Thanks for the comment!

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

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.

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.

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.

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.

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.

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?

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

>> 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.

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

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.

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.

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

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.

>> 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!

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?

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.

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.

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.

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

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.

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

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.

>> 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.

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)

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.

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

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

>>>> 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

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

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

Amen!

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

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