Home > General OB/GYN Topics, Obstetrics > Protracted thoughts on protracted labor…

Protracted thoughts on protracted labor…

When I was an intern in Charleston, SC, I quickly learned the importance of the labor curve.  When checking out with my chief, I was often asked the question “Is she on the curve?”  Quickly I learned the idea that women that “fall off the curve” were in a dysfunctional labor pattern, and were more likely to require a cesarean delivery.  I dutifully listened to all this, and did many a cesarean for active phase arrest.  As a junior level I did the cesareans, and as chief I called them.  But at the same time, I had doubts about all of this.
I’ve always thought that to deliver a baby by cesarean for an active phase arrest is to say either “I think this baby will not deliver” or “I think this baby will not deliver without injuring itself or the mother.”  Certainly one of these things is clearly true in some occasions, demonstrated by the scores of women with vesicovaginal fistulas in countries where there is no ready access to cesarean delivery.  But still, I always felt like the number of these cesarean deliveries was too high.   It is really possible that ten or fifteen percent of pregnancies are destined to end in a baby so stuck it can never deliver without injury?   Given the apparent success that is human reproduction, it just seemed unlikely to me.

The same thought has carried on to our management of the second stage.  Early in my internship I was taught that if a primiparous woman with an epidural was not delivered after three hours of second stage labor, it was time for forceps or a cesarean section, and we did a lot of these as well.  Some of these babies were massive, and the cesarean in those cases felt righteous.  Nothing was more relieving than pulling out a ten or eleven pound baby from a hysterotomy.  A shared smile between residents and a nod from the attending “that one wasn’t coming out from below!”  But sometimes the baby was only 7 pounds, and one had to wonder if you could say the same.   Was that average sized baby that wasn’t delivering really destined to die in there?  Seemed unlikely.

Added on to all this was the apparent truth that cesareans for arrest were not distributed equally across 24 hours of the day.  In fact, there were two prime times – late afternoon and around 4-5 AM: the few hours before the morning and afternoon board checkouts.  Nobody wanted to leave this inevitable cesarean for the next team.  Later in practice I saw these concerns coming into play even more among private practitioners who did not have the luxury of waiting for an unlikely vaginal delivery, being pressured by their full offices or waiting families.  As was demonstrated by Steven Leavitt in Freakonomics, humans respond to incentives.  And there are plenty of non-medical incentives to cut.

In my first position after residency at the University of Hawai’i, I saw a lot of women given a lot more time to deliver that Friedman would have recommended, and I saw that a lot of them delivered.   Perhaps due to cultural differences, or perhaps because the patient to resident ratio precluded close following of every low risk mother, people weren’t in such a hurry to deliver protracted patients.   And remarkably, a lot of mothers delivered that might have been cut where I had trained.  But perhaps it was the population: wide pelviced Polynesians rather than African Americans, and fewer teenage mothers.  It certainly played a part: after a few years I stopped being amazed at the ease at which a Samoan mother would deliver a ten or eleven pounder.  The idea of pre-emptive section for macrosomia seemed almost ridiculous.

And so, I have many questions about this, none of which I have answers for.   Was Friedman just wrong?   Does his curve describe something that just doesn’t exist anymore?  To be sure, the population he studied is not who we are caring for now.   His population was primarily women without epidurals who entered active labor.   We now use epidurals in the majority of labors, and labor induction is quite common, perhaps even the rule in some practices.  And given the large effect of genetics I saw in just two different places, can we really extrapolate Friedman’s data to all women?  And what about people who labor outside of the hospital?  What percent of them meet the definition of arrest yet go on to deliver, blissfully ignorant of their temporary fetal impaction.

Clearly, I don’t have answers to all of this, but it does make me think – and it has changed my practice.   I residency I pretty much cut when people hit two hours of arrest, and either pulled or cut at three hours of second stage.   These days, I wait it out, particularly if the strip looks good.   And I almost never cut a multiparous woman for arrest.  It just is too bizarre to me that a woman who did it before wouldn’t be able to do it again.

My biggest problem with all this is the question of what I should be teaching my residents.  Friedman’s curve is easy to teach, because it is objective.  The problem is that it may not be right.  But can I teach that it is wrong? And if so, what should I replace it with?  I don’t know.  For now I try to model benign neglect of putatively arrested women with reassuring fetal heart rate tracings…. at least until board checkout.

When I was an intern in Charleston, SC, I quickly learned the importance of the labor curve.  When checking out with my chief, I was often asked the question “Is she on the curve?”  Quickly I learned the idea that women that “fall off the curve” were in a dysfunctional labor pattern, and were more likely to require a cesarean delivery.  I dutifully listened to all this, and did many a cesarean for active phase arrest.  As a junior level I did the cesareans, and as chief I called them.  But at the same time, I had doubts about all of this.
I’ve always thought that to deliver a baby by cesarean for an active phase arrest is to say either “I think this baby will not deliver” or “I think this baby will not deliver without injuring itself or the mother.”  Certainly one of these things is clearly true in some occasions, demonstrated by the scores of women with vesicovaginal fistulas in countries where there is no ready access to cesarean delivery.  But still, I always felt like the number of these cesarean deliveries was too high.   It is really possible that ten or fifteen percent of pregnancies are destined to end in a baby so stuck it can never deliver without injury?   Given the apparent success that is human reproduction, it just seemed unlikely to me.

The same thought has carried on to our management of the second stage.  Early in my internship I was taught that if a primiparous woman with an epidural was not delivered after three hours of second stage labor, it was time for forceps or a cesarean section, and we did a lot of these as well.  Some of these babies were massive, and the cesarean in those cases felt righteous.  Nothing was more relieving than pulling out a ten or eleven pound baby from a hysterotomy.  A shared smile between residents and a nod from the attending “that one wasn’t coming out from below!”  But sometimes the baby was only 7 pounds, and one had to wonder if you could say the same.   Was that average sized baby that wasn’t delivering really destined to die in there?  Seemed unlikely.
Added on to all this was the apparent truth that cesareans for arrest were not distributed equally across 24 hours of the day.  In fact, there were two prime times – late afternoon and around 4-5 AM: the few hours before the morning and afternoon board checkouts.  Nobody wanted to leave this inevitable cesarean for the next team.  Later in practice I saw these concerns coming into play even more among private practitioners who did not have the luxury of waiting for an unlikely vaginal delivery, being pressured by their full offices or waiting families.  As was demonstrated by Steven Leavitt in Freakonomics, humans respond to incentives.  And there are plenty of non-medical incentives to cut.
In my first position after residency at the University of Hawai’i, I saw a lot of women given a lot more time to deliver that Friedman would have recommended, and I saw that a lot of them delivered.   Perhaps due to cultural differences, or perhaps because the patient to resident ratio precluded close following of every low risk mother, people weren’t in such a hurry to deliver protracted patients.   And remarkably, a lot of mothers delivered that might have been cut where I had trained.  But perhaps it was the population: wide pelviced Polynesians rather than African Americans, and fewer teenage mothers.  It certainly played a part: after a few years I stopped being amazed at the ease at which a Samoan mother would deliver a ten or eleven pounder.  The idea of pre-emptive section for macrosomia seemed almost ridiculous.
And so, I have many questions about this, none of which I have answers for.   Was Friedman just wrong?   Does his curve describe something that just doesn’t exist anymore?  To be sure, the population he studied is not who we are caring for now.   His population was primarily women without epidurals who entered active labor.   We now use epidurals in the majority of labors, and labor induction is quite common, perhaps even the rule in some practices.  And given the large effect of genetics I saw in just two different places, can we really extrapolate Friedman’s data to all women?  And what about people who labor outside of the hospital?  What percent of them meet the definition of arrest yet go on to deliver, blissfully ignorant of their temporary fetal impaction.

Clearly, I don’t have answers to all of this, but it does make me think – and it has changed my practice.   I residency I pretty much cut when people hit two hours of arrest, and either pulled or cut at three hours of second stage.   These days, I wait it out, particularly if the strip looks good.   And I almost never cut a multiparous woman for arrest.  It just is too bizarre to me that a woman who did it before wouldn’t be able to do it again.

My biggest problem with all this is the question of what I should be teaching my residents.  Friedman’s curve is easy to teach, because it is objective.  The problem is that it may not be right.  But can I teach that it is wrong? And if so, what should I replace it with?  I don’t know.  For now I try to model benign neglect of putatively arrested women with reassuring fetal heart rate tracings…. at least until board checkout.

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  1. November 8, 2009 at 5:07 pm | #1

    “What percent of them meet the definition of arrest yet go on to deliver, blissfully ignorant of their temporary fetal impaction.”

    Would you ever consider asking an out-of-hospital midwife for their opinion? I’m sure Amy Romano could provide you with some contacts (she being one).

    Since you’re discussing sectioning for suspected macrosomia, what do you think of ACOG’s current practice guidelines for fetal macrosomia? Any thoughts as to why there is such a disparity between practice and these established guidelines?

  2. November 9, 2009 at 3:45 am | #2

    I had a feeling I would find Jill commenting here as well! Jill, Nicholas told me this weekend that there’s a home birth midwife among his extended family, so I suspect he has discussed this with her.

    But I’ll weigh in.

    I loved this post. Thanks. I’m sure you and I handle long labors differently, but we agree on one thing. We practice and teach some version of the following:

    A faster birth is not intrinsically better or safer. Hastening a labor by artificial means should be done only if it:
    *will avert maternal or fetal/neonatal injury
    *will reduce maternal suffering
    *will reduce the likelihood of an operative delivery

    Unfortunately, we don’t have data that help guide us based on these criteria, so we make clinical judgments. Of course I have referred women for cesareans and assisted vaginal births for protracted or arrested labor. But I have also slept on 2 different women’s couches whose contractions completely halted at 7-8 cm x 8 hours. Both delivered vaginally (one was a compound presentation and got pitocin and an epidural after hospital transfer.) Some women’s bodies just need more time. I can’t imagine anyone at any hospital allowing 8 hours of no contractions (and no progress) when the woman has already progressed to what should be transition.

    One of the things that bothers me about Friedman is that it assumes that “average” equals “normal” and that statistical outliers are pathological. But all normal phenomena have statistical outliers. And anyone who has attended enough births has seen tight shoulders or even a true shoulder dystocia after a perfectly “normal” length labor.

    I understand that there is a “contemporary” labor curve currently being studied by ACOG. Participating centers had to have electronic health records and do a certain number of births per year, which automatically excluded all home and birth center practices and most if not all community hospitals, where labor may be managed more physiologically. Whatever curve they come up with will describe how labor is managed, but it is unlikely to give useful information about how long is “too long.” After all, it is most certainly not going to be measuring physiologic labor progress, even if they have enough women in the study who birthed without pitocin. And if the curve shows harms from longer labors, how do we know these harms are intrinsic to long labor and not attempts to speed it up. Indeed, many things that speed up labor can harm mothers and/or babies and increase the likelihood of operative deliver. Pitocin, AROM, fundal pressure, coached pushing, episiotomy, etc. On the flip side of that coin, we can create the need for these interventions by offering women labor environments that are likely to slow down labor or make it more difficult to cope – stick them in bed, bright lights, strangers, no effective pain relief options except epidurals available, etc.

    I give a talk on optimizing labor progress and talk about “Four Preventive P’s” rather than the 3 P’s and other variations, all of which I think address how to treat rather than prevent dystocia.

    Briefly, the four P’s are:

    Permission – freedom of movement, autonomy in decision making, freedom to vocalize, throw up, ask for help, or whatever it is the woman needs to do to get her baby out.

    Physical environment – there are some intriguing pilot studies showing beneficial effect of simple alterations like removing the labor bed and/or giving women freedom to rearrange furniture and props in her own room.

    People – continuous support from a doula or other trained labor companion has many documented benefits and should be the standard of care.

    Practices – avoid routine use of interventions that slow labor down. Avoid arbitrary time limits, etc.

    Of course, you don’t get the Four Preventive P’s in most hospital environments.

    Yes, there’s much to be learned about when and how to optimally intervene in a slow labor. But as long as we’re not doing what we can to safely help women avoid protraction and arrest problems, we don’t know which labors are long because there is a pathological cause or a true fit problem and which ones are long because of a problem that has arisen iatrogenically.

  3. November 9, 2009 at 5:25 am | #3

    Thank you both for your in-depth and thoughtful comments!

    I think we are all working with the same ideas here, though we approach these issues from different places at time. I think we all agree that achieving vaginal delivery is the optimal outcome, whenever possible, and that there are times that obstetricians intervene too soon. I would also add that there are times that intervention comes too late in out of hospital birthing environments, so it goes both ways.

    Amy I think your comments on the data, though, are spot on. We have difficulty interpreting the data for cause and effect. Even in the old active management trials, one has to consider that the trials are done in a hospital where somebody can decide to recommend a cesarean for arrest, something that would is not available in “nature”.

    Ultimately, though OBs and midwives have the same goals, we come from a different culture. That is going to change how we look at the same situation, and the conclusions we make based on the same observations. I think we can agree that strict interpretation of the Friedman curve likely leads to identification of erroneous diagnosis of a pathologic labor process.

    As obstetricians, I think we work under a different set of fundamental ideas than midwives.

    Obstetricians, in general, don’t think of a cesarean as a bad outcome. And in many cases, neither do our patients. I have a subset of patients who actually desire cesarean delivery from the outset for no reason at all. In some countries, cesarean delivery is the norm among anyone that has the money to pay for one (Brazil comes to mind.) I know many midwives, and some seem to think that a cesarean is a terrible outcome that somehow robs a woman of something. I just hope that people that believe this realize that this is a cultural belief, and cultures differ. To an OB, the outcome is the health of the mother and the baby, and the happiness of the mother. As such, if I have a mother who really wants a vaginal delivery, I will push things as far as I safely can to achieve that (and I admit that safety is judged within my model, not a midwife model.) But if I have a patient that expresses desire for a cesarean delivery and their labor has entered a grey zone where cesarean may eventually be required, I generally will do that for them. There are some situations where I might try to talk someone out of it, particularly if I think their desire to terminate labor stems from emotional immaturity rather than true desire (think 14 year old.)

    Amy>>> A faster birth is not intrinsically better or safer….Unfortunately, we don’t have data that help guide us based on these criteria, so we make clinical judgments.

    We have substantial data to support the active management of labor, based on large randomized trials in patient populations in Ireland. Women who were actively managed with amniotomy and pitocin achieved vaginal delivery more often than women who were managed passively. None of this says anything about the metaphysical aspects of labor intervention, only about achieving vaginal delivery.

    A recent trial found early pitocin administration to be associated with increased vaginal delivery “Nine trials with 1,983 women met the inclusion criteria. Early oxytocin was associated with an increase in the probability of spontaneous vaginal delivery (RR 1.09, 95% CI 1.03-1.17). For every 20 patients treated with early oxytocin augmentation, one additional spontaneous vaginal delivery is expected.” (Wei et al)

    Amy>> Nicholas told me this weekend that there’s a home birth midwife among his extended family, so I suspect he has discussed this with her.

    Believe it or not, Obstetricians realize that many cesareans are unnecessary all by themselves. The problem is that within our model, we don’t have a good way of determining which are truly necessary, within an identified high risk group. There are so many pressures that are put on the practicing OB/GYN, and as I mentioned, humans respond to incentives. Few midwives consider how they would approach these things if they were involved in five labors at the same time. Such pressures rarely exist in the midwife world, but come to bear often in mine. Another incentive that weighs on our mind is the incentive of not getting sued. This is huge when it comes to the interpretation of indeterminate fetal heart rate tracings. In our current legal system, the penalty for making a mistake, or even being perceived of having making a mistake, is so huge that it is no surprise that OBs lean towards cesareans in grey situations. It is very rare to get sued for doing a cesarean compared to the likelihood of being sued for not doing one. This is a reality that midwives may not have to face, particularly lay midwives. If the government wanted to make an effort to reduce cesarean, I believe the single most effective intervention would be nationwide tort reform.

    Thanks for all your comments!

    • Renee
      November 11, 2009 at 5:22 pm | #4

      I know that many women don’t see it as a bad outcome. But many of us do, and maybe more than you realize. At the 6 week post partum check up, generally the latest that you’ll see the mother, she may still be ok with her birth experience. But after healing physically and working to get into a routine with her new family, these feelings can change. You may see a woman at 6 weeks grateful,but ask her again at 6 months and it may be a totally different story. It can take time for the experience to be processed and looked at honestly.

  4. November 9, 2009 at 6:09 am | #5

    A few additional thoughts, then I have to pull myself out of the rabbit hole that is the internetz…

    I think the question of whether or not a cesarean is a bad outcome merits further discussion. I have seen both sides of this argued. But I think that a cesarean *that was safely preventable* is a bad outcome. As Jill has pointed out on her site and elsewhere many times, prenatal ultrasound or clinical diagnosis of macrosomia results in an untold number of cesareans – many without even giving the woman a trial of labor and other times after a labor that was overmanaged by a doctor with “10 lb baby” in the back of his/her mind. I’m sure it’s not news to you that many turn out to be normal-sized. Yes, unnecessary surgery happens for wrong diagnoses in other surgical specialties, too. But it’s called “unnecessary surgery for a wrong diagnosis” when it happens in say, my mother, who donated a lobe of her lung to Sloan Kettering when they erroneously told her she had lung cancer. But when it happens to a pregnant woman it’s just another way to get the baby out? I don’t think so. Sounds like a bad outcome to me.

    When the mother’s or baby’s condition makes the cesarean the safer way to get the baby out, it’s a good outcome. But thinking of it as just another way to get a baby out (not saying *you* do, but many OBs and as you note many women themselves do) just doesn’t sit right with me. I don’t think I have to run down the potential harms of cesarean surgery for you, which of course include risks in future pregnancies whether the woman births vaginally or by repeat cesarean.

    As for active management, my co-author just wrote a chapter for our upcoming book on obstetric research (Obstetric Myths versus Research Realities forthcoming from the University of Michigan Press.) in which she shows, among other conclusions, that reductions in cesarean have not “crossed the pond”. But whether or not AMoL is effective, I don’t believe the studies have demonstrated that it is safe. I’ll take the liberty of sharing one paragraph that raises alarm bells for me.

    “AMoL trials are not large enough to detect differences in occurrence of uncommon severe morbidity. However, the Dublin National Maternity Hospital conducted a large trial (13,100 women) of routine continuous electronic fetal monitoring (cardiotocography), a trial in which AMoL’s originators damned it with their own data (McDonald 1985). The neonatal seizure rate was 10 times (260 per 10,000) the rate in an even larger EFM study (14,600 women) (27 per 10,000) that took place in a U.S. hospital that did not practice active management. Seizure rate in the Dublin EFM trial was associated with longer labors and oxytocin use, in other words, the very labors for which AMoL prescribed high-dose oxytocin.”

  5. November 9, 2009 at 6:17 am | #6

    Regarding your fear of being sued: What is the actual risk that you will be sued? Have you ever broken it down into a percentage or is it just a cultural fear based on highly emotional anecdotes?

    Also, do you know of any examples in which tort reform has worked well in obstetrics? Proposition 12 in Texas didn’t live up to expectations.

    Hope you don’t mind me asking. It’s really hard to find any information that solidly supports this OB-GYN cultural fear of being sued. It’s such a sensitive, painful issue for many doctors to even address that I find they get defensive and ultimately aggressive to patients by way of intervention and coerced cesareans. With so many strong feelings about being sued, it’s always interesting how no one can really pull out of their pocket their approximate risk of being sued with any kind of data to back it up.

    I would sincerely appreciate any thoughts. I’m always e-mail available, too.

    Thanks.

    • December 6, 2009 at 10:47 am | #7

      I found a study by the ACOG that stated as of 2009 91% of OBs reported at least one liability claim during their careers and there was an average of 2.69 claims per provider. It doesn’t say how many the doctor’s won, settled, or lost by statistics. But it sounds like that fear of being sued is a lot more realistic than I thought. I thought it was mostly fearmongering by the malpractice insurance companies, but apparently there is a more than reasonable expectation by the doctors that they will be sued sometime during their careers. Of course, I do think a lot of the reason people sue is because doctors (in general, not specifically) assure them if they place their trust in the doctor and hospital they will have a perfect baby. No one can guarentee this, and I think if doctors told their patients upfront, ‘look, birth can go wrong despite all our abilities to correct. Sometimes injuries, even death, can happen, we will do our best, but you need to understand there are risks’, and told them, if there was a problem ‘I’m so sorry that X happened’, they would be at a much lower likelihood of being sued. I know that right now doctors of any sort are afraid to apologize in case it looks like they are accepting blame. But, when people deal with each other, they apologize because they are sympathetic that something happened, not just if it was their fault. I think doctors, afraid of legal action, have perhaps forgotten the basic concept that people are less likely to be upset with people who sympathize with them.

  6. November 9, 2009 at 6:38 am | #8

    Great conversation! I am happy Amy already covered the problems with the Friedman curve. I think it is much harder to find any support saying the Friedman curve has any external validity today than it is to find countless articles saying it is out of date and way too restrictive. Why teach it? (It’s “objective”?) Why use it in hospitals? Why do some clearly non evidence based protocols remain established?

    On to the malpractice argument: I think there is more evidence against the malpractice argument that for it, also, to tell you the truth. The only good support of that theory is yes, obstetricians do tend to SAY that is why they do what they do.

    South Florida (my ‘hood) has the highest cesarean rates in the country, the highest obstetrical malpractice payouts and the highest malpractice premiums. Why isn’t the ever escalting cesarean rate here preventing these malpractice suits? And, the obstetricians here have effectively performed their own tort reform by arranging to go “bare” and not carry malpractice insurance, for the most part. So, as long as they only keep $250,000 in apparent assets, they have performed a method of back door tort reform to $250,000 payouts.

    I think that can be answered when one actually studies the issue. Here is a study in the AJOG from a year ago that shows improved evidence based protocols decrease cesarean sections, poor outcomes AND malpractice. Another study, this time in the green journal later the same year, showed that the majority of malpractice suits were truly due to substandard care, and could be linked to specific documentation issues.

    So, how about providing better care and ending up with better outcomes in obstetrics to prevent malpractice? That may include not following a clearly outdated labor curve, and not rushing primips to cesareans for prolonged pushing stages or suspected “large baby” but not true macrosomia or CPD?

    • March 5, 2010 at 1:00 pm | #9

      Super old reply here, but here goes…

      >> On to the malpractice argument: I think there is more evidence against the malpractice argument that for it, also, to tell you the truth. The only good support of that theory is yes, obstetricians do tend to SAY that is why they do what they do.

      But what’s the difference? If people are doing something out of fear of malpractice does it matter if that threat is really there? People are certainly worried about that threat.

      Malpractice fear is often unjustified, as we can be sued for anything, and maybe that thing we do to avoid a lawsuit actually creates a situation that causes a lawsuit. I try not to practice this way, but its a big driver for a lot of folks, especially if they have been sued before.

      I hear moms on the web talk about PTSD from their cesarean. Obstetricians get PTSD from their lawsuits!

      • MomTFH
        March 7, 2010 at 12:48 pm | #10

        I didn’t realize this was a reply to me right away.

        And, funny, now I notice there’s a typo in my comment. That should say “more evidence against the malpractice argument THAN for it”.

        I think what you are trying to say: if it’s a real motivation, who cares if it’s an accurate fear or not? I think the same argument can be made for many things. For example, people perform episiotomies for fear of a bad tear, even after evidence started showing it was more likely going to cause a big tear than prevent one. So, was there a point to telling birth practitioners the truth? Yes. Are some practitioners still using episiotomy, and thinking they are preventing something, mistakenly, while arguably causing it? Yes.

        But, the way I look at it, if these practitioners are really scared of these outcomes (extended tears and malpractice suits), wouldn’t accurate information about the real causes of such dreaded things be welcomed and incorporated by most rational practitioners, then? It has been the case for episiotomy. Let’s hope changing the dialogue on malpractice by reflecting real evidence can also change practice patterns.

  7. November 9, 2009 at 7:07 am | #11

    Thanks again for the dialog -

    Jill >>> Regarding your fear of being sued: What is the actual risk that you will be sued? Have you ever broken it down into a percentage or is it just a cultural fear based on highly emotional anecdotes?

    I don’t have much fear of being sued myself, and I think I rarely practice defensive medicine per se, but I think I’m more of an exception than the rule. Sometimes I worry that my relative lack of defensive practice will come back and bite me.

    The fear of being sued no doubt is more emotional than rational, but it is a a real influence nontheless. In some states (NY is a good example), there is a very strong possibility of a lawsuit after an unanticipated bad outcome. As such, physicians will do what they can to avoid those, sometimes even exposing themselves to an anticipated bad outcome (surgical complication of cesarean) to avoid an unanticipated bad outcome (fetal asphyxia or brachial plexus injury.) This isn’t an area of evidence, because evidence isn’t what is driving behavior. The impact of being sued is so great on a physician’s practice that much will be done to try to avoid it. Physicians do get sued, mostly for outcomes they could not prevent. It does affect practice patterns, whether or not there are studies that say it does. It is a very common topic of discussion among practicing obstetricians, and it does drive care decisions in some circumstances. If physicians could be assured that medical malpractice were decided by a panel of experts rather than lay people, practice would be different.

    Amy>>> I think the question of whether or not a cesarean is a bad outcome merits further discussion. I have seen both sides of this argued. But I think that a cesarean *that was safely preventable* is a bad outcome.

    I think this is an unfair statement. The point is that we don’t know which cesareans were safely preventable prospectively. Allow me this analogy to your statement: 100 women have kidney masses that may be cancer, but only 10 of them actually have cancer. All get biopsies, and several have minor complications. Nonetheless, the biopsies were appropriate in all 100 cases, because we didn’t know which ones had cancer and which was didn’t. If somebody has a complication and ultimately doesn’t have cancer, its hardly fair to say that the complication was safely preventable.

    I don’t know the details about your mothers lobectomy, but I would hope that the doctors that performed the surgery were concerned enough about the mass that they felt open biopsy was necessary. If biopsy were the only way to determine the nature of the mass, it was necessary, assuming that your mother wanted to know what it was and would have wanted treatment if it were cancer. The fact that it was negative didn’t make the surgery unnecessary, or a bad outcome, in my opinion. To think this way hold us to the standard of being all knowing, which we are not. If we always knew what the mass was, there would never be a need for biopsies. We would just go straight to treatment, or just tell the patient they’re fine and not to worry about it. But we don’t know.

    Amy >> But I think that a cesarean *that was safely preventable* is a bad outcome

    I would reiterate that not all cultures, or all subsets of women within our culture, look at cesarean as a bad outcome. Not all women look at labor as some sort of metaphysical experience. They just look forward to their baby being delivered, however it is done. Fortunately patients self select their practitioners based on these ideas. Women who have a very strong preference for vaginal birth, prefer not to have an epidural, and are considering home birth will tend to select a midwife for their care. Women who have different views may choose an obstetrician. Its not a matter of right and wrong, its just a choice.

    Amy >> As Jill has pointed out on her site and elsewhere many times, prenatal ultrasound or clinical diagnosis of macrosomia results in an untold number of cesareans – many without even giving the woman a trial of labor and other times after a labor that was overmanaged by a doctor with “10 lb baby” in the back of his/her mind.

    Amy I completely agree with you here. Macrosomia is a very sketchy indication for pre-emptive cesarean, and I almost never do this. The issue isn’t cesarean because the baby isn’t going to deliver, its cesarean to prevent a predictable shoulder dystocia. Even the ACOG literature admits that the number of cesareans one would need to do to prevent one shoulder dystocia is quite large, and that most shoulder dystocias occur in women without clear risk factors. I do think that some doctors recommend cesarean for a baby that does not clearly meet the definition of macrosomia. Part of the problem is that we don’t have good tools for estimating fetal weight at term. Ultrasound is not very accurate this far along in pregnancy.

    The problem, to get back to a point above, is that if a mother with a 10.5# baby wasn’t offered cesarean delivery, and goes on to deliver a baby that gets a permanent Erb’s palsy, it would be almost impossible to defend in court if a lawsuit was brought. We could argue all the data in the world, but we couldn’t change the fact that a cesarean would have prevented that outcome, and some doctors would have offered it. The lay jury doesn’t always care about the data.

    —-

    I have no desire to do cesareans that are not really needed, ergo my original post. The problem is that we are not very good at figuring out which are really needed. I freely admit that there are some holes in the obstetrical model of labor management, which I hope will get filled in the future.

    • November 9, 2009 at 11:46 am | #12

      I agree that this is a great discussion. And there is an OB-Gyn in our midst. Well, sort of. MomsTFH is a med student who will be going for her residency in OB-Gyn.

      There’s a lot we agree on and some stuff that we’ll have to agree to disagree about. But I just wanted to return to the discussion to say that there are more reasons to want to avoid a cesarean than for the “metaphysical experience” of giving birth vaginally. There’s much discussion going on right now in the natural birth community about how much the birth experience matters, and you might be surprised to discover that there is quite a bit of diversity of opinion among us on that. I’ve had unmedicated vaginal births twice and it is quite a “high” but that’s not what mattered most to me about them. I’m glad I didn’t start motherhood recovering from surgery. I’m glad my birth didn’t put me at excess risk of hemorrhage, infection, rehospitalization, death, complicated subsequent pregnancies, etc. I’m also glad I didn’t have breastfeeding problems, as so many women recovering from surgery do.

      And if you don’t agree that the goal should be about safely preventing the cesareans that are safely preventable, why muse about protracted labor in the first place? My strong sense in reading your original post was that you were motivated to reign in the number of cesareans you did for labor progress disorders – and have done so successfully over the course of your career – but were looking for evidence to justify your evolving approach. We agree that there isn’t much evidence to go by, but it’s still a worthy goal. It’s also not impossible to study, but I think we owe women supportive care that facilitates normal progress – as the standard of care – and can work from that to measure the benefits and risks of different management strategies. I also recognize that this is a pipe dream in our current system and culture (societal and obstetrical).

      • November 9, 2009 at 2:15 pm | #13

        Amy >>> And if you don’t agree that the goal should be about safely preventing the cesareans that are safely preventable, why muse about protracted labor in the first place? My strong sense in reading your original post was that you were motivated to reign in the number of cesareans you did for labor progress disorders – and have done so successfully over the course of your career – but were looking for evidence to justify your evolving approach.

        That’s the goal! I’m just trying to figure how to do it, or maybe just commiserate on difficulty of the task. If you think delivering doing a cesarean for dystocia is troubling, try a cesarean for a “bad strip” with a 9,9 apgar baby! When it comes to fetal strips in labor, we are good at telling which babies are healthy, but we are poor at knowing who is having a problem. Too many cesareans happen for fetal distress relative to the number of babies born with true low cord pHs. I know a lot of these babies would do fine if nobody was monitoring them, but we can’t get away from that either.

        Thanks for all your comments!

    • February 11, 2010 at 1:23 pm | #14

      I haven’t read through the entire conversation, so perhaps my comments are redundant, but I think the reason to avoid a cesarean is primarily due to the present and future risks for the mother and baby (and future babies). Mom’s risk of dying is increased with a cesarean delivery; post-op infections and blood clots are common and significantly more common than after vaginal delivery . In future pregnancies, the risks of miscarriage and stillbirth are increased, as are the risks of placenta accreta and percreta (further threatening the lives of mother and baby). If future babies are born by planned cesarean, there is always a risk of iatrogenic prematurity and RDS.

      To me, it is not about metaphysics or womens’ dreams of a vaginal birth and what is “normal”, but what is healthiest for mom and baby. Odd that no one so far has brought that up.

      I am really concerned that, as the rate of cesareans increases, a ticking time bomb is being created – women and babies will die or be harmed by placenta implantation issues or RDS.

      Samantha McCormick, CNM
      Baby Love Birth Center

    • Tricia
      January 10, 2011 at 8:14 am | #15

      It seems to me the issue isn’t so much the conception of labor and vaginal delivery as a mystical experience, but that C-sections entail additional risks of morbidity and mortality to mother and baby both immediately and in future pregnancies. Moreover the evidence of impaired outcomes associated with C-sections is increasing. While the harms (other than post-surgical pain, infection and other obvious symptoms and complications) may not be apparent to the parents or readily attributable to the C-section, and thus not trigger law-suits, the fact remains that the harms are real and measurable (at least statistically across large numbers of births). As such, an unnecessary or non-indicated c-sections should be considered a bad outcome as it imposes unnecessary additional risks on mother and baby.

  8. November 9, 2009 at 7:10 am | #16

    Dr. Fogelson, thank you so much for your honesty.

    As far as the active management of labor in Ireland – one criticism I have read of that data is that the protocols included the continuous presence of a nurse or similar caregiver – a factor which has independently been shown to decrease labor time and c/s rates. Sorry, I don’t have a reference for this but I believe it was Henci Goer.

    • Renee
      November 11, 2009 at 5:13 pm | #17

      I am starting training as a doula and was just reading about this in The Doula Book the other night. The women did have a nurse midwife with them the whole time.

  9. November 9, 2009 at 7:16 am | #18

    MomTFH >> “(3) cesarean delivery is best viewed as a process alternative, not an outcome or quality endpoint;”

    Your reference, not mine :)

    Thanks to all for your comments. I’m open to all views, and learn from all perspectives. Hopefully some MDs will join in and come to my rescue! I’m lost in the Valley of the Midwives!

    • MomTFH
      November 9, 2009 at 3:35 pm | #19

      Yes, the reduction is cesarean was a secondary outcome. It seemed to be a natural result from following evidence based protocols for inductions and augmentations.

      I am studying to be a DO, so I reserve the right to speak my own mind;)

      • MomTFH
        November 9, 2009 at 3:36 pm | #20

        Oops, that should say “the reduction IN cesareanS”.

        So, regardless if it was part of the protocol or an effect of the protocol, less cesareans and less malpractice cases resulted.

      • November 9, 2009 at 3:52 pm | #21

        Everybody gets to speak their own mind, even DOs.

    • February 11, 2010 at 1:24 pm | #22

      You don’t want my husband, an ob/gyn, to join in. He won’t save you. He feels the same way I do.

  10. November 9, 2009 at 2:17 pm | #23

    So we have basic ideological differences which stem from our professions. My opinion is that we need each other and that we need to respect our differences. The nature of the OB/GYN (of which I am one) is that, as Dr. Fogelson pointed out, you often have 5 women in labor at the same time which necessitates “active management,” based on the Dublin studies, i.e. augmentation of labor with Pitocin, artificial rupture of membranes, and C-section if things seem to be stalling. Everyone is on a schedule, whether it be the resident reporting to the chief, a private practitioner who has an office full of patients to get to, or a laborist who is “running the board.” This is very different than the one-on-one approach of a midwife who rarely has more than one person in labor, unless she has a busy hospital-based practice (who in that case, is more likely to be utilizing more active management measures). It honestly requires matching the patient to the type of practitioner that is sensitive to their approach to birth. For those who want to have their baby in a medicalized setting with a C-section being sometimes not just an acceptable outcome but a desired elective procedure, than obviously this is not a midwifery candidate. For those who desire little intervention and view c-section as to be avoided if at all possible, those are great midwifery patients. My preference is the freestanding birth center which can try to meet the needs of most of those patients with the hospital OB at close contact if needed. The malpractice crisis is very real, and the “culture” extends to patients who want to blame someone, most naturally the doctor, when an outcome is not perfect. This is not just an emotional anecdote, it is a very real problem that extends to society. Tort reform is one answer, realistic expectations are another, and patients wisely choosing practitioners is another. Would we have fewer C-sections if we had fewer elective inductions? Surely. Would we have fewer C-sections if mothers could move around, have active birth assistants and be allowed to labor at their own pace? Surely. Is a C-section automatically a failure? No way. What we need is an understanding that the very nature of a hospital OB practice is going to result in a higher C-section rate than say Ina May Gaskin’s approach. But these are two different worlds, which I believe could both benefit if they would each appreciate each other’s strengths and work collaboratively so that a woman’s wants and medical needs are both met.

    • MomTFH
      November 9, 2009 at 3:41 pm | #24

      Didn’t the Dublin protocols also involve one on one continuous labor support? It doesn’t have to be provided by the midwife or the physician. I think the Cochrane Database and the USPSTF regard this, in the form of doulas, to be one of the most effective labor interventions involved in the original protocol for active management.

      I hope to eventually work with a freestanding birth center.

      • November 9, 2009 at 8:56 pm | #25

        I’d love to hear from you after a few years of OB/GYN residency and see what you think. I’ve worked with a few DOs who did allopathic OB/GYN residencies. Some kept the same attitude they came in with, and some changed dramatically. Both are perfectly fine.

        Keep in touch!

  11. Lisa
    November 9, 2009 at 8:30 pm | #26

    This might help with your Friedman curve diemna. http://womens-health.jwatch.org/cgi/content/full/2003/219/1 Also, I can’t find a source, but I’ve heard many times that Dr. Friedman has said OBs misunderstand & misuse his curve.

    >>”I would reiterate that not all cultures, or all subsets of women within our culture, look at cesarean as a bad outcome. Not all women look at labor as some sort of metaphysical experience.”

    Given all the info now available about the dangers of cesareans for mothers and babies, avoiding unnecessary surgery is hardly about anything metaphysical. It’s about avoiding very real risks. Even if there were absolutely no risks to cesareans, having to take care of a newborn while recovering from major surgery is hellish.

    As for women who want a cesarean, how many actually know the risks? Cesareans are generally considered no big deal, safe & painless, while the medical profession has succeeded in making natural birth appear something terrifying & dangerous.

    >>”The malpractice crisis is very real, and the “culture” extends to patients who want to blame someone, most naturally the doctor, when an outcome is not perfect.”

    Drs have entirely brought that on themselves. I can’t count how many times I’ve seen drs imply or even state outright that if the woman would just do what she’s told, her baby will be healthy. Of course the doctor is going to be blamed in situations like that, even if he/she did nothing wrong. When a woman gives up her rights because of a promise (however impossible said promise is to keep) of course she’s going to be pissed & hold the person who promised responsible when the outcome is other than promised.

  12. emjaybee
    November 10, 2009 at 4:31 am | #27

    Dr. Fogelson, I wanted to thank you for having this discussion; it is so hard to find *any* forum where midwives and OBs are talking openly and factually about birth management and c/sections. And I wanted to reiterate that for many of us who are working to bring c/section rates down, it is not about culture, or metaphysics, religion, or personal fulfillment. It is about *safety* (in avoiding the risks of unnecessary surgery), and asserting our rights within a hospital system to have a say in what is done to our bodies (and our children’s bodies). The data suggest that many current practices, such as a high c/section rate, are not increasing safety, and may be reducing it. The mere fact that routine episiotomies persisted for so long despite a lack of evidence for their necessity and that women are *still* so often encouraged to labor and birth laying down, which defies all logic, speak to some deep fundamental flaws in how birth is managed in a hospital. In fact, when you speak of culture, you are right; but it is *hospital* culture, not that outside, which is actually at play. And that culture is influenced by a long history of assumptions, traditions, and in some cases, sexism in the medical profession itself, as much as it is by good science. OBs save lives, and c/sections save lives; I would not want to birth in a country without access to either one. But there are a lot of fundamental assumptions at the heart of how birth is handled that need rigorous questioning. For one, that’s come up here, if much of how OBs practice is dictated by having multiple women in labor at a time and other scheduling issues, why can that not change? Perhaps midwives could be of assistance in this. Surely the hospital’s scheduling policy is not as important as good practice for laboring women?

    • November 10, 2009 at 11:33 am | #28

      Thanks for your comments and support of the blog!

      emjaybee >>
      The mere fact that routine episiotomies persisted for so long despite a lack of evidence for their necessity and that women are *still* so often encouraged to labor and birth laying down, which defies all logic, speak to some deep fundamental flaws in how birth is managed in a hospital

      I think we generalize about each other a bit much. I don’t encourage women to labor lying down, nor do most of my colleagues. I am happy to have a woman walk around the labor deck or be in whatever position she wants, as long as she has a reasuring looking tracing for 15 minutes out of every few hours. A lot of our patients choose to have epidurals, which certainly limits their mobility, which is a tradeoff they choose to make, which I neither encourage nor discourage.

      It would be great if each patient could have a full time doula or midwife helping them. In many communities this is made possible at free standing birthing centers. I am a big supporter of these centers for low risk women, and think their use likely decreases cesarean delivery rates and other interventions.

      • Renee
        November 11, 2009 at 5:11 pm | #29

        Certainly it is generalizing, but when something is overwhelmingly the norm, sometimes that has to be done for the argument’s sake. We’re addressing the problems that we see as causing increases in the c-section rate and though there are providers as yourself that go against the norm, looking at the stats of medicalized delivery you can’t deny that they are the norm.

    • November 12, 2009 at 6:06 am | #30

      There is no question that as of right now, a substantial portion if not majority of practicing OB/GYNs do not see a cesarean delivery as a bad outcome, even if its indication was gray. I hear from you all that you would like to see a change of attitude that might lead to more effort to prevent some of these cesareans.

      I agree with this goal, and hope that this blog gets looked at by enough folks to start some part of that change.

      Nicholas Fogelson MD

      • Doug Hepburn M.D.
        October 2, 2011 at 9:33 am | #31

        The real problem is that all practicing ob’s have done vaginal deliveries where we regretted that we didn’t do a c/s. I would rather do 10 gray c/s’s than have one black and white bad outcome vaginal delivery. When the number becomes 10,000 gray ceasarean’s for one vaginal delivery then I have a problem. When someone can tell me how many ceasarean’s required to prevent one damaged or dead baby is too many we’ll have a starting point. {of course that number will be different for every woman} When I applied for my american boards my c/s rate was 12% now its closer to 30%. Am I a better or worse ob now?

  13. Simone
    November 14, 2009 at 11:57 pm | #32

    Dr Fogelson, this is a very interesting discussion. You may want to read Proactive support of labor (www.proactivesupportoflabor.com) This book addresses many of the issuses you raise here and that concern so many people.

  14. November 16, 2009 at 6:34 pm | #33

    I just wanted to say how impressed I have been with this conversation and this topic. As a nurse that works in L&D, I find myself being torn between two worlds that very often refuse to acknowledge that the other has both faults and merits.

    In regards to how long is too long in labor, I have often wondered about this. I would love to see research done that explores this more. Specifically, how long a woman can wait as long the tracing in ok. At what point do we say, “ok, this baby really isn’t coming out”? I think where I live, births tend to be very managed, but physicians are willing to wait quite a while before they call a section. I had one lady who had stalled at 8cm and they waited for around 12 hours before they called her section.

    I feel like more discussions like this one would be useful and bring in the different viewpoints is wonderful as it adds so much more. So, I appreciate the effort.

  15. November 19, 2009 at 5:34 am | #34

    Thank you to Lisa for pulling up that resource about the accuracy/misuse of Friedman’s curve! I recall hearing at a conference that after it was published, Friedman spent the rest of his life till he died trying to retract it, or modify it as he felt it was not valid as published.

    And another question that begs to be asked is how many “arrest of active labors” are iatrogenic and could have turned out differently if the women could eat and drink in labor, did not have inductions but spontaneously started labor, were not flooded with intravenous fluid, did not experience AROM, did not have vaginal exams every 2 hours or were not continiously connected to EFM, etc. If labor was allowed to start on it’s own and follow the normal physiological path, what might the results be.

    Thank you for this great article and for sharing your thoughts, experiences and omments! I very much appreciate it!

    myobsaidwhat.com

    • November 20, 2009 at 7:28 am | #35

      Thanks for your comments and for supporting the blog!

      You make some good points -

      Many inductions are elective in nature. Sometimes this is for the convenience/efficiency of a OB/GYN practice, but often it is to meet the needs of would like their labor to be scheduled. Natural? Of course not. But its the world we live in. Does it lead to cesareans that would have not occurred if everybody was allowed to labor naturally? In some cases yes. Inductions at 41 weeks have not been shown to increase cesarean rate relative to expectant management, and probably do reduce the rate of natural post due intrauterine demise.

      Most patients in labor get 100-125 cc of IV fluid an hour, and in most cases they are not drinking or eating much, so it shouldn’t be a great net gain or loss. This amount of fluid does not differ much from what people intake over the course of a day (if they are drinking fluids as one should anyway.) There is no doubt that the full liter of fluid that gets bolused in prior to an epidural slows down contractions for a period of time. This is mediated by a downregulation of antidiuretic hormone, which being one peptide different from pitocin, usually exerts a contractile effect. More fluids -> less ADH -> less contractions. Prospective trials have shown this to effect a 20-60 minute delay in delivery overall.

      Its hard for me to think that AROM would ever lead to arrested labors, given the large body of evidence that says that AROM speeds delivery and gets people into labor. Before the availability of pitocin, AROM was used alone as an induction method, and it worked pretty well. I was on mission in Micronesia and needed to get a pre-eclamptic woman delivered, and there was no pitocin to be found (or pumps to safely give it). I AROMed her and she had a baby 12 hours later. An anecdote for sure, but consistent with my experience over and over again, and the experience of most if not all practicing obstetricians. That being said, AROM in an unfavorable patient can be a risk factor for infection, particularly if there are a lot of vaginal exams subsequently, which may lead to an increased cesarean rate.

      >>> If labor was allowed to start on it’s own and follow the normal physiological path, what might the results be.

      Believe it or not, the vast majority of elective induction is driven by patient demand. Women who choose to seek obstetrical care usually don’t want their pregnancy to go on any longer than it has to. I discourage elective induction before 41 weeks, but many folks will allow inductions at 39 weeks, which in some cases may lead to cesareans that could have been avoided. The data we have suggests that if the cervix is adequately favorable, induction does not increase the cesarean rate. The real problem is the inductions in unfavorable women (closed/thick cervixes, nulliparas), which are usually not elective but rather for some maternal indication (ie pre-eclampsia)

      Thanks for your comments!

      • erin
        March 8, 2011 at 8:21 am | #36

        Where is the large body of evidence that shows that AROM speeds people to deliver and gets people to labor. I’m familiar with this research:

        http://www2.cochrane.org/reviews/en/ab006167.html
        “The review of studies assessed the use of amniotomy routinely in all labours that started spontaneously. It also assessed the use of amniotomy in labours that started spontaneously but had become prolonged. There were 14 studies identified, involving 4893 women, none of which assessed whether amniotomy increased women’s pain in labour. The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”

        and also no evidence to support AROM for induction of labor alone – http://www2.cochrane.org/reviews/en/ab002862.html

  16. December 5, 2009 at 4:24 am | #37

    I’m not a professional, either OB or Midwife, just a lay researcher with a passion for study. Dr Fogelson, have you looked at world wide averages for first time (or subsequent) labors? I’ve read in several articles and reports that the average for first time delivery is between 24-32 hours while subsequent labors average 12-16 hours. I believe one of the reports was put out by WHO. I also wanted to chime in on the c-section points made. Study after study, including ones I’ve read released from the CDC state that c-sections increase maternal mortality, and have read several that also show a statistical increase in the baby needing breathing support, including intubation, increase NICU stays, low 1 and 5 min apgars, and even long term negative effects (even after accounting for those c-sections done on babies who had known risks for these things and had medically required c-sections). Since a c-section is instinctually dangerous, more so than vaginal birth for mother and healthy baby, why wouldn’t a c-section, regardless of cultural preconceptions or how a mother ‘feels’ about it, be considered by the medical community to be a “bad outcome” when it wasn’t absolutely necessary? (and I think relating a c-section to a biopsy is incorrect, a c-section is major adominal surgery with longterm effects on both mother, future pregnancies, and baby, I literally can’t imagine another medical procedure that would be comparable because c-section is the only major surgery that is done electively or to ‘err on the side of caution’) The WHO has released data stating that c-section rates between 5-10% outweigh the risks and are beneficial for maternal/fetal mortality/morbitity, that there isn’t much difference either way between 10-15%, but over 15% the risks of c-section outweigh the benefits and maternal/fetal mortality/morbitiy starts going back up. Since the midwive model of care consistantly produces a c-section rate between 4-7% (I realize that is 1% off the stated statistic and yes, there seems to be apx 1% of woman under midwife care that SHOULD have c-sections, statistically, that do not) while the modern US hospital model of OB care is producing a c-section rate that averages about 35%, wouldn’t that in and of itself prove that the midwife model of care should be followed above the current OB practices to decrease maternal/fetal morbitity and mortality? Why fix something that isn’t broken? In other countries that have lower maternal/infant mortality/morbitity the vast majority of pregnancies are treated by midwifes and OBs only see the ‘high risk’ pregnancy patients (statiscally about 10%). I am confused by your apparent acceptance of change for the better and statements about how you do not practice some of the more disproven practices (like forcing a woman to stay in bed during labor, good for you!), yet your (apparent) hesitation to accept the midwife model of care despite its proven track record. I do not see why an OB doctor couldn’t incorporate a ‘midwife’ model of care just because it happens to be currently practiced by midwives.

    • December 5, 2009 at 8:18 am | #38

      >> I’ve read in several articles and reports that the average for first time delivery is between 24-32 hours while subsequent labors average 12-16 hours.

      You’re right, but its important to note that when an OB says “in labor” we mean in active labor. Your numbers include latent labor, which can be an extended period of time prior to the onset of active labor.

      >>sections increase maternal mortality, and have read several that also show a statistical increase in the baby needing breathing support, including intubation, increase NICU stays, low 1 and 5 min apgars, and even long term negative effects (even after accounting for those c-sections done on babies who had known risks for these things and had medically required c-sections).

      Also true. What’s funny is that you are quoting data at least partially from a paper I authored.

      Am J Obstet Gynecol. 2005 May;192(5):1433-6.
      Neonatal impact of elective repeat cesarean delivery at term: a comment on patient choice cesarean delivery.

      >>The WHO has released data stating that c-section rates between 5-10% outweigh the risks and are beneficial for maternal/fetal mortality/morbitity, that there isn’t much difference either way between 10-15%, but over 15% the risks of c-section outweigh the benefits and maternal/fetal mortality/morbitiy starts going back up.

      Its important to note that WHO later admitted that this was not based on any hard data. Nobody know what the right percentage of cesareans is. Personally I think the question itself is flawed. There is no “right number”. It depends on what you value. I think we do too many, but some cultures do far more based on patient preference alone. Some cultures do fewer. Different segments of American culture have different views on this as well. If you take all the blog responders on this post as a representative sample, it is quite biased – not that I don’t love all my responders, but it would unfair to say the population on this post is a fair representation of Americans as a whole. The vast majority of the patient population I have taken care of in my career does not feel as negatively towards cesarean delivery as most of the responders here.

      >> I do not see why an OB doctor couldn’t incorporate a ‘midwife’ model of care just because it happens to be currently practiced by midwives.

      I think over time we are changing, but I don’t think there is interest in incorporating a “midwife” model of care. We are OBs, not midwives. If things change it will be a change in what OBs do, not “lets all be midwives!”. Its just not what we are. Believe me, it goes both ways. most OBs would like to see midwives incorporate some things that we do into their practice. Both sides could influence each other in positive ways, in my opinion.

      OBs tend to work on the high sensitivity model, where we will trade a few overdiagnoses for missing fewer diagnoses. Midwives work on a higher specificity model, where they will avoid some overdiagnosis, but perhaps be slower to diagnose, or never diagnose at all, some true pathological conditions. These are not right and wrong they are just different. In statistics we call a graph of this relationship a receiver operator curve. This actually originates from early radar operators, who ran the sensitivity dial of their radar up and down trying to figure out the best setting. Too high, and every bird looks like a plane. Too low, and we don’t know the bombers are coming until the bombs are landing.

      OBs are looking harder for the bombers, and because of that sometimes we see birds. Midwives sometimes miss things that an OB would miss, and I think this is because in many cases they are less familiar with the true pathological conditions of pregnancy. I’ve seen a number of patients have missed diagnoses of gestational diabetes because their midwife chose to use a less sensitive screening test than an OB would do, resulting in uncontrolled diabetes throughout the third trimester, ultimately leading to a cesarean delivery that might have been avoided with tight sugar control. So it goes both ways. In my opinion the best system is to have midwives and OBs collaborate in joint practices, going for the best of both worlds. Sometimes these practices work great. Sometimes the two parties have too much difference in their practice styles, and they don’t work as well. A lot of it is ego, and believe me its not just on the part of the OBs.

  17. December 6, 2009 at 4:55 am | #39

    >> You’re right, but its important to note that when an OB says “in labor” we mean in active labor. Your numbers include latent labor, which can be an extended period of time prior to the onset of active labor.

    Perhaps I have a misunderstanding of the Friedman’s Curve as I have the information on it from second hand sources, I’ve never been able to find the actual orignial paper. My understanding of the Curve is that a woman is expected to progress 1/2 to 1 cm for every hour of labor. It is further my understanding that ‘labor’ in this case starts from either a) regular contractions or b) breaking of water. I am aware of many women who were admitted to L&D with contractions stable and regular but 10 minutes apart and/or only 1 or 2 cm dilated. I am also aware of many women who were sectioned when they were at 4-5 cm (or even 3-4!) for not meeting the Curve. So it was my understanding that OBs expected woman to go from those first consistant 10 minutes apart contraction to the pushing phase following the Curve. Perhaps my knowledge of OBs who are practicing it this way is not actually following the Curve, rather using it as an excuse to section woman for convience. Obviously not relavent statistically but my first birth contractions started 10 min apart and around 30 sec long at 7pm (never had irregular contractions), when the midwife checked me at 5amish I was 7cm dilated and fully effaced (contractions still 10 min apart, 30 sec long), then took til around 4pm to get to the pushing phase. Its my understanding in a hosptial I would have been diagnosed with ‘failure to progress’, but my labor fell perfectly within the world wide average for 1st time births (almost exactly 24 hours long from start to finish)

    I have not heard that the WHO retracted that statement, in fact I saw it in a very recent publication,(I do know it has been recently changed, as the first time I saw it years ago it was 3-4% of pregnancies on the low end of beneficial and 10% at the high end, now its 5-10% with upto 15% still seen as safe given the benefit/risk relation) so am very surprised and will have to research that further. I have also seen similiar numbers reported from other places, but I always use the WHO because most people don’t see them as ‘biased’. To me preservation of human life can always be used as a ‘gold standard’ of what is ‘right’, regardless of preference or culture, but I understand how some could feel that cultural perception may be more important.
    I also find it very ironically funny I ended up quoting your own research back to you (yes, that was one of the papers I read)! That makes twice I’ve done that. The first was in a person to person conversation with a PhD biochemist. (when talking about mitrochondrial dna, he was pleased I’d read his paper)

    • December 6, 2009 at 5:25 am | #40

      “Bad Outcome” is a slangish doctor term that means different things to different people. A person dying is a bad outcome. A person having a severe complication is a bad outcome. A person having a surgery that goes well, who maybe under some other reality might have labored longer and eventually delivered vaginally, would would not be considered a ‘bad outcome’ by most physicians.

      Nicholas Fogelson MD

      • Traci G. Perg
        February 18, 2010 at 8:07 pm | #41

        What about the woman who ends up having a severe complication (post operative wound infection with a drug resistant bacteria) from the cesarean section that might not have been done had she been allowed to labor longer and eventually delivered vaginally? To me, that was, and is a very, very bad outcome.

  18. December 6, 2009 at 5:12 am | #42

    >> first birth contractions started 10 min apart and around 30 sec long at 7pm (never had irregular contractions), when the midwife checked me at 5amish I was 7cm dilated and fully effaced (contractions still 10 min apart, 30 sec long), then took til around 4pm to get to the pushing phase. Its my understanding in a hosptial I would have been diagnosed with ‘failure to progress’

    I discourage my residents from using the term ‘failure to progress’ as it is a wastebasket term that means nothing. The technical OB definition, in your case, would be a protracted active phase. The treatment for this would likely have been to do nothing, given that you had been progressing already. Some OBs might have recommended starting some pitocin. Cesarean at that point would make no sense, and I don’t think reasonable OBs would do this.

    I agree that sectioning a patient at 4 cm is a difficult thing to justify, based on labor curve alone. In some cases this is done for ‘failed induction’, which would mean an induction that isn’t working after some arbitrary amount of time (24-48 hours usually). This is a very subjective call. In some cases one might just quit and come back another day. If delivery is clearly required, such as a mother with severe pre-eclampsia or uterine infection, then section would probably be in order. If a patient arrives in labor and ‘arrests’ at 4cm, I would tend to believe that the patient is not in active labor at all. There have been exceptions to this in my career, however, particularly in very small or young (young teenage) women with babies that are particuarly large. I have seen a number of cases where less than five foot women who have babies with very large guys have babies that they physically could not deliver, as their pelvis just wasn’t wide enough. The babies never even engage in the pelvis, and when they enter labor they may indeed arrest at 3-4 cm of dilatation. Cesarean is certainly in order there. The same happens in the animal kingdom when different breeds of a certain species mate and create a labor-incompatible offspring.

    >> To me preservation of human life can always be used as a ‘gold standard’ of what is ‘right’, regardless of preference or culture, but I understand how some could feel that cultural perception may be more important.

    When you look at thousands and thousands of women, you might be able to find an impact on maternal mortality with cesarean, but this is more of a statistical thing than a clinical thing. Truly bad outcomes are exceedingly rare, and are present in vaginal deliveries as well. There are all kinds of things we do in medicine that have some danger to them, but we feel that there is a benefit that justifies this risk. Women and men have all kinds of surgeries that are elective, and take small risks of death each time. Nobody needs to have a hernia repair, but millions of people have them because they improve their quality of life, and they are willing to accept the tiny risk associated with surgery.

    We should strive to avoid unnecessary cesarean deliveries whenever we can, but lets not go overboard with the dangers of the procedure. There are known complications, but the vast vast majority of women who have a cesarean will never have a problem. I want to avoid cesareans because its a more difficult recovery for mom, and over a lot of women there are more problems with cesareans than vaginal deliveries, but I’m not afraid for any particular woman having a cesarean. By and large, it is incredibly safe.

    Nicholas Fogelson, MD

  19. MomTFH
    December 6, 2009 at 5:28 am | #43

    I don’t think it is going “overboard” with the dangers of the procedure to say its risks matter clinically AND statistically. Remember, a cesarean section makes a difference in recovery, pain, length of hospital stay, breastfeeding success, and complications in future pregnancies and deliveries. It’s not just a matter of mortality. That being said, the maternal mortality task force in my state lists cesarean section as an independent risk factor for maternal mortality. But, I don’t think that is the main substance of most of the opposition to non medically indicated cesareans.

    It is not a hypothetical statistical difference between two “choices” of delivery. One is an intervention with risks that need to be balanced by risks of not intervening.

  20. December 6, 2009 at 5:32 am | #44

    >> One is an intervention with risks that need to be balanced by risks of not intervening.

    Agreed

    >> Remember, a cesarean section makes a difference in recovery, pain, length of hospital stay, breastfeeding success, and complications in future pregnancies and deliveries.

    OK I’ll try to remember this. The idea that you think I or any other OB doesn’t know this makes me laugh a bit :)

  21. December 6, 2009 at 8:25 am | #45

    Dr Fogelson, I have to say, I really wish you lived in my area! I don’t like OBs in general, and won’t deliver with one if I have a choice and a low risk pregnancy. But I have come across MANY doctors who treat me like I am some kind of annoying child for bringing up my concerns about treatment (not just OB, pain management, general practice etc), most can’t get rid of me soon enough. You have been absolutely polite, respectful (and of a lay person too!), and detailed in your answers to my/others points (although, for your last one there, I’ve actually personally heard an OB doc say that recovery from c-section is no longer than vaginal birth and there are no complication to future pregnancies). It is so refreshing to meet a doctor who is not dismissive of being asked to consider another’s point or to give backup to their own. I have had nothing but difficulties trying to get a doctor/OB in my new town after a move, having been turned down, refused treatment, and denied even an initial meeting with nearly everyone in town just because I have a disorder they are unfamiliar with. I am not being hyperbolic when I say reading this blog and especially your (very quick) comments back to me has restored my faith that there ARE good OBs out there, and good doctors in general. This is what I imagine talking to a doctor about something must have been like back when they first made housecalls. Thank you!

    • December 6, 2009 at 8:43 am | #46

      Thank you for your kind comments.

      Doctors could practice medicine differently if patients were willing to pay cash by the hour. We could take all the time the patient desired. Nobody made housecalls and then filed an insurance claim.

      • December 8, 2009 at 3:44 am | #47

        My husband and I have had numerous conversation about how healthcare has led far more to increased cost and decreased patient care than it has to anything else! (and, in my case, its less a point of time, I always make sure I’m booked for a 30 min appt, and more that I am asking the questions to begin with instead of just assuming anything they tell me is gospel and anything they don’t tell me is unimportant)

  22. Jill Fremont
    December 7, 2009 at 4:12 pm | #48

    Dear Mr. Fogelson,

    I am a in the process of becoming a Bradley Method instructor and also just had a totally drug-free birth several months ago. In my training this weekend, my instructor discussed “The Natural Alignment Plateau” – a phrase she coined after observing many mothers “fall off that curve”. Most mothers go on to deliver a beautiful baby without medical interventions. I would like to say of course, I am no doctor, but I appreciate the willingness you have to look further into the situation with an open mind. You mentioned pelvic size before in other cultures. I don’t mean to be offensive, but I feel as if most doctors don’t feel like an American woman is capable of giving birth on their own (due to pelvic size or whatever else it may be). I would like to encourage you to look at information given by The Bradley Method regarding the Natural Alignment Plateau. It happens in over 50% of unmedicated natural births. Doctors deal mostly with dilation, effacement, and station as signs for progression of labor, however, there are many other signs of labor progressing, such as: dilation, effacement, station, strength of contractions, time between contractions, duration of contractions, behavior changes in the woman, loss of modesty, etc. Marjie Hathaway suggests that during the time where the woman has fallen off the curve several things may be happening which are necessary to accomplish before the baby should be orn. Thes include 1. physical alignment of the baby’s presenting part in relation to the mothers pelvis, 2. softenting of the cartilate in the pelvis and increasing felxibility of the ligaments and tensdsons as the mother’s body prepares to accommodate the baby, 3. time for the breast to form all the immunities necessary to protect the baby after birth, 4. the baby may be in need of more massage from the contractions to stimulate it’s nervous system and prepare it’s lungs for breathing on the outside (less RDS), 5. Mothers go through many psychological changes in labor. Some mothers report being unable to let go and as soon as they do, labor progresses, 6. Also babies may be undergoing psychological and emotional changes during this time. When vaginal exams are continuously done giving a “report card” to the mother, this can become discouraging and halt labor all together sometimes. Just because a mother is not dilating, does not mean that she is not progressing in labor if you look at labor in a different way. I went from staying at 5 centimeters for hours to birthing the bag of water and then pushing immediately. I denied medical intervention and was able to birth my child just fine with no complications. I may add that I do not believe in pelvic size of other cultures as superior to any other pelvises you may see here in the U.S. In other cultures, there is less intervention and of course the mothers go on to deliver their babies just fine.

    One more thing I wanted to add: Just because a baby is large, does not mean that the mother cannot birth it. I believe that if your body makes it, you can birth it… it just works most of the time that way. In fact it has been proven that larger babies are easier to birth as they provide more pressure on the cervix and equal dilation whereas a smaller child may not.

    I want to thank you for your willingness to listen to these ideas proposed by Dr. Bradley. Please look into his information. I think you may find it interesting as you seem open to some suggestions and I saw that you were questioning the sections done as women fell “off the curve”. Dr. Bradley had a 3% C-section rate in 22,000 births and over 90% of all the births he did were unmedicated. Please feel free to email me for more information. The things I have quoted above can be found in “Husband-Coached Childbirth” by Dr. Robert Bradley. Thank you for your time.

    Jill Fremont

  23. December 7, 2009 at 6:43 pm | #49

    Jill – thanks for your comments. I am familiar with the Bradley method, but yours is a good review of that philosophy. The ideas you provide make some sense, are are helpful to a lot of women who feel the Bradley method is a good fit for them.

    >> I believe that if your body makes it, you can birth it… it just works most of the time that way. In fact it has been proven that larger babies are easier to birth as they provide more pressure on the cervix and equal dilation whereas a smaller child may not.

    Yeah… Can’t agree with that at all. I’m not sure what source you believe proved that fact, but I’ve never seen it. Bigger babies are harder to deliver, and its not hard to imagine why. Women are clearly capable of producing babies that they cannot deliver, particularly when they are affected by gestational diabetes or other source of macrosomia.

    Thousands of women in less developed countries are affected by vesicovaginal fistulas (holes between the vagina and bladder) because they were unable to deliver an infant vaginally and there was no availability of cesarean section. They are left with this injury after necrosing their bladder and anterior vaginal wall from the constant pressure of the impacted fetus.

    >> I may add that I do not believe in pelvic size of other cultures as superior to any other pelvises you may see here in the U.S. In other cultures, there is less intervention and of course the mothers go on to deliver their babies just fine.

    Nobody is ‘superior’ to another, but there’s no question that some ethnic groups have larger pelvic outlets than other ethnic groups, and have tendencies to have different sized babies. There are many genetic characteristics that differ between different ethnic groups. Though I cannot give you exact numbers of average pelvic outlets, I can tell you from a great deal of personal experience that some genetic groups are able to birth very large babies with minimal trouble. Having practiced in many different places, I can tell you that Samoan and Palauan women, for example, are able to deliver a 10+ lb baby with little difficulty, while the same baby in most caucasian women would on the average lead to a much longer, and potentially unsuccessful labor.

    The important thing is that we don’t prejudge a woman’s ability to have a baby. Doing a pre-emptive cesarean because you think the baby won’t deliver makes no sense to me. There is no question in my mind that larger babies are harder to deliver, but that certainly wouldn’t keep me from helping any woman to try to deliver any baby. The labor will tell the story. In some cases a 10# baby will deliver just fine in a 5’0″ 16 year old girl, but sometimes it won’t. That doesn’t change the fact that different prelabor conditions influence the likelihood of vaginal delivery. Starting with the presumption that all babies will deliver vaginally if you wait long enough is a very dangerous thought. It is simply not true, and failing to act in some of these cases could lead to fetal or maternal injury or death.

  24. Jill Fremont
    December 9, 2009 at 2:07 pm | #50

    Mr. Fogelson,

    I think your statements are fair. I too do not believe that there will be 100% of women able to deliver their own babies and that at times a C-section would be necessary, but our culture overuses them. The main thing that I do believe is that we are created with a hormonal map that has a specific sequence in labor. For example, as you know, we have oxytocin (manmade form = pitoicn). If we interfere in the map of labor, for example take the normal sequence that would follow our own body’s delivery of oxytocin and replace it with something manmade, then we have halted our body’s hormonal labor map. A woman who may have been able to deliver the baby on her own, may now have a baby who is in fetal distress because the doc has “pit to distress” (which by the way I think this is a terrible concept). Anyways, what I’m trying to get across is that if some women trusted their own bodies to do what they are supposed to with no medical intervention, they would probably go on to deliver (of course under normal circumstances and a healthy pregnancy). I wish more OB’s were like you and at least willing to question our normal ways of doing things. I would also encourage you to take a look at the last statistics of the birth center in which I delivered my daughter. The website is http://www.thebirthplace.org. Please take a look at the size of these kids. They are little chubby babies! My daughter was 7lbs. 1 0z. and she was the runt :-) Jennie Joseph, the midwife, has done a lot of work around the nation for healthy pregnancies and to decrease infant mortality. Please take a look at her concepts. I truly agree with her in many ways. She has a method called the JJ way in which she encourages all women to have full term “chubby” babies and that is exactly what she gets! I have enjoyed the posts here. Thank you so much!

  25. December 9, 2009 at 7:57 pm | #51

    >>>> The main thing that I do believe is that we are created with a hormonal map that has a specific sequence in labor. For example, as you know, we have oxytocin (manmade form = pitoicn). If we interfere in the map of labor, for example take the normal sequence that would follow our own body’s delivery of oxytocin and replace it with something manmade, then we have halted our body’s hormonal labor map…..I’m trying to get across is that if some women trusted their own bodies to do what they are supposed to with no medical intervention, they would probably go on to deliver. <<<

    Herein lies the difference between science and empiricism. You have presented a theory, and then described a model of belief that accepts this theory as already true, and then recommended a course of action based on this new truth. This is empiricism. I see something -> I decide what it is -> now I have new knowledge.

    Science works a bit differently. The scientific method of determining what is true starts in the same place as empiricism, that is, with a theory or question. But now instead of reasoning why or why not that theory is true, we instead conceive of a method for proving that theory, via experimentation or modeling of some kind. We then run that experiment, and get the results. These results, assuming our experiment was properly designed, tells us what is really true and what is not. We then make new changes to our theories, and thus new questions to ask through further experimentation. If you believe in science, this is the only way knowledge of the natural world can truly be gained.

    This is ultimately why OBs have a hard time accepting many of the theories that midwifery presents. We know that we do some things that may not be right, but in order to make changes we want real data created via the scientific method, not empirical theory. There are many ideas presented with midwifery such as "natural labor" and "woman centered care" that ultimately don't mean anything to a scientific mind. They are perfectly nice ideas, but they don't really compel any OB to change our way of thinking. The theories you present in your description of the Bradley method are a good example. They are nice theories, but they should be the beginning of knowledge finding, not the end. This is not to say that midwifery has not participated in real science, as there is no doubt that there have been some substantial contributions.

    I am absolutely willing to look at obstetrical practice and see what we should do better, and I think most doctors are. But we need real scientific data before we're going to strongly consider changing basic practice. It has happened before, such as the shift away from episiotomy as data was produced that showed it to be harmful. Delayed cord clamping (or natural cord clamping for you taxonomy nuts out there) may become more mainstream on the back of recent data.

    >> I would also encourage you to take a look at the last statistics of the birth center in which I delivered my daughter

    I didn't see any stats on their site, but in light of the above comments, ultimately they don't mean a great deal. Stats are considered observational data, or the lowest form of scientific information. Observational data allows us to formulate questions, but almost never does it actually reveal what is true and what is not. Only by comparing one group against another group in a controlled way can we eliminate the bias inherent in observational data.

    To address "pit to distress"
    This is an misunderstood concept. There are some situations, typically in inductions of infants that are compromised in some way (growth restriction, pre-eclampsia), that the baby may not have adequate placental blood flow to tolerate the stress of strong uterine contractions. These inductions are typically performed because of fetal testing that indicates an increased risk of intrauterine fetal death. In some cases, the mother may have a protracted active phase and require pitocin, or already be on pitocin for induction. At some point, the fetal heart rate tracing may indicate that the fetus is not tolerating the contractions and the pit is turned off. This may happen several times. At this point, the idea of "pit to distress" comes into play. Ultimately the woman is not contracting hard enough to effect cervical dilatation without an induction agent, and so it is applied even knowing that the baby may not tolerate it – "pit to distress". If the baby can handle the contractions, the induction continues. If not, the pitocin is stopped, which leads to rapid recovery of the babies heart rate tracing, and a cesarean is performed.

    "pit to distress" has no real place I can think of in the augmentation of a naturally progressing labor (which seems to be what you are referring to.) The term is a bad one, as clearly we have no interest in causing the baby to have problems. The term is really a slang term. It is a way of referring to the way some compromised fetuses will respond to induction of labor, but it is not a goal in and of itself.

    Thanks again for your comments!

  26. Jill Fremont
    December 10, 2009 at 3:47 pm | #52

    Mr. Fogelson,

    I am liking our conversation as I am learning things from this that I did not know. Your comments are enlightening. Thank you for explaining the “pit to distress” as it does have a very bad connotation.

    Maybe you can help me out on this… I have been reading the green and gray journals. At this late hour I can’t think of a specific item, but I’ll get back with you later. The main thing I have noted is that a lot of the items discussed go along with natural birthing concepts. (Again, I’ll get back with you on the particulars as I’ve been up with my teething daughter all night) What I have noticed in my particular case is that my OB doesn’t “recommend” natural birth – and I must add I had a totally “normal” pregnancy. I asked her why and she said she doesn’t recommend it for anyone. I’m not sure why. I truly believed my body was able to deliver and so I switched over to the midwife and of course I did. Anyways, back to my point about the green and gray journal… most of the items I have read go right along with what my midwife is discussing as her normal care. However, when I asked my OB – she seemed she would do the total opposite. I don’t understand how an actual OB can go against the medical knowledge presented in the green and gray journals. Do you have any insight on this? I begin teaching my first class in January and although it will be natural birthing concepts, I would like to encourage all students to work with their OB to obtain what they would like and the birthing experience they desire (of course under a circumstance of a healthy pregnancy). One thing that The Bradley Method stresses is the fact that if you stay low-risk, you have more choices so we teach proper nutrition in the first class.

    I would like to build a bridge for my students to get the care and experience they desire instead of us “natural birthers” being against the OB’s. Any suggestions? Thanks again!

  27. Jill Fremont
    December 10, 2009 at 4:16 pm | #53

    Mr. Fogelson,

    I was able to go back to my notes… Regarding EFM – I read an article saying something along the lines that taxpayer dollars were rescuing EFM as it was in disarray. Then it went on to say that when it is faulty that sometimes the woman would go on to get C-sectioned. It referenced parts of the journals where it also stated that this was true. What are your thoughts on EFM and if it is in disarray, why must it be imposed when entering the hospital?

    Also I wanted to comment on science vs. empiricism. I do not want to discount statistical information, but if you take a randomised controlled trial and use only statistics, averages, and probability, then you are taking the individual woman out of the picture. Nature itself operates on a bell curve – I don’t believe in “normal” because what are the people that fall to the other ends of the spectrum. They are still people and just because they do not fall on the middle of the continuum, they can still have great outcomes in birth. To me, natural birth is very individualized of course with a different outcome for each woman. For example, birth is one of the most athletic events on the planet. We wouldn’t expect someone to go run a marathon with no food for fuel, however, in a hospital setting they do not want you to eat for fear that if you need a c-section and vomit then you will get it into your lungs (not sure of the medical term for this). I do know however that this rarely happens and my next question, what if someone is C-sectioned in a true emergency right after lunch or something. Some of these things just don’t make sense to me. In our society that is so willing to sue doctors, it is unfortunate because they will tend to go with the safe side instead of that which may be best for that particular woman. I know one thing… I wouldn’t have made it through my labor with no food. I ate little bites of protein the whole time to stay energized.

    Can you comment on this? I really would like to know how medical doctors decide what is “best” for everyone. Thanks.

  28. December 11, 2009 at 7:22 am | #54

    >> I do not want to discount statistical information, but if you take a randomised controlled trial and use only statistics, averages, and probability, then you are taking the individual woman out of the picture.

    You’re right on here. Statistical methods do eliminate the outliers by definition. Clearly we all individualize care for each woman, but I do try to use the statistically proven ideas as the foundation of care.

    >> EFM

    This is a pickle. It is part of the standard of care, and will likely never go away, despite the fact that in low risk pregnancies it does not seem to improve outcomes and increases cesarean rate. For now, it is part of modern obstetrics. It may be replaced by something better, but I do not forsee a future of unmonitored birth. Many hospitals do allow monitoring for 15 minutes out of every 1-3 hours though, particularly if the patient has no epidural and wants to walk around in the room or in the halls.

    There are two big reasons we won’t rid ourselves of EFM. 1 – Lawyers have established it as the community standard of care, or at least we think this. 2 – All of us have had experiences where we did an emergent cesarean and delivered a fetus that had a horrible strip and indeed was near asphyxiated when it was delivered. Without EFM we never would have caught that. As statistics eliminate the outliers, they may not catch the benefit of EFM in these situations. Given #1, many are uncomfortable with the idea of missing an event like this, despite data that does not show an overall benefit to EFM in populations.

    If a patient has desires regarding EFM that are not available/allowed in the hospital, she may prefer care with a midwife who is more comfortable with unmonitored birth.

    >>>…in a hospital setting they do not want you to eat for fear that if you need a c-section and vomit then you will get it into your lungs

    This is individualized, but in general this is true. The concern is that a patient may vomit under anesthesia and aspirate the food into the lungs, which can be a very bad event with bad sequelae. This is passed on from rules we follow prior to major surgery. Some of this is evidence based and some is not. Its more of an anesthesia issue than an obstetrics issue, so you would need to go to the anesthesia literature for that one (though ultimately I think this is more of an empirical idea than evidence based.)

    >> how medical doctors decide what is “best” for everyone

    I can speak for myself only here, and in general am always just speaking for myself, even though I occassionally claim to know how “OBs think”.

    We just do what we think is right, based on our training and experience. Everything we do is a combination of things we have been taught, thinks we have learned in personal experiences, things we have read, and things we are born with. We are not so different from everybody else. We try to follow evidence, and make it the basis of our knowledge, but like everyone we are influenced by anecdotal experiences and follow empiricist decision making processes at time. Each different physician is a different person. There is no textbook that says exactly what to do in every instance, so we all interpret what data we do have in a somewhat different way. Ultimately a patient has to find a physician that they like and trust, that hopefully shares enough common ground and values with them that they will make recommendations and decisions that are adequately consistent with their desires.

    Your desire to read the literature is impressive and admirable. A lot of your questions may, however, be better answered in a recent obstetrics textbook such as “Gabbe’s Obstetrics” or “William’s Obstetrics“. Textbooks have detailed reviews of the current literature, and better describe the basic topics than current literature. Literature is about what’s new, but does not concern itself with the basics as much.

  29. December 11, 2009 at 12:43 pm | #55

    Wanted to chime in on the last exchange. With the article/research I have been able to access/have had mentioned in literature, ‘they’ say (sorry, do not have the research right here since its all packed from the move or I would quote specifics) there hasn’t been a death from asperation during c-section in at least the last ten years.
    What I don’t understand, and, since its not an OB issue probably won’t get answered here, is why they think asperating undiluted stomach acid is better than asperating diluted stomach acid?? I have “asperation attacks” from uncontrolled acid reflux about once a month (on average). Usually it is when I have something in my stomach (because when I have a bad acid reflux day I am careful to keep some soft, simple carbohydrates in my stomach), it sucks, its scary (worse to watch I think), and it gives me breathing problems for 2-3 days afterwards. But I have asperated undiluted stomach acid (in the morning before I had a chance to eat) on two occassions. Both occassions were so much worse. I almost called 911, my lungs ‘seized’ and I didn’t think I could get them to start breathing again. It was terrifying and left me with breathing difficulties for twice as long as usual. So why isn’t it perferable during all times that doctors are worried about asperation to make sure there is something mild in the stomach to dilute the acid if it does happen to get into the lungs? (I find rice, bread, or a glass of milk works great)

    • December 11, 2009 at 1:09 pm | #56

      We give women a bottle of liquid antacid prior to rolling back to any cesarean to deacidify the stomach.

      • December 13, 2009 at 2:45 am | #57

        Ahh, that makes sense. One of my worse fears for my own health (realistically as opposed to worst case senarios) is to have an asperation attack while in labor! I used gaviscon during my first labor.

  30. Jill Fremont
    December 11, 2009 at 4:52 pm | #58

    Mr. Fogelson,

    Again, thank you for your response. I only wish there were more docs out there with your consideration and willingness to explore other options. This has been a big issue for my family trying to find an OB that would work with us so we switched over (reluctantly I might add) to midwifery care. I must say that their care truly pleased us and I couldn’t have asked for a better experience. My wish is that one day OB’s and midwifes can come together for the betterment of all women. My other hope is that our society starts to educate themselves and take their birth seriously and not leave it totally in their care provider’s hands. If more women would educate themselves, I feel there would be different outcomes and doctors may be willing to work with someone. I find it funny when a woman wants to go in a have a natural birth, but has done no preparation whatsoever. I don’t think the docs take them very seriously either. However, with the proper preparation and guidance from doctors/midwives, I feel the woman will have a more desirable experience.

    I hope that other doctors become willing to question normal protocols in order to provide the best care for all women. What would you suggest I tell my students in order to get their best experience? Some people walk in with a birth plan (for natural birthing) and docs and nurses laugh. How can they go about letting the doctors and nurses know their wishes for a natural birth are serious and how can they do that in a hospital setting?

    Have a great weekend!

    • December 13, 2009 at 6:26 am | #59

      Birth plans that have reasonable requests such as avoiding episiotomy whenever possible, delayed cord clamping, avoiding pain medications… these are all fine.

      But some birth plans basically gut an obstetrician’s ability to do what he/she thinks is right – no cesarean under any reason, no pitocin ever, etc…

      This is all fine, but if that’s the model one wants to think of labor in, one would be better off working with a midwife. When the birth plan starts to erode what an obstetrician thinks of as a safe labor, it gets in the way of care.

  31. Elizabeth Metzger
    December 17, 2009 at 11:00 pm | #60

    As a doula, Bradley method instructor, and student midwife; your blog and these dialogues are most amazing and tremendously appreciated. Thank you. Even if those from the midwifery model and those from the medical model wind up disagreeing, it is so valuable to be able to communicate.

    You have no idea how often I have heard OBs claim that there is no risk to cesarean. Earlier you laughed at the idea that anyone had to tell an OB that “a cesarean section makes a difference in recovery, pain, length of hospital stay, breastfeeding success, and complications in future pregnancies and deliveries.” However, I have heard this not once or twice, but many many times: “oh, it will have no impact whatsoever.” “It really is just the safest way.” “Oh, you’ll be able to do whatever you want for your next birth.”

    I witnessed one particularly awful situation: a 100% healthy, low-risk mother was induced at 41 weeks for no reason other than dates. After two days of unsuccessful cervidil and pitocin (baby still looked perfect, sac intact!) the OB told her that either she could go home where her baby could “very likely die”, or that she could have a c/s which held no risk whatsoever, except for some exceptionally rare things that only happened in high risk situations. This OB has a 70% c/s rate, by the way. Then, after surgery, an infected wound that landed her in bed and barely able to sit up for more than a week, and a traumatic circumcision for the baby (why in gods name are OBs still agreeing to do these?!) the mother never successfully breastfed her baby. The OB practically scolded her for even questioning whether or not the surgery could have any impact on breastfeeding.

    Anyway…I would be curious to know if you had any thoughts as to why Dr. Bradley had such a high success rate? It might be easy to think about the method in terms of nice theories, but his outcomes were indeed quite impressive, spread over decades and tens of thousands of patients. Also, regarding those theories, Jay Hathaway has compiled more research and data than one would think is humanly possible. In your quest for answers perhaps you could ask to sit through a Bradley teacher training session next time they are in town.

    You said:
    <<>>

    This truly baffles me. It seems inverted from what the truth should be: that we should have real scientific data before we strongly consider instituting obstetric practices in the first place. From what data are we gathering the information for the way things are currently practiced? Episiotomy never was evidence-based, yet somehow it became standard practice for decades. It seems to me that if you start with the premise that pregnancy is a normal life event, and that women’s bodies are designed to give birth, you would need to have extremely solid proof that it was necessary to interfere with that; rather than looking for proof in order to NOT interfere.

    Sorry my thoughts are so scrambled….my last comment is in reference to your repeated example of the women who actually prefer cesarean. My question is, who is informing these women’s choices? Women don’t decide they need or want cesareans in a vacuum. Being Brazilian doesn’t give you a “surgical fetal removal” gene. Personally, I think it is motivated by misplaced power, money, and fear, which somehow filters down to convincing women that their bodies are wholly dysfunctional. It is misogyny at its worst.

    • February 12, 2010 at 2:46 am | #61

      I think maybe you are misquoting me a bit… but its been a long thread now reactivated.

      My feeling is that everybody gets to choose what they want, and there is a wide variety of acceptable options. The example you mention is unfortunate, but hardly representative of normal obstetrical practice. I can also give examples of completely incompetent midwifery care, but I won’t as I don’t think they define all midwifery. Each practitioner is different, and there are varying levels of skill, compassion, consideration, whatever in each person.

      Where we differ is that I don’t believe that my point of view should define what everybody else does, and I think you do. You have a strong belief about what the correct model of birth is, and your comments lead me to think that you think that others should agree with you, and if not they need to be “rescued” from their uniformed ways. It is this very way of thinking that creates a divide between obstetricians and other pregnancy practitioners, on both sides. The fact that you do not agree with a culture that prefers cesarean delivery, or you think that it is based on misogyny or misinformation, is irrelevant. Its like the Star Trek Prime Directive – you have to respect the culture as it is, even if you don’t agree with its roots.

  32. December 18, 2009 at 5:51 am | #62

    >> a 100% healthy, low-risk mother was induced at 41 weeks for no reason other than dates

    Not no reason. Because a 41 week mother will experience IUFD 0.6% of the time in the subsequent week, and induction at 41 weeks does not increase cesarean rate over expectant management. Based on what you say here, the management after that was questionable. Anybody with a 70% cesarean rate has either a ridiculously high risk practice or is doing way too many cesareans.

    >> and a traumatic circumcision for the baby (why in gods name are OBs still agreeing to do these?!) … Dr. Bradley had such a high success rate….

    THESE ARE CULTURAL ISSUES. Some people think a penis should look a certain way, and in some cultures circumcision decreases infectious disease transmission rates. Some people have absolutely no interest in an unmedicated labor without an epidural, which precludes Bradley. Bradley is basically doing nothing and letting nature happen. This is fine, we cannot ignore the fact that pregnancy and childbirth is the single most dangerous time in a woman’s life. OBs are just trying to be there when they’re needed, and each and every one of us has to make decisions about when that is. We never assume that _doing nothing_ is the right thing. Doing nothing does lead to significant problems, even death, in some cases. We do our best to figure out when we need to do something to prevent these problems.

  33. Jill Fremont
    December 22, 2009 at 8:04 am | #63

    >> Obstetricians, in general, don’t think of a cesarean as a bad outcome. And in many cases, neither do our patients.

    This is unfortunate. I think that women in general are so vulnerable in pregnancy and especially during labor. Of course all mothers want what is “best” for their baby. We also put our trust in our care providers to advise us on this topic of what is best for mom and baby. This is why it is so important to pick a care provider who will hold your beliefs and sticks by them as much as possible.

    Unfortunately, I believe a lot of women are wrongly advised in the hospital. I am not speaking of cesareans in which the baby’s life is actually saved, I am speaking of situations where there is no problem, but labor needs to be managed (for whatever reason). The mom (or dad) will usually take the advice because it is coming from a “professional”.

    I know many women elect to have a c-section. I wish they were advised over and over about the risks. I think our society is fear-driven. After all, some of the only births I had seen before the birth of my daughter were on health channels where everyone is in an emergency and needs a section. I thought my birth would probably be the same and I am scared to death of surgery, thus my quest for educating myself on my options.

    >> I believe could both benefit if they would each appreciate each other’s strengths and work collaboratively so that a woman’s wants and medical needs are both met.

    I think this is what all women should strive for. I like what Dr. Bradley said about “managing labor”… The doctor is like a lifeguard and as long as all are swimming, they are fine. If someone starts to sink – a doc can jump in.

    When I was laboring with my daughter, many obstacles presented themselves: the possibility of a prolapsed cord, prolonged labor, the baby not coming down the canal, etc. I did everything in my own strength to give birth to her and realized that nothing was working. I was advised by my midwife to go to the hospital. I placed the shoes on my feet as my husband asked for 45 more minutes of my time. Within those 45 minutes, the water sack broke and we zoomed through transition and the next thing I knew we were pushing. I am thankful to my midwife, because I felt safe enough in her care for her to recognize that intervention may be necessary and yet she would not request it of us if it wasn’t.

    I guess I say all of this to encourage doctors and midwifes to work together. I long for the day that a natural birth can be achieved without putting up a fight at the hospital (in a healthy normal situation). I wish pregnancy and birth were not treated as such a scary time in a woman’s life, but a time to self-educate, ask questions and obtain an outcome you are comfortable with.

    Thank you to all the midwives, doulas, and doctors conversing on this topic together. This is truly the only way we can learn to come together and achieve wonderful outcomes for women.

  34. January 9, 2010 at 9:53 am | #64

    All aspects of the (iatrogenic and/or preventable) labor disorders discussed above are scrutiniously explored in the intriguing book “Proactive Support of Labor, the challenge of normal childbirth”,recently published by Cambridge University Press. The book also offers adequate alternatives for current medical excess in childbirth. Given the lively discussion above this book might truly be an eye-opener for many visitors of your weblog. The concept of “proactive support of labor” strikes a new balance between natural birth and intervention and invariably enhances women’s satisfaction with childbirth without any risk for the babies. More information can be found on the publication’s website: http://www.proactvesupportoflabor.com

  35. February 11, 2010 at 8:47 am | #65

    Most of us in the business haven’t read Freidman’s original paper, but I have. 55% of the 500 women in his study were delivered with forceps. Even among the 200 women he deemed to have “ideal” labors, 46% were delivered with forceps. I have never understood how we could use as a guideline for what is a normal length of labor a set of primarily assisted births.

    http://journals.lww.com/greenjournal/Citation/1955/12000/Primigravid_Labor__A_graphicostatistical_analysis.1.aspx

    (this link might only work for ACOG members. if you would like a pdf copy of the article, email me waterbirthmw@aol.com)

    Samantha McCormick, CNM
    Baby Love Birth Center
    Cape Coral, FL

    • March 5, 2010 at 8:15 am | #66

      But would this affect the intepretation of the active phase data? I wouldn’t think so. But clearly Friedman was not dealing with inductions, and his data is unappropriately being applied there.

  36. February 11, 2010 at 1:29 pm | #67

    >>> In my opinion the best system is to have midwives and OBs collaborate in joint practices, going for the best of both worlds. Sometimes these practices work great. Sometimes the two parties have too much difference in their practice styles, and they don’t work as well. A lot of it is ego, and believe me its not just on the part of the OBs.

    Amen!

  37. February 11, 2010 at 1:38 pm | #68

    We should strive to avoid unnecessary cesarean deliveries whenever we can, but lets not go overboard with the dangers of the procedure. There are known complications, but the vast vast majority of women who have a cesarean will never have a problem. I want to avoid cesareans because its a more difficult recovery for mom, and over a lot of women there are more problems with cesareans than vaginal deliveries, but I’m not afraid for any particular woman having a cesarean. By and large, it is incredibly safe.
    Nicholas Fogelson, MD

    Loving this discussion. Must point out that the major danger to women and babies is not the primary cesarean (although you cannot be honest and still equivocate – cesareans are more risky for moms and babies – this point is not debatable, based on the literature – moms have post-op infections and blood clots at higher rates than vaginal birth moms and babies have more NICU admissions), but the dangers in subsequent pregnancies, when still birth and miscarriage are increased and increased odds of improper placental implantation threatens the health and life of mom and baby, not to mention the risk of uterine rupture – which can and does happen (although infrequently) even without a trial of labor or VBAC attempt.

    Let’s be honest here, we are not possibly having this discussion about reducing cesareans simply because it is uncomfortable for a mom to care for her newborn after a cesarean birth.

    Samantha McCormick, CNM
    Baby Love Birth Center

  38. February 11, 2010 at 1:45 pm | #69

    Nicholas Fogelson :
    Thank you for your kind comments.
    Doctors could practice medicine differently if patients were willing to pay cash by the hour. We could take all the time the patient desired. Nobody made housecalls and then filed an insurance claim.

    Now you are being honest. Nice job.

    Thank you for admitting that surgical births are sometimes performed just to get the birth over with.

    I DO take all the time a client needs in labor. That is my job description. Some are quick, some are long, it all balances out.

    If a baby wants to take 2 days to be born, I will be there, by the woman’s side the entire time. Does it suck to get paid bupkas by medicaid for these births? sure thing. Does it feel good when a woman with great insurance has a 2 hour labor and catches her own baby and doesn’t need a vaginal repair? yup.

    It all balances out. I do not run a meter during birth. I am not a taxi driver.

    Samantha McCormick, CNM
    Baby Love Birth Center

    • February 12, 2010 at 3:52 am | #70

      You are quoting me a bit out of context, or maybe I just wasn’t very clear. I think I was referring more to in internal issue with how we deal with our office practice and billing. I wasn’t suggesting that anyone should get paid by the hour in labor management, as that would really be a conflict of interest.

  39. February 11, 2010 at 1:51 pm | #71

    >>>> Science works a bit differently. The scientific method of determining what is true starts in the same place as empiricism, that is, with a theory or question. But now instead of reasoning why or why not that theory is true, we instead conceive of a method for proving that theory, via experimentation or modeling of some kind. We then run that experiment, and get the results. These results, assuming our experiment was properly designed, tells us what is really true and what is not. We then make new changes to our theories, and thus new questions to ask through further experimentation. If you believe in science, this is the only way knowledge of the natural world can truly be gained.

    >>>> I am absolutely willing to look at obstetrical practice and see what we should do better, and I think most doctors are. But we need real scientific data before we’re going to strongly consider changing basic practice. It has happened before, such as the shift away from episiotomy as data was produced that showed it to be harmful. Delayed cord clamping (or natural cord clamping for you taxonomy nuts out there) may become more mainstream on the back of recent data.

    How about the science that clearly shows the continuous fetal monitoring has not shown any of the expected promise in preventing compromised babies and preventing cerebral palsy, but has only increased the use of obstetrical interventions, including cesareans?

    Samantha McCormick, CNM
    Baby Love Birth Center

    • February 12, 2010 at 2:51 am | #72

      You’re right on there. External fetal monitoring in low risk labor is probably a bad thing, which I do not defend. It has become entrenched into practice and standards of care. Despite the evidence, the prevailing thought is that if monitoring were not performed, the rare fetal death that will occur would be completely indefensible in court, which is probably true. If you can think of a way to get an entire system to stop caring about getting sued and losing, let me know.

      Again, the scales of liability are not balanced. It is very easy to get sued and lose over an unpredictable bad outcome (random fetal death). It is very hard to get sued for a predictable bad outcome (wound infection, bleeding complication, accreta down the road)

  40. February 11, 2010 at 2:35 pm | #73

    Nicholas Fogelson :
    Birth plans that have reasonable requests such as avoiding episiotomy whenever possible, delayed cord clamping, avoiding pain medications… these are all fine.
    But some birth plans basically gut an obstetrician’s ability to do what he/she thinks is right – no cesarean under any reason, no pitocin ever, etc…
    This is all fine, but if that’s the model one wants to think of labor in, one would be better off working with a midwife. When the birth plan starts to erode what an obstetrician thinks of as a safe labor, it gets in the way of care.

    OK, Nicholas, I’m losing my temper with you.

    If you re-read the above post you will see that you implied several things:

    a) midwives are willing to provide unsafe care

    b) midwives are willing to agree to birth plans that say “no cesarean under any circumstances” or no induction/augmentation.

    There is not a midwife alive who would agree to such a birth plan.

    What planet do you think we are practicing on?

    Some women are going to need induction/augmentation. Some midwives might use castor oil/breast pump/arom instead of pitocin as a first-line option, but we all know that not every baby is going to come out how we want/plan it.

    Some women are going to need a cesarean. There are midwives skilled at breech deliveries who will assist a woman where most OBs would automatically schedule a cesarean, for example. We might have more patience for the labor process and “let” a woman push longer or be ruptured longer than many OBs, but we are not in the business of “vaginal birth or bust”.

    You are also (I hope) exaggerating. I certainly hope there are not parents out there naive enough to pen a birth plan that excludes induction/augmentation and cesarean. Anyone who writes such a birth plan does not need a midwife, they need a psychiatrist, stat.

    Samantha McCormick, CNM
    Baby Love Birth Center

    • February 12, 2010 at 2:56 am | #74

      If you’re losing your temper against month’s old noncontemporaneous conversation, take a step back and don’t take it so personally.

      >> There is not a midwife alive who would agree to such a birth plan.

      I’ve met lots of midwifes that in my opinion endorse a world view completely antagonistic to the medical model, making it very difficult for the patient to enter the medical system in a atraumatic way. I have had patients that tell me that they want to avoid a cesarean “at any cost”, which is so ridiculous. I have to ask if they really mean that – at any cost? At the cost of losing the baby? At the cost of injuring the baby? Because that’s the reason I would do a cesarean. I don’t do cesareans for convenience. My hospital has 24 hour coverage, there’s just no reason to do that.

      >>> I certainly hope there are not parents out there naive enough to pen a birth plan that excludes induction/augmentation and cesarean. Anyone who writes such a birth plan does not need a midwife, they need a psychiatrist, stat.

      As I said, most birth plans are reasonable, but sometimes they aren’t. I don’t write them, I just read them.

      One of my professors use to say tongue in cheek that the problem with birth plans is that babies can’t read.

    • February 12, 2010 at 5:17 am | #75

      I’d also add that your perspective is as a CNM, which is probably more aligned with the medical model than some midwives out there. Some midwives, mostly non-CNM practitioners, don’t have the same ideas of what is safe and unsafe care. To me, laboring a VBAC at home is unsafe, but some would disagree. So when you say I am saying “midwives are willing to provide unsafe care”, you have to take into account that we don’t all agree what the word “unsafe” means. Every choice as potential dangers, and things get confused when we don’t agree which dangers are the most important ones.

  41. February 11, 2010 at 3:02 pm | #76

    Nicholas Fogelson :
    >> a 100% healthy, low-risk mother was induced at 41 weeks for no reason other than dates
    Not no reason. Because a 41 week mother will experience IUFD 0.6% of the time in the subsequent week, and induction at 41 weeks does not increase cesarean rate over expectant management. Bradley is basically doing nothing and letting nature happen. This is fine, we cannot ignore the fact that pregnancy and childbirth is the single most dangerous time in a woman’s life. OBs are just trying to be there when they’re needed, and each and every one of us has to make decisions about when that is. We never assume that _doing nothing_ is the right thing. Doing nothing does lead to significant problems, even death, in some cases. We do our best to figure out when we need to do something to prevent these problems.

    Are you suggesting that the midwifery model or the Bradley Method supports “doing nothing” as opposed to the medical model, which “does something”?

    I think you might want to take a breath and think through your responses on this forum.

    You seem to be a thoughtful practitioner and seem to be supportive of “patient choice”, but as you answer these posts, you are sounding more and more like a typical jerky OB who is fed up with parents wanting to be part of the process and one who thinks that all thinking women should go to midwives who will just “go with the flow” and let mothers and babies die.

    We are aware of the statistics about post-term still birth and the risks/benefits of induction. We counsel our clients about them and do careful post-dates monitoring. At our birth center, we do an NST at 40 +/- 2-3 days, a BPP at 40 +/- 5 days, an NST at 41 +/- and 41 +/- 5 days, and another BPP at 41 +/- 3 days. We educate our clients about careful surveillance of fetal movements, especially past the “due date”. However, we are also aware that the average first time mom will spontaneously go into labor 7-10 days past the “due date” and that inductions carry risks. We are also precluded by legitimate safety concerns from conducting inductions with pitocin at the birth center (primarily because we do not have continuous fetal monitoring, and because we cannot readily perform an emergency cesarean).

    Given the choice between giving up their planned, unmedicated birth center birth (which in our case is generally a waterbirth) or having an induced hospital birth (said hospital does not allow water birth) SIMPLY because they have passed the 41 week mark and have a fractional chance of stillbirth, the majority of our clients choose to await spontaneous labor. We suggest castor oil and/or breast pump and offer membrane stripping.

    Our state laws prohibit birth at the birth center past 42 weeks. Our back up OB (my hubby) would not support it, anyways.

    We do not “do nothing”. We actively help the process along, without burning any bridges or subjecting clients to interventions they do not want or need.

    We induce women at the hospital for hypertension, IUGR, GDM, etc. We transfer primip breeches to the OB for scheduled cesareans (or version, which few of our clients are willing to risk – they mainly want a safe outcome for their baby).

    But the healthy pregnancies we leave more or less alone to end when the baby decides the time is right.

    It has happened that a 41+ weeks woman has asked to be induced at the hospital. Given the risk for stillbirth, we do not refuse these requests.

    In the 5 years I have run the birth center (80-100 births/year), we have “run out of time” exactly once. In other words, our methods of “soft” induction have been successful 99% of the time in healthy pregnancies. No one has gone past 42 weeks. A few have opted for hospital induction in the 41 week, but the majority have gone into spontaneous (assisted by our midwife methods) prior to 42 weeks and we have not had a stillbirth. I realize that our numbers are not large and that any day a baby could die without warning, but our clients are generally very pleased with our methods.

    However, we most certainly do not “do nothing”.

    Samantha McCormick, CNM
    Baby Love Birth Center

    • February 12, 2010 at 3:08 am | #77

      It sounds like you and your birth center do a great job of taking care of your patients/clients and meet a great need.

      Regarding “doing nothing”, to me Bradley is about what is done during labor. If Bradley ever talked about what should be done with post-dates testing, I never heard of that part. I don’t think he did.

      As far as you’re impression of me, its up to you. I write what I am thinking at the time I write it. It is my blog (this forum you mention) after all. I don’t believe in this current political view that every word must be vetted to make sure the right message is getting across. People say self-contradictory things all the time, as people don’t feel the same about things all the time.

      I am a thoughtful OB who is far more than average accepting of midwifery practices and models, but I’m not a midwife. I am completely supportive of a midwifery model that tries to give patients the experience they desire while still being cognizant of the real dangers of pregnancy and delivery and takes appropriate precautions. I am not supportive of a model that only emphasizes the “naturality” of labor and pregnancy and minimizes the potential bad outcomes to the point of not dealing with them, or with folks that disparage allopathic obstetrics so much that their patients come to the hospital already hating us.

      Routine induction at 41 weeks has not been shown to increase cesarean delivery rates, and over thousands of women will prevent a few still births. That being said, it does not take into account the intellectual/emotional/metaphysical benefit of allowing natural labor to come on and avoiding an induction. I agree that if patients want to avoid induction, awaiting onset of labor from 41 to 42 weeks with a NST in there somewhere is fine. In my training we did this, but subsequent randomized data has supported a 41 week induction as not increasing cesarean rates, and that is why the majority of OB practice has moved to this model.

    • February 12, 2010 at 3:17 am | #78

      PS – somewhere in there I said that Bradley “is basically doing nothing and letting nature happen, which is fine”.

      If I am wrong about this, educate me. What is Bradley’s method to you?

  42. February 13, 2010 at 8:47 am | #79

    Nicholas Fogelson :
    You’re right on there. External fetal monitoring in low risk labor is probably a bad thing, which I do not defend. It has become entrenched into practice and standards of care. Despite the evidence, the prevailing thought is that if monitoring were not performed, the rare fetal death that will occur would be completely indefensible in court, which is probably true. If you can think of a way to get an entire system to stop caring about getting sued and losing, let me know.
    Again, the scales of liability are not balanced. It is very easy to get sued and lose over an unpredictable bad outcome (random fetal death). It is very hard to get sued for a predictable bad outcome (wound infection, bleeding complication, accreta down the road)

    Very true. We all have to deal with it. Some midwives who practice without legal status don’t have to worry about being sued, but they do have to worry about going to jail after a bad outcome.

  43. February 13, 2010 at 9:35 am | #80

    Nicholas Fogelson :
    PS – somewhere in there I said that Bradley “is basically doing nothing and letting nature happen, which is fine”.
    If I am wrong about this, educate me. What is Bradley’s method to you?

    My experience of the Bradley method in two communities has lead me to not be a big fan, and I wonder if the “anti-hospital” people you (Nicholas)run into are primarily Bradley “educated”.

    Let me explain, before I totally piss off all the Bradley fans out there: (please note, these are my own experiences and do not reflect anything more than my own experiences)

    1) Birth center in NJ, circa 1997. 33 weeks pregnant woman, first baby. Took Bradley classes (rather than the birth prep class offered by the birth center). Is have preterm contractions apparently caused by a UTI. I want her to take antibiotics to cure the UTI and (hopefully) stop the contractions, so that she doesn’t have a premature baby. Her response “My Bradley instructor told me not to take any medications.”
    Granted, she may have misunderstood what her teacher said.
    It took 45 minutes (while the waiting room filled with clients) to convince her that I was not going to harm her or her baby and that, in fact, I had her baby’s best interests at heart.

    A childbirth preparation class should never set up the provider as the “enemy”, which has been my experience more than once with Bradley “educated” clients.

    2) Cape Coral, FL, 2009. Home birth client (not my client) transfers to hospital because home birth midwife picked up fetal heart rate decelerations with doppler. My husband, an OBGYN, assumes care. Baby seems good on initial monitoring. Mom decides that she would like some stadol for pain. The Bradley instructor is also the doula. While the nurse injects the stadol, the doula gets down on her knees and prays loudly that the pain meds not kill the baby.
    Baby’s heart rate show ominous changes and the doctor tells the mom that she needs a cesarean to save the baby. The doula has by now been escorted out of the room (for her previous behavior). The mom and grandmother are in complete agreement to the cesarean and are visibly worried about the baby. The husband places his body in front of the bed as the nurses attempt to wheel the mom to the OR. He yells at the doctor that “he is not GOD and only GOD can decide if the baby lives or dies”.
    Husband is escorted out by security and mom gratefully accepts a cesarean. Baby born healthy.

    Granted, these are some pretty unique individuals and Bradley, per se, is not to blame. But that Bradley instructor is still teaching and being a doula.

    Unsuspecting parents who want to be educated about pregnancy and birth will take her class and come away with a radical view that hospitals and doctor are the “enemy”.

    In theory, the Bradley method teaches parents to be advocates for themselves and prepares them for this role by educating them deeply about the process of labor and birth. The classes are longer and more intensive than “standard” lamaze or other classes. Most birth prep classes are 3-5 2 hour sessions; Bradley is usually 12 2 hour sessions.

    From the bradley web site: “Our classes cover a few topics that are rarely discussed in other classes like: how to reduce the need for an episiotomy and the likelihood of a tear, how to avoid needing a cesarean, how to make the best of it if a cesarean is necessary, and what the coach should do if the baby is accidentally born in the car. ”

    Each Bradley instructor is going to have their own perspective and teaching method. I think it is the “how to avoid a cesarean” that is most misused by Bradley teachers and most misunderstood by Bradley parents.

    While there are certainly doctors who push interventions more than others and might be too aggressive, I have also never understood why Bradley teachers didn’t do more to help their student choose the “right” care provider. The teachers all know who the “knife-happy” docs are in their communities. Instead of instilling fear and mistrust of the parents’ provider, why not educate them and help them choose a more appropriate provider? Perhaps some do.

    In my experience as a midwife and labor nurse, many/most Bradley parents come into the hospital hostile and on-guard.

    I worked for 5 years as a labor nurse at Mount Sinai hospital in NYC. When Bradley couples came in, the charge nurse always gave them to me, because the other nurses couldn’t deal with them and I was, at least, sympathetic and willing to be their liaison with their doctor. The physicians would commonly be observed at the desk, literally pulling their hair out, head in hands, not understanding how their seemingly “nice” patient had suddenly turned into such a problem, refusing any suggestions or advice from their physician (there were no midwives). Some parents taped their birth plan to the door of their labor room.

    I was upset to observe such hostility and mistrust. These parents had effectively hired their physician. Why were they so sure that the doctor was wrong? Why did they think that 12 weeks of classes put them in a position to understand the labor process better than a board certified OB? Why weren’t they instead birthing at a birth center or at home, because they clearly didn’t want anything the hospital had to offer, or at least going to a more patient-friendly doctor and hospital?

    Mount Sinai was a great place to be induced and get an epidural, or to have a complicated pregnancy or preterm baby, but it was definitely not a place to have a natural, patient-led birth. There were other hospital-based providers who would have been a better fit. Why not go to a doctor or midwife who was already on their side, rather than trying to change the way their doctor had been practicing their whole careers? A handful of patients were not going to change hospital policy about fetal monitoring or the mandatory newborn admission to the nursery by 45 minutes of life.

    I suspect it is this sort of patient who Nicholas is referring to when he talks about patients who write a birth plan that precludes cesarean or suggests that the Bradley method supports “doing nothing”.

    I certainly hope that not all Bradley instructors instill fear and mistrust into their students, but in my experience, many parents come out of Bradley classes with some seriously misguided ideas and a serious distrust of their providers and what constitutes a necessary intervention.

    I’m probably going to piss off a whole lot more of you with this analogy (which works for me; I was raised Catholic): the Bradley method is alot like institutionalized religion; the basic teachings and tenets of Christianity are beautiful and worthwhile (love everyone, turn the cheek, etc) but when put into practice so often lead to hatred, pain, guilt, and war. In the same way, the idea that parents should be educated and empowered to prepare for birth is admirable, but when it is taught by Bradley educators, it very often leads to fear and distrust.

    putting on my steel-lined big girl panties

    Samantha McCormick, CNM
    Baby Love Birth Center
    Cape Coral, FL

    • February 13, 2010 at 10:18 am | #81

      Wow! I think you’ve captured a lot of what me and a lot of OB/GYNs feel about the Bradley method. I’m not at all against a concept of natural labor and am down with just about any method that helps a woman to experience the labor how she wants, but when it comes with near religious zeal against the medical system it can be hard to deal with.

      It is so difficult to be a physician to a patient who inherently distrusts me not because of of who I am, but because of what I represent to them. Fortunately it is pretty rare, and usually it can be defused with a few kind words and some effort to recognize what is important to the patient.

      • Traci G. Perg
        February 18, 2010 at 9:14 pm | #82

        You know, I feel like I have to comment here. Not every laboring mom who views her obstetrician with hostility and mistrust has had that view implanted in her by out of hospital birth classes or natural birth advocates. There are a great many women, myself included, who feel that way because of the care they received from their previous obstetrician. I will never be able to walk onto a hospital labor and delivery unit again and feel safe. During the course of my labor with my first son I was forcibly held down while my obstetrician inserted an IUPC into me while I was screaming “No! Stop! You’re hurting me!” He then charted that I was “having difficulty with contractions”. He refused to give me any pain medication after that procedure unless I agreed to an epidural, to the point he laughed in my face when I mentioned other alternatives. When I reminded him that I was dilated to only 3 cm and an epidural increases your chance of a c-section if administered before 5 cm he laughed again and said that it wasn’t true, although he did falsify the charting and write that I was dilated to 5 cm when I “requested” an epidural. When the IUPC, predictably, did not function correctly, the labor and delivery nurse spent four hours making phone calls trying to inform him of the fact. When he finally returned her calls, it took him another four hours to arrive to replace it. (The times are written in my medical records.) I was terrified to let him touch me again, but this time the insertion was painless and the catheter functioned correctly. From 3 cm dilation at 11 am to 10 cm dilation at 10 pm a cesarean delivery for failure to progress was mentioned five times. At 10 cm, despite having incredible urges to push, I was told not to push, that I had to “labor down”. At that point the obstetrician told me that the baby had not descended past -1 station and we “had to do” a cesarean section. The sum total of his pre-operative instructions to me were “Honey, you’ve been at this a long time, let’s go down the hall and have a baby.” and “You’re a nurse. You know that any surgery has risks.” No mention was made of the reproductive risks that would follow me the rest of my life and put my life and my future children’s lives in danger. In surgery my hands were tied down, my questions were not answered. I was terrified, shaking and not a single person other than my husband would look at me or talk to me. None of the practitioners in the room would give me the slightest assurance that my baby and I would be okay. My baby was healthy with Apgars of 8/9. He should have been since he didn’t have a single deceleration throughout the entire labor. I recovered well physically from my surgery with no complications. So, nobody died, and nobody had any serious physical complications. Therefore, I did not have a bad outcome. The fact that I couldn’t walk past the doors to that surgical suite without having a panic attack didn’t count. The fact that I had to quit my job in NICU because I couldn’t walk past those doors didn’t count. The fact that I had nightmares for years didn’t count. The fact that I was diagnosed with PTSD, necessitating medication and therapy didn’t count. The fact that my obstetrician essentially committed rape by instrumentation didn’t count. Nothing counted except the fact that mom and baby left the hospital with no visible damage except a nicely healing cesarean scar. Because there was no “harm” I couldn’t bring charges against the physician if I wanted to. And you guys want tort reform.

        I planned a homebirth with my second baby. Was it riskier to labor for a VBAC out of the hospital? It depends on how you define risk. I was comfortable that my midwife could monitor for complications and recommend a transfer if necessary. I wasn’t certain that every possible complication could be avoided or accounted for but I was damned certain that she wouldn’t call for other people to hold me down while she forced something into my vagina while I was screaming “No! Stop! You’re hurting me!”

        My former obstetrician practiced at a tertiary referral center in a large shared practice. The hospital delivered over 3000 babies per year. Someone, a partner, a colleague, a nurse, an administrator, someone had to know that this man treated patients this way. Someone had an obligation to protect women from him, and they failed. As his patient, I felt powerless to do anything other than avoid insofar as possible any further contact with him or with any other medical doctor for the rest of my life. As obstetricians, you should be policing yourselves so that doctors like him don’t continue to do harm. So, when you’re lamenting the fact that women don’t trust you, don’t forget to consider reasons other than “those wacky natural birth freaks” that they might have for their mistrust.

  44. February 19, 2010 at 6:55 am | #83

    Ms Perg –

    Thanks for your comments. I’m sorry you had such a negative experience with your birth, and that experience led you to mistrust obstetrics and/or obstetricians in general. The experience does sound like it was awful for you, and I cringe at hearing how you were treated. There are some bad eggs in every field, mine included. You’re right that we don’t police ourselves well, though I think the same can be said for just about any field. From the outside it might seem that such a thing is easy to police, but actually its not. Choosing to take a hard stand against a colleague is a potentially career ending move, and is not taken lightly by anyone. It isn’t something that can be casually done. Perhaps it shouldn’t be that way, but like the reality of the medical malpractice, it is what it is. Did you report the physician to the medical board yourself, or did you worry about how it would affect you as a nurse to do that?

    If you have the need for the help of an obstetrician in the future, I hope you are able to connect with one that meets your needs better.

  45. Traci G. Perg
    February 19, 2010 at 7:33 am | #84

    I did not report the physician to the medical board but it was not out of fear for my career that I made that decision. I reported the incident to our hospitals risk management team and spent approximately ten months dealing with them. Long story short, they maintained that the physician had not violated any hospital policy. The only apology I ever received from them was “I’m sorry you feel that way about your birth, but most of our patients want c-sections and are very happy with the care they receive.” I was given the option to write a statement and place it in my chart, but it was unclear to me what purpose that would serve. The hospital holds Magnet Certification and routinely made the Forbes 500 best places to work list, as well as the Top 100 hospitals in the nation. I had no reason to believe that my experience would have been different at any other hospital. I spoke with five attorneys, including the attorney for the plaintiff in Meador v. Stahler and Gheridian and was told that I had no case because I had suffered no harm. After approximately a year, I felt that I could devote no more energy to this matter. I also had no confidence that any resolution would be forthcoming. I would like to point out that at no point did I ask for, or even desire financial compensation. What I wanted was a real apology, an acknoweldgement that my rights were violated. I wanted to hear that no means no, even in the delivery room. I wanted policies in place that would protect women from violation at least as much as they protect physicians and facilities from liability. I saw then, and still see now no indication that such policies are desired by physicians or hospitals. When a woman says “patients rights” she is answered with “physican liability”. When she says “bodily integrity” she is answered with “tort reform”. When she says “patient autonomy” she is answered with “malpractice”.

    • February 19, 2010 at 1:12 pm | #85

      Sorry to hear that you did not get the resolution you were looking for.

      You mentioned before that we wrongly desire tort reform, yet also mention that malpractice exposure was quoted as one of the reasons you were treated the way you were treated.

      Though I don’t defend what went on in your case, as based on what you describe it sounds like your rights were not respected, malpractice does have a huge amount to do why women’s autonomy is limited in some situations.

      A great deal of people on this blog and elsewhere feel strongly that VBAC is being unfairly limited, which is a problem that rests solely on the back of the malpractice crisis. The lack of support for VBAC by some OBs and most hospitals is based on the massive settlements that will occur for every injured or dead baby that results from a uterine rupture. It doesn’t matter that these cases are rare, as each will result in potentially tens of millions of dollars in losses. Informed consent is of little value in court when a baby is dead.

      You mention that we should police ourselves better and somehow should have removed your doctor from circulation, but then at the same time say that five different attorneys would not bring a malpractice case against him. Given that malpractice was not committed in any legal sense, should doctors then be responsible for policing doctors who are assholes? don’t adequately respect their patient’s desires?

  46. Traci G. Perg
    February 19, 2010 at 5:02 pm | #86

    To put it bluntly, I think it should be easier, not harder, to bring criminal or civil charges (whichever is most appropriate) against physicians who treat their patients the way I was treated by my former obstetrician. In any other setting, what he did would have been recognized as criminal battery if not outright sexual assault. The situation is so dire as it is, patients have little recourse against doctors who are sadistic or incompetent. Tort reform would simply allow those doctors to continue hurting their patients with even less fear of reprisal.

  47. March 7, 2010 at 5:22 pm | #87

    Thanks for the great article! I’ve also really enjoyed reading the comment threads. I have rarely seen such a thorough discussion contrasting midwifery methods and obstetrical methods that is so civil and thoughtful and which did not quickly degenerate into a screaming match. Thanks for facilitating such a calm and well-reasoned discussion!

    • March 8, 2010 at 5:12 am | #88

      My pleasure and thanks for participating. Dialogue is what its all about. Hopefully we have moved from 50% civil to at least 90% :)

  48. Susan Peterson
    August 16, 2010 at 3:24 pm | #89

    You have said several times in this thread that women who don’t want the type of care you provide should perhaps seek out a midwife. Dr. Poppy said this also. You have also said that you don’t believe that home VBACS are safe. So what about the woman who has a C section with her first baby, and lets say that it was for a good but non-repeating reason. (Although you admit that there is a not negligible chance that it might have been for a not so good reason.) At that point she has to give up her hopes for a quiet, non hurried birth in which she is the one in control? There are no options for this woman in your scenario. Her next two or four or six births have to be according to the medical model. And she would be very lucky if they were vaginal deliveries at all in the current climate.

    So I don’t think you can just say, well if a woman doesn’t like it that way, she has other options. She often doesn’t.

    (I am someone who has had 8 VBACS, the last six of them at home… and most of them ten pound babies. After the 11 pounder in the hospital the OB told me that ‘size was no object’ for me obstetrically. I guess I must have some Samoan in me! )

    Susan Peterson

    • August 16, 2010 at 3:31 pm | #90

      Susan – Thanks for your comments. I agree with everything you just said, but have this to add –

      Why do we assume that women can have a completely noninterventional VBAC birth and also have the same level of safety that is present in a monitored in hospital birth?

      There is not some automatic rule that these things must coexist, and personally I don’t think that they do.

      Its great that you had such success with your VBACs, but I can’t predict who is going to have that success and who won’t. I can only predict that if 200 people VBAC at home, one will have an absolute disaster that is completely preventable, and that’s not a situation I could recommend.

      I think the “quiet and unhurried” part can be achieved, as long as doctors/nurses/hospitals are cooperative with and supportive of those goals.

    • August 16, 2010 at 3:34 pm | #91

      >> At that point she has to give up her hopes for a quiet, non hurried birth in which she is the one in control?

      And here is the difference between how OBs look at birth and how the NCB movement looks at it. Nobody is in control. Birth is just going to happen, with the good and the bad. Mostly good fortunately. Nobody gets to control the bad things that can happen. We can only be prepared to deal with them. In my opinion failing to prepare for the truly bad under the idea that we are in control is asking for trouble.

  49. Susan Peterson
    August 16, 2010 at 3:54 pm | #92

    Frankly the scenario described by Dr. Poppy absolutely horrified me.

    This is what she said, “The nature of the OB/GYN (of which I am one) is that, as Dr. Fogelson pointed out, you often have 5 women in labor at the same time which necessitates “active management,” based on the Dublin studies, i.e. augmentation of labor with Pitocin, artificial rupture of membranes, and C-section if things seem to be stalling. Everyone is on a schedule, whether it be the resident reporting to the chief, a private practitioner who has an office full of patients to get to, or a laborist who is “running the board.”

    I don’t think anyone should have to have a baby that way. If some women as you say, don’t mind, well, it’s a free country, but I think this is totally contrary to the intrinsic nature of birth. I really would consider having to have my baby under those circumstances to be a nightmare, and I am not exaggerating.

    By using the word “nature” I don’t mean that there are naturally no bad outcomes, or that any baby you can grow you can birth, or anything of that order. But while there are broad general patterns, uninterfered with birth really is not standardized and is not amenable to being scheduled. Apparently you are able to do so, but not without consequences. I think some of those consequences are medical, such as the 30+% C section rate. But I don’t think the loss of the experience of giving birth is an unimportant consequence. No, I wouldn’t put having that experience above having my baby live, and neither would the vast majority of women. But that doesn’t make that experience not important. You say valuing this is cultural. Well, I guess that can’t be denied. I don’t think all cultural values are equal, or equally in accord with the real nature of human beings. Some cultures circumcise little girls, and that is a cultural value also, but it doesn’t make it fine with me. I have pretty much a similar-not the same- opinion of a culture that devalues giving birth.

    Even if those of us who feel this way are a small percentage of women we deserve to be able to give birth the way we choose, and to have the safety of medical back up if this turns out to be one of those births which cannot be accomplished safely without intervention. To my mind this means that really low risk women should be able to give birth at home with providers who have an appropriate amount of training for that situation and who are able to have a good enough relationship with doctors to feel comfortable seeking their help in a timely manner. It means that women with higher risks should be able to give birth in a hospital attached birth center, in a home like atmosphere but with intermittent monitoring and rapid intervention available nearby. Only those whose births are really very high risk need a medicalized birth…and even for them the attempt should be made to consider them as people and give them what it is possible to give them of the joy of the birth of their baby, while putting their safety and that of their baby first.

    Susan Peterson

  50. August 16, 2010 at 4:12 pm | #93

    Susan – I completely agree with you. People who want a less interventional birth in an safe environment should be able to get that.

    >> No, I wouldn’t put having that experience above having my baby live, and neither would the vast majority of women.

    So here is the philosophical question. You wouldn’t put it that experience above having the live baby, but you still would choose that experience. Therefore, you believe that avoiding all this intervention and monitoring isn’t associated with any additional risk.

    I’m not saying I agree or don’t agree with this, because I do think that a noninterventional birth can be achieved in a safe environment, but ultimately that is the issue.

    Doctors do tend to get involved with birth too much. There are a lot of pressures for babies to birth on an unjustified schedule, even when there is 24 hour coverage of labor and delivery. I wish that more docs would just let labor happen, but this isn’t how everyone is trained. Dr Poppy’s description is sadly true in many situations, and this is tragic.

    I agree that many environments for safe birth should be available. I don’t think that delivering a baby at home, even in a low risk birth, is as safe for mother or infant that delivering in a hospital, but fortunately the differences are small on a numerical level, if they are present at all. It is a shame that in hospital experience is not malleable enough to adapt to every woman’s needs while still providing the safety resources it affords.

  51. Susan Peterson
    August 16, 2010 at 4:21 pm | #94

    No, I wasn’t in control of those undefinable variables which make one labor take four hours and the next take 15 hours, of course not. But I was in control of whether I lay down (usually NOT), sat, stood or walked. I didn’t have to interact with strangers. I was in control of whether I wanted to eat and drink or not. I was in control of who was there with me. I wore what I wanted or nothing if I wanted. I had my whole house and yard to walk around in. I could go on taking care of my kids and talking to them, up until the time when I felt unable to do so. I didn’t have to consult with anyone about what position I would give birth in. No one stopped me from feeling the baby’s head coming if I wanted to. (which happened in one of my hospital VBACS, the nurse pulled my hand away.) I held and nursed my baby as soon as it was born, and I didn’t have to ask or negotiate for this as if the baby belonged to the hospital. If my kids happened to be awake and around, they watched the birth, but if they needed to sleep, their beds were right there. I guess this sort of thing is what I meant by control.

    I made every effort, right from the first to make sure my scar was strong. I snuck brewers yeast and liver powder into the scant food they allowed me after my C section, and took my vitamins from day one. After the first and subsequent VBACs,while I was still open, I asked the doctor to put his hand up and feel the scar, so in the next pregnancy I would know that at least I hadn’t started with a thinned out scar. I counted grams of protein day after day when I was pregnant. I was lucky to have a doctor who gave me prenatal care, worked with whoever helped me at the births, and came afterwards to examine me and the baby. I didn’t think that I had NO risk, but I guess I thought my risk was lower than the statistic indicated. I made my choice and I certainly would not have blamed anyone else if something had gone wrong.
    I see that it is different to make these choices for someone else when you are legally regarded as having the responsibility.
    Susan Peterson

    • August 16, 2010 at 5:52 pm | #95

      Nicholas Fogelson :
      I can only predict that if 200 people VBAC at home, one will have an absolute disaster that is completely preventable.

      Dr. Fogelson,

      I am in complete agreement on the rate of UR being 1/200. But where I do disagree with you is your statement that every one of those ruptures is “an absolute disaster.” Can you point me to studies that support that statement. My understanding is that the mortality (absolute disaster??) rate is about 1/9000, if I remember correctly. Not sure of the morbidity rate off the top of my head. Am I incorrect in my understanding that the vast majority of UR are detected and proceed to surgery where the outcome is good for both mother and baby? I know that there are horrific ruptures with bad outcomes of permanent and significant damage to mother and or baby, but what is that rate?

      • August 16, 2010 at 6:06 pm | #96

        >> I can only predict that if 200 people VBAC at home, one will have an absolute disaster that is completely preventable.

        Referring to a uterine rupture occurring out of hospital. UR occurring in hospital are usually managed quickly enough to prevent bad maternal and fetal outcomes.

        There are no published data on uterine ruptures occurring at home, but one certainly isn’t going to have as much success as one has when they occur in hospital. Uterine rupture usually is associated with large maternal bleeding. The uterus gets 20% of cardiac output. If even conservatively only 25 % of the uterine blood flow is exiting the ruptured uterine walls, that’s less than 10 minutes to severe hypovolemic shock and 20 minutes to complete exanguination.

        Given the time it would take for the homebirth VBAC rupture to be identifed, ambulance to arrive, get to hospital, make it to operating room, disaster is the likely outcome.

        Maybe you didn’t pick up that we were talking about VBAC at home?

        I’ve heard a few people claim that a uterine rupture at home is somehow going to be OK, but there folks have never seen a uterine rupture from the inside.

        I’m up way too late.

  52. August 17, 2010 at 5:06 am | #97

    Yes, I realize that you are speaking about home VBAC. No, I have never seen a UR from the inside, only what little I could peak at over the drape of a dehiscence. My question remains the same. Of the 1/200 UR ruptures, what percent are ” absolute disasters” with death or permanent damage to mom or baby. And if the answer is 1/9000 mortality rate which I recall from reading in a previous study, (from a presentation by Dr. Andrew Kotaska, speaking on risk) then could it not be possible that some people find that level of risk acceptable enough to VBAC at home. In a nutshell, I mean to say that it is my understanding that it is the rare UR that is “an absolute disaster”and that the background risk for fetal death is 1/2000 in all labors, so what makes this so dangerous. And the regs regarding OOH VBAC vary from state to state, which leads me to believe that there is more to it than just punching the numbers. In some places, it may not be community standards, but that is a post for another day.

  53. August 17, 2010 at 5:32 am | #98

    But 1/9000 mortality rate is in a hospital, not in a home. People and babies usually don’t die from uterine ruptures because of surgeons, anesthesiologists, and blood banks. You can’t extrapolate that safety to an environments where those resources are 30-60 minutes away. And before I hear that the hospital is 10 minutes way, I will reiterate that the trip to the hospital is only a part of what needs to happen before an injured mother gets to the operating room.

    UR is not an absolute disaster because usually happens in a hospital. UR outside of a hospital is likely to be a terrible outcome.

    >> only what little I could peak at over the drape of a dehiscence.

    Scar dehiscense/uterine window is not uterine rupture. Stats on uterine ruptures (in any study I have read) is clinical rupture with a continuity of space between the uterine cavity and the peritoneal cavity.

  54. August 17, 2010 at 5:33 am | #99

    Getting shot in a hospital probably has a much lower rate of mortality than getting shot outside a hospital. UR is the same way. Traumatic injuries need to be dealt with quickly to get the best outcomes.

  55. August 17, 2010 at 5:41 am | #100

    How many home VBACs is a midwife going to attend in a career? It can’t be that many. Therefore most will have positive experiences and pooh-pooh the idea that those experiences were substantially more dangerous than VBACing in the hospital.

    If uterine rupture happens 1/200 times, a midwife that has a career laboring 100 VBACs has an only 40% chance of seeing a uterine rupture over that entire career. 60% of the time no rupture.

    The 60% will feel righteous. The 40% will lament their neglect of the data and the obvious inadequacy of the home environment for dealing with traumatic blood loss.

    • August 17, 2010 at 6:45 am | #101

      Nicholas Fogelson :

      >> only what little I could peak at over the drape of a dehiscence.
      Scar dehiscense/uterine window is not uterine rupture. Stats on uterine ruptures (in any study I have read) is clinical rupture with a continuity of space between the uterine cavity and the peritoneal cavity.

      Yes, I am not implying a dehiscense is a UR, only stating that of my small < 100 vbac birth sample size, most in a hospital, this is the "closest" to UR that I have seen.

      I guess it comes down to comfort with the level of risk, and that needs to be determined by both the family and the provider, with EACH doing what they feel comfortable. As always, thanks for the discussion and forum to have this conversation.

  56. Alexandra
    September 18, 2010 at 8:14 pm | #102

    “So here is the philosophical question. You wouldn’t put it that experience above having the live baby, but you still would choose that experience. Therefore, you believe that avoiding all this intervention and monitoring isn’t associated with any additional risk.”

    First, thank you all for the lively discussion, and particularly Dr. Fogelson for making it possible. This blog and the exchange of views has been so helpful to me as I contemplate my homebirth (first pregnancy, 16 weeks, no traumatic birth experiences now or hopefully ever). But, I just have to say that I couldn’t disagree more with Dr. Fogelson’s conclusion above. I honestly believe that the majority of women who choose homebirth (which by definition has fewer interventions and monitoring than would be available in the hospital) are aware that they are taking some additional or at least different risks. While I don’t believe that pregnancy in general is inherently dangerous or risky, I’m acutely aware that there are very real complications that can arise during labor that require urgent medical intervention, and that by choosing not to deliver in the hospital, I may not have access to those interventions if I need them. I’m choosing a homebirth because I want to “try” to have natural, unmedicated childbirth with as few interventions as possible and I think I’m far more likely to be successful under the midwifery model of care. But at the end of the day I really want a healthy baby! Even if I could find a midwife who would attend me, I would never attempt a twin breech VBA3C at home just for the experience (just hyperbole, but I hope you get my point). I think that the choice of provider and birth location involves weighing many potential risks and benefits and I freely admit that I’m taking a gamble that a bad outcome could result. But I could also have a bad outcome in the hospital or an outcome that I would consider to be bad, such as an infection or a difficult and painful recovery from a c-section that interrupted or interfered with my ability to take care of, bond with and breast feed my baby, even if it didn’t result in the baby’s injury or death. My point, which I hope Dr. Fogelson agrees with, is that women should be able to make these choices and not be effectively cut off from OB care if needed and forced to pay out of pocket for a homebirth because it’s not the “Standard of Care” according to one’s health insurance company.

  57. Debbie Bryant
    June 20, 2011 at 7:22 pm | #103

    This one of the biggest reasons why I choose to birth at home ~ not because I believe that doctors are “bad” (although some are, just as some midwives are), but because I understand that some of the decisions they make are made out of fear of being sued ~ and rightfully so! I understand that they have families of their own to look out for and cannot always take the risk that something could go wrong and they receive all the blame. That is why I choose to birth at home ~ so that I can freely make labor/birthing decisions that are not based on fear. I really appreciate the work that you are doing, though! Not just blindly following the norm, but researching and putting into practice what is safe, effective care for your patients! Wish you the best!

    • June 21, 2011 at 2:43 am | #104

      I feel that delivering at home is a trade off. There is no doubt that some actiosn in the hospital are made because of medicolegal concern, but there is also little doubt that there are rare situations that can unexpectedly arise that cannot be adequately dealt with at home. Many studies have supported a 1-2x increase in neonatal and/or perinatal death with homebirth. Absolute risks remain low, however, and everybody gets to decide what elements of the risk/benefit equation mean the most to them.

      Thanks for the comment!

  58. July 31, 2011 at 7:43 pm | #105

    hello there and thank you for your info – I’ve certainly picked up anything new from right here. I did however expertise some technical points using this website, since I experienced to reload the website a lot of times previous to I could get it to load correctly. I had been wondering if your web hosting is OK? Not that I am complaining, but slow loading instances times will often affect your placement in google and could damage your high quality score if ads and marketing with Adwords. Anyway I’m adding this RSS to my email and could look out for a lot more of your respective fascinating content. Ensure that you update this again soon..

  59. marg goodwin
    July 11, 2013 at 8:17 pm | #106

    I query the fashion of male presence (usually the father) in the birthing environment. There seems to be an unusually high incidence of protracted labour, unruptured membrane, poor dilation, I believe that we are not sufficiently evolved to have lost our primitive sense of threat when there is testosterone present. Have any studies been carried out to determine whether an all female attendance is more beneficial to the smooth progress of birth or is there no significant difference? Assuming this is relevant to forceps/section delivery.

    From an intelligent, concerned and observant mother of two and a granny.

  1. November 9, 2009 at 12:48 am | #1

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