are interested in that perspective.  I do not wish to imply that Burcher does not value women’s agency and autonomy, but we may approach the concept differently.

I do have problems with preventive ethics, at least as they are conceived by Chervenak.  I mentioned in particular Chervenak et al’s  piece “Obstetric Ethics: An Essential Dimension of Planned Homebirth” in which he states strongly that it is an obstetrician’s duty to convince women not to birth at home and to birth at a hospital.  Chervenak carries his ideas about obstetrical judgement based in beneficence to the conclusion that the obstetrician must convince a woman to do what the obstetrician thinks is best.

However, a woman may have vastly different values that lead her assessment on a very different path.  Anne Faidman’s wonderful book The Spirit Catches You and You Fall Down offers numerous examples of this conflict between the values of doctors and those of their patients.  While the book is primarily about the care of an epileptic child in a Hmong family, there are also a number of examples given about childbirth.  One section noted that many of the Hmong women in the book preferred to give birth with a little-respected family physician because he did not “cut” (meaning episiotomies and other surgical procedures–cutting the body is anathema to traditional Hmong beliefs) and because he would hand over the placenta to the family (the placenta was used in important post-birth rituals).  The more highly respected obstetricians held their own clinical judgment in higher esteem than the beliefs and values of their Hmong patients, and the patients sought care elsewhere.

Burcher, it seems, has a different approach to the idea of “preventive ethics” than Chervenak, one that is a true exchange involving shared decision making.  He is right to be honest with women about what is not possible, either because of structural constraints (the hospital will not allow it) or ethical ones (the doctor believes s/he cannot in good conscience provide what the woman requests).  I said in my original post that I though he had a reasonable approach to “non starters.”  I might even go further than he did on the “refuse me an epidural no matter what” question.  I would not be willing to work with a woman who gave up her autonomy and made me the gatekeeper of her care.  That is not shared decision making.

My issue with the “maybes” had more to do with Burcher’s  concerns about his colleagues and their approaches to care.  I understand that “maybe” is circumstantial–my position was that really the maybes are either “of courses” or “non-starters,” depending on the emergent situation.  It’s impossible to go through every possibility in advance to know which would be which.  While Burcher himself might be working with his patients to make sound decisions in the moment on the “maybes,” I do worry that many practitioners view the “maybe” as a way to placate women, with the situations in which the “maybe” becomes an “of course” so limited that the “maybe” is more accurately categorized as a “non starter.”  In my original post, I gave the example of the way many practitioners approach VBAC requests.  Again, if there is an evidence-based reason to do something, what would be the justification for removing that possibility based on a practitioner’s “comfort zone”?  Is the practice evidence based or not?  Is it safe or not?  It seems there are very limited situations in which the practitioner herself/himself would be the determinant (for example, an exception would be vaginal breech birth, which many practitioners no longer know how to attend safely).

Albany Medical Center, where Burcher practices, has a cesarean rate over 40%, indicating that much of the time, Burcher’s colleagues are not adhering to evidence based practice.  I am concerned that many doctors are happy to follow women’s non-evidence based requests when it suits them — for instance, performing non-medically indicated cesareans or inductions — but are not willing to comply with requests that are evidence based, such as eating during labor, laboring in water, or freedom of movement during labor.  I am also concerned that many physicians use non-evidence-based practices routinely, such as continuous electronic fetal monitoring for low risk women, routine oxytocin (Pitocin) augmentation,  routine amniotomy (breaking the bag of waters), or prophylactic cesarean for suspected macrosomia (big baby). Some practitioners view these practices as non-negotiable, and some hospitals institute them as protocol even though a woman’s request to forgo them is based in science while the practices themselves are not.

Burcher says, “If I say I can’t participate in what a patient requests, that is also my right.”  I agree with Burcher that the conflict between the rights of the patient vs. the rights of the practitioner are real and ethically complex.  I have written about conflicts in these rights here and here, and I am sure I will have future posts exploring this fraught issue.  It sounds as if Burcher’s decisions are generally based in evidence and ethics, but I do not have confidence that all practitioners abide by Burcher’s standards.  Is it ethical for a physician to refuse to provide evidence-based care because for some reason the evidence does not coincide with the physician’s “comfort zone”? Is it ethical for the physician to insist on non-evidence-based care, or care that has substantial evidence of harm, because it does fall within the “comfort zone”?  While I believe that physicians, like their patients, are autonomous beings, I would not want them to answer yes to these questions.

And thus I still ask if it is ethical for a colleague to refuse to follow a birth plan that Burcher has negotiated with a woman, and for Burcher to present that as acceptable.  “Maybe” should depend on the evidence and a shared decision making process, not on a nebulous, one-sided “comfort zone.”

I have heard that some women have painless labors, though I have never met one of these women personally. However, from my personal experience, childbirth was not the worst pain I ever experienced–having my wisdom teeth out was much, much worse.  Plus, after the oral surgery, all I got was some stumpy, bloody teeth.  It was much more fun to get a baby.

That said, women are often terrified of childbirth pain, and analogies abound: take your lower lip and pull it over your head; piss a pingpong ball; poop a watermelon.

So generally women want to plan for some pain relief in labor and birth.  For reasons I don’t completely understand, what this relief entails becomes a matter of controversy.

The Bible justifies pain in birthing as a punishment for Eve’s sin in the Garden of Eden.  The New International Version of the Bible translates Genesis 3: 16 as, “I will make your pains in childbearing very severe; with painful labor you will give birth to children.”  You can read the predictions of  birth agony in various translations here: http://biblehub.com/genesis/3-16.htm

As such, when chloroform, ether, and other chemical/pharmaceutical/medical forms of pain relief became available in the 1800s, there were objections to their use on religious grounds because great pain and suffering during childbirth were seen as being ordained by God.  I am not Jewish or Christian, but it seems to me there is not a marked difference in the use of pain relief among Biblical believers vs. non-believers (except perhaps on the most extreme end of the spectrum).  You can read more about the social history of anesthesia here: http://ecti.english.illinois.edu/reviews/52/vannatta-snow.html

Some people now proclaim that wanting “natural” childbirth, or childbirth without chemical, pharmaceutical, or medical forms of pain relief, is anti-woman or anti-feminist.  And certainly denying women these forms of pain management (in a process involving shared decision making and informed consent) would be a terrible thing to do.  However, forcing women to have this kind of pain management or not informing them of their other options hardly seems “pro-woman.”

There are many ways to relieve pain.  We go through pain all the time in major and minor ways–sometimes we medicate it and sometimes we don’t.  Techniques such as deep breathing, distraction, counter pressure, heat, cold, water, massage, acupressure, dim light, and myriad other things can be effective in managing all kinds of pain, including labor and birth pain.  No one should tell women that these are her only possible options for pain relief either (unless she is in a situation where that is actually true, such as a surprise birth on the bus).

However, some people discount non-chemical, pharmaceutical, or medical forms of pain relief as no pain relief at all.  For instance, a recent article in Harvard Magazine about rising cesareans rates said that one woman profiled had “written up a “birth plan” that included trying to go without pain relief.”  I really, really doubt that her goal was to go without pain relief.  Who in their right mind says, “Let me feel every bit of  pain.  Let’s heighten the pain potential–bring it on!” (the article is available here : http://harvardmagazine.com/2012/11/labor-interrupted)

As such, while birthing centers are quite clear that they do not offer chemical, pharmaceutical, or medical forms of pain relief, hospitals are not always clear that they do not offer, suggest, or support non-chemical, pharmaceutical, or medical forms of pain relief.  For instance, if you ask a hospital if they have tubs for laboring women (birthing centers sometimes call these “aquadurals”), they may say “we don’t allow water birth.”  Getting water-based pain relief in first stage labor does not mean one has to deliver in the tub (though through shared decision making and informed consent, it seems that choice should be up to the woman as well).  Some hospitals will say a woman can bring her own tub.  It’s hard to imagine a situation where it would be suggested that a woman bring her own epidural.

No one gives marathon runners a hard time for wanting to run marathons.  In fact, running a marathon is usually seen as an achievement to be lauded.  To laud a women who wants to birth without an epidural or other drugs, however, is somehow seen as demeaning to women who do want epidurals or drugs.  Is a marathon runner demeaning to non-marathon runners?  Even if the marathon runner is actually proud of having run the marathon while you get a little winded when you go up the stairs too fast?

Women are capable of making their own decisions about pain relief, but first they need to know their options.  These options then need to be available.  Having a plan for an unmedicated birth also does not mean a woman can’t change her mind–just as deciding to run a marathon does not make it mandatory to finish it.  Even in a birthing center, a woman may choose to transfer to a hospital in order to get an epidural.  This happens.  And just as the marathon runner might be disappointed not to have finished the race, there is nothing wrong with a woman feeling a little disappointed if her pain relief  or other birth plans went awry.

There is no reason to demean any woman’s informed choice about pain relief in labor and birth, nor to deny or denigrate the forms of pain relief a woman ultimately chooses.  What it is important to do is provide complete and accurate information, make a full array of choices available, and support a woman’s plans and ultimate decisions.  That is being pro-woman.

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