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

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.

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.

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:
<<>>

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.

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.

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!

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.

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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.

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.

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!

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!

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!

>> 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.

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

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.