Archives for posts with tag: Vaginal birth

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.

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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.

In response to the recent New England Journal of Medicine article “A Randomized Trial of Planned Cesarean or Vaginal Delivery for Twin Pregnancy,” Michael Greene, chief of  obstetrics at Massachusetts General Hospital in Boston, published an accompanying editorial, “Delivering Twins.”  As I mentioned in my previous post, you must have a subscription to NEJM to read the editorial (or have access to a library that does).  I am going to offer some analysis here anyway.  This post is a little technical because the editorial is from a medical journal. But read on–it’s important stuff!

A quick primer: An RCT is a randomized control trial.  It is the gold standard for evidence based medical practice.  People who meet the criteria to be in a study are put into two groups by random assignment (like a lottery or counting them off 1, 2, 1, 2).  One group gets the usual treatment and the other group gets the treatment that is being tested.  Then the researchers use statistical testing to see if the people who got the new treatment had better outcomes than the people who got the usual treatment.  If the outcomes are the same, we might look to see if one of the treatments has other advantages, such as lower cost.

Now for the analysis:

Greene’s editorial excuses current practice from thoughtful debate and offers conjecture on why planned cesarean is a better route for twin deliveries despite the evidence from the RCT.

In his first paragraph, Greene explains the rise in twin pregnancies, which are more likely in older mothers and women who get pregnant through assisted reproductive technologies.  Both of these circumstances have become more common.

He then discusses the rise in cesarean rates (under 5% in the 1960s, around 21% in the mid 1990s, but almost 33% today), and particularly the rise in cesareans for twins (around 54% of twins were delivered by cesarean in the mid 1990s, but around 75% are today).  We then get this statement:

Although the national perinatal mortality rate has fallen steadily during this time, from 14.6 deaths per 1000 births in 1985 to 10.5 deaths per 1000 births in 2006, it remains legitimate to ask whether all those cesarean deliveries were necessary to ensure the lowest possible maternal and perinatal morbidity and mortality.

First, Greene conflates correlation and causation, an error scientists loathe in the general public.   Recent studies have not attributed declines in perinatal death to an increase in cesarean section–not even through correlation.  The CDC notes that much of the decline in perinatal death is decline in fetal death, which implies that there is better prenatal care for women,  which allows for conditions that can cause fetal demise (e.g. uncontrolled diabetes) to be treated more effectively. Perinatal death is also reduced by developments in neonatal care, as evidenced by the steadily declining age of fetal viability.  In fact, having had a previous cesarean is linked to an increase in perinatal death rates.

The second (and perhaps more egregious) aspect of this statement is that it does not point out that maternal mortality has nearly doubled during the same period, making the United States one of the most dangerous developed nations for birthing mothers despite having the highest childbirth costs in the world.  While there is no definitive link between decreased perinatal mortality and cesarean for the period Greene cites, there is a link between maternal mortality (and morbidity) and cesarean during this period.  It is true that maternal death is much rarer than infant death, so the absolute risk for women is small, despite the relative risk being high (see this post for an explanation of absolute vs relative risk).  However, physicians generally  consider relative risk very seriously when it comes to infant outcomes, as evidenced by the intense antipathy most obstetricians have for planned home birth.

It seems if Greene were keeping up with literature, he would be aware that the question he says is “legitimate” to ask–“whether all those cesarean deliveries were necessary”–has already been answered.

Greene goes on to note that “many, but not all” observational studies have indicated that planned cesarean for twin births is preferable.  He goes on to note that

…these observational studies are inevitably vulnerable to criticisms regarding potential biases and inadequate adjustment for relevant covariates.

He then goes on to explain that the new study is a randomized control trial (RCT).  The RCT is the gold standard of medical research.  Cochrane reviews (which set international standards for evidence-based care) generally base their recommendations on the results of RCTs.  ACOG puts practice guidelines into three categories, with “A” being the highest ranked.  “A” guidelines are based on evidence from RCTs.

After giving an overview of the study design and results, Greene asks,

How should patients and practitioners view the results of this study, which showed no significant differences in important fetal, neonatal, or maternal outcome measures on the basis of the planned route of delivery?

His response is that many women delivering twins would up having cesareans even if they planned for vaginal birth (of course, this happens to a large number of women with uncomplicated singleton pregnancies as well).  He then offers this zinger:

the results of this study suggest that a plan to deliver appropriately selected sets of twins vaginally is a reasonably safe choice in skilled hands.

First of all, the study already put limits on cases where vaginal birth should be considered, the primary condition being that the first twin had to be head down (the second twin could be head down or breech).  Why the caveat about “reasonably safe”?  The study found that planning a vaginal birth is just as safe as planning a cesarean birth under the the criteria specified in the study.  And what is this about “skilled hands”?–is he implying that many obstetricians aren’t skilled?  Delivering twins, as he pointed out earlier, is an increasingly frequent occurrence.  Why would OBs not be trained in this important skill?  About 10% of the planned cesareans in the study wound up being vaginal deliveries, indicating that an OB must be prepared to deliver twins vaginally even when a cesarean is planned.  The chain of logic then indicates that if the OB’s hands aren’t skilled enough to do a vaginal delivery of twins, the obstetrician should not be caring for women with twin pregnancies.

Greene then goes on to suggest that the study did not have enough power to detect very rare occurrences that (he believes) would show cesarean to be the safer route.  This is disheartening, as doctors often cling to technocratic practice in spite of copious evidence from observational studies, saying that they can only trust the results of an RCT.  Here, we have the opposite–the observational studies offered some support for planned cesarean over planned vaginal birth, and the RCT does not.  But Greene still suggests that current practice should continue in accordance with the findings of the observational studies.  His response offers further indication that many obstetricians privilege technology over science and choose to remain entrenched in current practices in the face of contrary evidence  (an idea also reinforced by the article’s accompanying video featuring supine birthing positions).  For Greene (and many other American OBs), technocratic practice is normal , and  “natural” (physiologic/normal/biological) practice is the deviation.

Greene also does not discuss costs.  In general, cesareans are far most costly than vaginal births, so if the outcomes are identical, why would one have a preference for the more expensive option?

Jon Barrett, the lead on the research study, was “dismayed” by Greene’s response and said, “Rather, I hope the findings will be a wake-up call, a reminder that natural birth should be the preferred option.”  Amen, Dr. Barrett.

And perhaps, most important of all, both Dr. Greene and Dr. Barrett should mention the importance of giving women information to make their own decisions.

A new study was just released on best practice for twin delivery: planned c-section or planned vaginal birth.  You can read lay-versions of the study from the Los Angeles Times, Medscape, and the Daily Globe and Mail (the leads on the study are Canadian).  You can also watch a video outlining the study where the article appears on the New England Journal of Medicine website (note that the woman birthing vaginally in the video is on her back–not an evidence based position for birthing).

The basic conclusion of the study is that in absence of complications, there is no reason to plan a cesarean for a twin birth.  While many women who plan vaginal twin births still wind up facing complications that lead to cesareans, well over half successfully deliver vaginally.  Among women who had planned twin cesareans, outcomes were no better than among the planned vaginal birth group (in which the majority of cesareans were not planned and would therefore be classified as “emergency” cesareans).  One of the only differences found was that, on average, the vaginally birthed twins gained about a day of gestational age before birth, a small gain that can make a big difference for a preterm infant.  Nearly half of the twins in the study were born preterm (before 37 weeks gestation).

Despite the finding that there is no advantage to planned cesarean, according to the Globe and Mail article

Michael Greene of the department of obstetrics and gynecology at Massachusetts General Hospital in Boston said that while the outcomes are the same, “these results do not indicate that all sets of twins should be delivered vaginally.” Rather, he said that decision should rest with the obstetrician-gynecologist and that current practices – 75 per cent of twins born by C-section in the United States – should remain.*

Should remain.  Should.

And the decision should rest with the obstetrician-gynecologist.  Not with the person giving birth.  With the person who is not.

Because if you are a pregnant woman, planning major abdominal surgery when there is no advantage to you or your infants should be your doctor’s choice?

As the title says, fun and profit.

The study notes that even under current practice, about a quarter of twins are born vaginally, so there must be OBs who support planned vaginal birth even without the results of randomized control trial (RCT, considered the gold standard for evidence-based practice) that show it is safe as the alternative.

I would always recommend working with OBs who practice evidence based medicine and with OBs who don’t feel that their own preferences entitle them to perform unnecessary surgery on other people.

* Michael Green has an editorial in the NEJM to accompany the twin study article.  Here is the link, but you need a subscription to read it.

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