Home > Obstetrics, Rants and Raves > The Myth of the Unnecessary Cesarean

The Myth of the Unnecessary Cesarean

nec·es·sar·y: being essential, indispensable, or requisite

One thing I have learned by being active in the obstetrics and birthing blogosphere is that there are a whole lot of people out there that think that most cesarean deliveries are unnecessary. While most of them will admit that some cesareans are medically required, its pretty rare that the ones that have had a cesarean looks at their cesarean that way.

A popular term bandied about is “Unnecesarean”, a catchy little phrase that implies the underlying belief that most cesareans are unnecessary. Frequently, commenters state that they had a cesarean that they didn’t want, and that at some point later in their life someone let them in on the secret that their cesarean wasn’t really necessary, and this is completely accepted as fact. In some cases, people believe that they were robbed of the vaginal birth they were destined to have, or even that they were somehow raped by the their physician.

Frankly, I am tired of it.

Anyone that has followed my writing knows that I am not a big fan of cesareans, and believe that a fair number of the cesareans we do might be avoided. I have discussed the relationship between sensitivity and specificity for identifying abnormal labor and heart rate tracings, and how where we put our thresholds will effect how many cesareans we do. I have discussed how the Friedman curve is too strict, and that to hold women to this curve is to place the label of abnormal on a huge number of women who area laboring normally, potentially leading to avoidable cesareans. I have even talked about how VBAC access needs to improve, and that we should be encouraging more women to attempt VBAC.

That all being said, I have never seen an unnecessary cesarean delivery(*). In fact, no one has.

What some members of the blogosphere likes to call “unnecessary” cesareans are misnamed. They are misnamed because the word necessary implies something that cannot be applied to this situation. As was noted in the introduction, necessary means something that is essential, indispensable, or requisite. Specifically to cesarean, necessary would imply that the procedure is required in order to have a favorable outcome for the fetus or mother. The problem with the term is that we don’t know what would have happened if we hadn’t done the cesarean, and as such we have no idea if the cesarean was necessary. If fact, the true necessity of any cesarean can never be determined, as we will never know what the outcome of the alternative decision would have been. As such, it is completely unjustified to label any particular cesarean unnecessary, and with apology to Jill, the term “Unnecesarean” isn’t fair.

So assuming that there are some cesareans going on that might have been avoided, how should we talk about them? How about using the correct terminology: indicated vs unindicated. When something is indicated, it means that given the current state of practice and knowledge, the proposed procedure should be done. Unindicated means that it shouldn’t be done. Unlike “necessary”, these terms can be used prospectively. They do not claim that the choice they lead to is absolutely the correct choice – they only mean that with the best information we have at the time, it is the most appropriate course of action.

So here are indications for cesarean:

  • nonreasurring fetal heart rate tracing remote from delivery. In most cases, this means a NICHD Category III tracing that cannot be resolved through medical treatment or expedious vaginal delivery.
  • An elective repeat cesarean in a woman who after appropriate counseling chooses one.
  • Arrest of dilatation
  • Arrest of descent
  • Previous uterine surgery with high risk of uterine rupture
  • Maternal pelvic reconstructive surgery with a desire to preserve the repair
  • Malpresentation of a singleton pregnancy
  • Malpresentation of a subsequent baby in a multiple pregnancy, when breech delivery of the second twin is not feasible.
  • Maternal request

Are these indications absolute?  Of course not. They just mean that when these indications are present, we think that a cesarean in in the best interest of mother and/or baby. Does that mean that to not do the cesarean would absolutely injure either party? No. It just means that the risk/benefit of pursuing vaginal delivery is no longer in favor of it, to the best of our knowledge.

So lets not call cesareans unnecessary. Lets just say that maybe a particular cesarean was not indicated. We can all have a great intellectual discussion about what it means to truly have an arrest of dilatation, or whether or not a breech singleton can be safely delivered vaginally. We can argue about that risk/benefit analysis, and even retrospectively argue that the risk/benefit of a particular situation was prospectively misinterpreted. We should pursue these arguments, because dialogue helps us to develop our knowledge. But arguing that a cesarean was unnecessary because one believes that they were going to go on to have a healthy vaginal delivery without it is fallacious. It implies something that just isn’t true, and is ultimately unfair to all parties involved.

* At least not by my definition of the word unnecessary.  As the commenters have pointed out, it depends on how you use the word (added 7/28/10)

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  1. July 27, 2010 at 2:58 pm

    I totally agree. I think it would be more beneficial to discuss the parameters of when a c-section becomes ‘indicated’ (progress, ctg interpretation etc.). I also think we need to change our focus and start looking at what factors increase the chance of a physiological birth with a healthy outcome. Soo Downe suggests maternity practice, research and policy should be framed by the concept of ‘salutogenesis’. We might find more useful answers than attacking interventions in hindsight and focussing on the negative. Unfortunately the research in this area is scarce.

  2. Aly
    July 27, 2010 at 3:00 pm

    Seems like splitting hairs to me, unindicated vs. unnecessary. Unindicatedcesarean.com would not a good website name make. The contempt that obstetricians have for women’s decision making power in regards to their bodily integrity is amazing to me, as evidenced by the letters to the editor in the NYT. Thank you for not being perpetuating the “ob vs woman, or ob vs midwife” war, Dr. Fogelson, in particular for naming elective cesarean as an indication.

    I think you hit the nail on the head with “we have no idea if that cesarean was necessary.”

  3. July 27, 2010 at 3:03 pm

    Thanks for the first comment! I completely agree about looking at the factors that promote normal birth:

    here’s a few:

    1) avoiding unindicated inductions
    2) control of gestational diabetes
    3) delaying hospital admission until the onset of active labor

    • Briana
      July 27, 2010 at 5:37 pm

      I don’t know if mine was truly an ‘unnecesarean’ but the term perfectly sums up my feelings about the birth of my first child. At the time the decision was made to take me in for an emergency C-section, I would agree that it was ‘indicated’ according to your charts (arrest of descent), but what makes it feel like it could have been unnecessary was the sequence of events before that.

      As you say, it’s impossible to know what would have happened if things were different, but I believe that the interventions used to hurry the birth (specifically breaking my water to hurry labour), could be what caused my son to become stuck and unable to descend. I had a VBAC with my second child, this time with a midwife instead of an OBGYN and I saw the difference in how she advocated for measures to avoid surgery. The lead OBGYN on staff believed a C-section was “indicated” with my second too, but the midwife got him to agree to wait and see (while the OR was prepped for an emergency surgery if necessary). I got my VBAC with no complications and only a small tear.

      If the first surgery was not an Unnecesarean, the second surely would have been.

      • Pam
        June 11, 2011 at 3:03 pm

        Those are very good points Briana. I have no doubt that every OB thinks that any given cesarean is indicated and necessary given the events at at the time. But as Briana points out, it is necessary to look beyond the narrow period of time when the cesarean decision point was reached, and see if there were other points during the labor when difference choices would have resuted in NOT getting to a cesarean decision point.

        Briana’s VBAC is a good example. OBs standing by in the even of an emergencies, but a well managed labor with a lot of attention to the mom are ESSENTIAL to a vaginal birth. Lack of attention, observation and woman-centered care contribute greatly to veering toward the cesarean decision point.

        A woman OB I once knew said that she could get any women to agree to a cesarean within 20 minutes. Pointing to the indicators is easy. Working with the woman so that you never get to the indicator point requires a LOT more patience, hands-on care and observation of the movements of the mother. Machines (thinking of the electronic fetal monitor) are NOT a substitute for hands-on palpatation and getting the mom to move around to assist the decent of the baby.

        That is why many women feel that their cesareans were unncessary. Not because there was not a point where the baby or mom was in crisis, but because the care before that point was often machine centered rather than woman centered.

    • March 28, 2011 at 5:14 am

      Those would be an excellent start. But there needs to be more clarification on “unindicated” inductions. Far too many are for arbitrary reasons such as for suspected fetal macrosomia where a lot of the research aknowledges the practice “does not improve outcomes”. I think when this is put on the table (especially for a first time mom) and she is unaware that there is a lot of controversy surrounding this very common care practice a physician has created a situation where he is inducing without the patient’s true informed consent. Many times before her body is ready for labor increasing the risk of a failure to progress scenario, or high doses of Pitocin (coupled with an epidural…which with poor staffing can allow mom to be positioned poorly, flat on the back and not turned frequently enough) lead to more cases of fetal distress.

      I totally and whole heartedly agree with #3. As a doula I really work hard to educate and help clients wait until the onset of active labor before we make the commute from the home to the hospital. I don’t need to do cervical exams to do this – I’m *usually* dead on as far as guestimating her progress just by observation alone.

  4. July 27, 2010 at 3:08 pm

    Nicholas… I think you are missing a well researched factor – one to one midwifery care ; )

  5. D'Anne Graham
    July 27, 2010 at 3:10 pm

    Your indications for sections are creedal according to your faith/philosophy/training and limited skills. I know multiple practitioners that risk out no one and have 1% section rates. None are male and none are OB’s. You’re training is your handicap. You would NEVER question that you are the risk factor, not women’s bodies, nor birth.

  6. July 27, 2010 at 3:11 pm

    I think what we may find in this discussion, is that some women really feel like their cesaerans where unnecesary because the doctor didn’t want to wait for them, they had something else to do and just wanted to get it over with ect. I think women might argue that doctors are doing c-sections not because they are indicated, but because they just want to, to better fit their schedule.

    Personally, I don’t know too many doctors that would do that, but that doesn’t mean it doesn’t happen. I think this is where I have heard women get the most upset. They feel like their doctor was not working for their’s(or their babies) best personal interest. That there was no indication, but just the doctors personnal preferance. That being said, the c-sections that I have worked with as a nurse, have been exactly how you described here. There was reasonable evidence to suggest that it would be better to have a c-section.

    • July 27, 2010 at 3:41 pm

      rachelleavitt – I think you have identified the only cesarean I could ever really call unnecessary – the one done purely for the convenience of the physician. I don’t this happens a lot, but it shouldn’t happen at all.

    • OB doc
      July 29, 2010 at 5:08 pm

      And yet, if the women feel that way (that they are being hurried), they can refuse the C-section. They aren’t being taken to surgery without signing a consent form. I agree that the situation they find themselves in is not ideal, and that they may be in too much pain/too exhausted/too pressured by family members to think clearly enough in that moment or to ask “WHY is the C-section necessary?”, but the fact is that no one is undergoing a true violation of their bodily integrity, which is alleged on many of the anti-C-section sites. I have said it in other places and will say it here again: if you have a doctor who does not answer your questions or with whom you do not feel comfortable asking questions ahead of the labor, or if you feel that your philosophy doesn’t jive with his or or philosophy: GET A NEW DOCTOR. Before you labor. Or, as above, see a certified nurse midwife. You and your original doctor will fare better. And then, in a subsequent pregnancy, if you have a C-section and your doctor will not entertain the idea of VBAC, ask him or her: WHY? Specifically. Is it that he/she doesn’t do VBACs, that the hospital doesn’t do VBACs, or that there was something at the time of your surgery that actually prevents a VBAC from being a consideration (this happens, but is relatively rare).

      • March 28, 2011 at 5:38 am

        You take for granted that your clients are as educated as you are to begin with. You are in a position where people look to you for safe solutions to their problems that cause the least amount of harm. So blaming women for not choosing their care provider correctly or not knowing The Pregnant Patient’s Bill of Rights (or that such a thing even exists) defers your responsibility to give the standard of care and implementing evidence-based practice into your routine care practices.

        I shouldn’t have to hunt and stress to interview OB after OB, Midiwife after Midwife, review hospital cesarean rates, provider cesarean rates, drill my provider over when they induce labor, or impose routine procedures, etc. to find one I think is safe. I do agree with your thoughts that more women/families should be more educated and prepared for this very important upcoming event and I really wish they would as well.

        But doctors should abide by the Hippocratic Oath just as nurses should uphold the ANA Code of Ethics in protecting their patients and advocate for their rights. If an induction or cesarean isn’t indicated – don’t offer it. If a woman is a candidate to have a VBAC – offer it.

        If a woman is coming to your office and wanting an early elective induction because she is miserable and wants an epidural just as soon as she can get one maybe (a lot of providers in my area would totally take the bait) there should be more education that her choices for a more interventive birth may very well necessitate a cesarean delivery for causes that may have otherwise been avoided.

      • March 28, 2011 at 1:05 pm

        I agree – a lot of patient do seek early induction, and in a busy OB/GYN practice this can be tempting. While elective induction is an option, it should always be with the information that inductions before 41 weeks, particularly when the cervix is unfavorable, are associated with an excess of cesareans and adverse outcomes compared to awaiting spontaneous birth.

      • August 12, 2013 at 4:59 pm

        At my local hospital for my first baby, it wasn’t possible to pick the OB who would deliver me. The OBs worked on call at the hospital, and if I went into labor while my OB (the one who did my prenatal care) was on call, she would deliver my baby. If not, I got whatever other doctor was on call. I had no choice over the doctor. It was basically the luck of the schedule, and I didn’t have very good luck. This is how a lot of hospitals work now. In terms of VBAC, it’s often a challenge just to find someone who will do them at all. If you live in a city, you have more options, but if you live in a small town, you might not have a doctor or hospital in your area that will even do VBAC. You have one option: c-section.

        I get tired of hearing, “You signed a consent form.” Yes. I signed a consent form after 48 hours without sleep and 16 hours of hard labor. I was woken from a deep sleep, thanks to the epidural I’d received less than an hour before, to a doctor yelling at me that I needed to have a c-section NOW or my baby would die and someone thrusting that magical consent form into my face and all but holding my hand while I signed my name on a form I never had a chance to read. I was exhausted after hours of the greatest pain I have ever experienced and days without any sleep, and I was terrified because a doctor, someone who has received years of training and has vast expertise on a subject I’d spent all of 9 months brushing up on in my spare time, told me a c-section was necessary to save my baby’s life. Of course I signed it.

        I don’t understand why women who do not have nursing or medical degrees are held to a higher standard in ensuring they receive the best care than the doctors who invest years in training and education in order to provide the best care. I manage web sites for a living and had 9 months to research birth before I experienced it. I read my baby books, and when my doctor said I was to be induced, I looked up some information on the process and the drugs, but ultimately, I trusted the medical professionals at my hospital to treat me with respect, to be honest with me, to act ethically and responsibly, and to make the best decisions for my care. Instead I was lied to and abused by strangers at a time when I was at my most vulnerable. Are there things I could have done differently? Absolutely, and I have mountains of guilt and regret regarding the choices I made. Ultimately, though, I’m not an obstetrician. While there may have been a few things I could have done differently that might have changed *my* outcomes, I am not responsible for sky high c-section rates or the practices that created them. A laboring woman should not have to know as much as her doctors and nurses and fight medical staff tooth and nail to avoid being cut open for no real reason other than the doctor wants a quick and easy end to a challenging labor, and in order for that to change, it has to come from the medical professionals.

  7. July 27, 2010 at 3:20 pm

    Interesting discussion. I do agree that perhaps the frustration with the word “necessary” is just a matter of semantics. I think the idea of unnecessary cesareans applies better to the population level and less neatly to the individual level. Because we know that, for example, nurse-midwives treating the same population base as obstetricians have comparable outcomes with lower cesarean rates. It is entirely logical to then say that some cesareans are unnecessary; if you can achieve just as good maternal and fetal outcomes with less surgery, it goes to follow that the excess surgery–again, on a population level–was not necessary. Another workable term that comes to mind is “avoidable” or perhaps “preventable.” Sure, by time many cesareans are called, perhaps they are necessary…but a different set of actions and decisions during labor might have led the woman down a path more likely to end in vaginal birth than surgical birth.

    Now to just voice a comment to the contrary, I’m thinking to my sister-in-law’s birth, which took place about 4-5 months ago at UNC in Chapel Hill. She chose a CNM practice and had a marathon labor: 38 hours, 12 hours stalled at 8 cms dilated. All of the backup physicians were pushing for cesarean but the CNMs agreed with my SIL that as long as she and the baby were doing fine, there was no absolute need to go to surgery. About 10 hours into the stall and 30+ hours into labor, my SIL chose an epidural and pitocin to help her rest and to see if it would get labor going a bit stronger. A few hours later she pushed out a very healthy baby. Okay, so I know this is a story of a vaginal birth, but if a cesarean had been called–and it had been, several times, by the attending physicians–it would have been unnecessary. This isn’t the same situation as a woman calling her cesarean unnecessary, but I think how it illustrates that some surgeries are unnecessary, although of course there’s no way to “prove” it unless we can invent a time machine.

    One more anecdote that comes to mind: I have a friend who is a family physician and who attends about 80 births a year in a small rural hospital (about 1/3 of the total births). Although she doesn’t focus on her cesarean rate as the end goal, it always ends up right around 10%. The rest of the births at her hospital are attended by an OB group whose c/s rate is 30%. What explains the difference? She attributes it to the difference in practice style between her and the OB group–the OB group routinely induces at 39 weeks, whereas she doesn’t, etc etc etc. So again, on a population level, you could say that their 30% rate is unnecessary (or avoidable, or not entirely indicated, or preventable, or whatever).

    But I do like the first comment about the need for more understanding of what sets the stage for normal, spontaneous, vaginal birth. Or rather, more *application* of what we already know.

    • July 27, 2010 at 3:44 pm

      Thanks for the comment. You’re right that the proposed cesarean you mentioned was unnecessary, but as you say, we can only say that because we can look at in the retrospectoscope.

      No doubt that avoiding induction is very important to reducing cesarean rate. A paper in the July green journal showed a 2x rate of cesarean for induction of primips vs primips arriving to the hospital in active labor.

    • Dianne
      July 29, 2010 at 4:08 am

      Rita: I had a c-section for (initially) failure to progress at about 12 hours in with dilation of 2-3 cm. Spontanous ROM at beginning of labor. No fetal distress unless I changed to certain positions the fetus appeared to not “like”. Would you call that unnecessary?

      Let me give you a hint: When the c-section was started, the OB found that the fetus’s head was deflexed. Totally undeliverable vaginally. Oh, and the fever of 105 hit just as the procedure was about to start, suggesting that a delay might have led to a fairly nasty infection. (As it happened, since the infection hadn’t had time to really take hold, delivery and 24 hours of antibiotics cleared it up entirely.)

      So, the retrospectoscope calls this one justified. This could have been your SIL’s story. The only difference, really, was luck. She turned out to have a problem that could be solved with rest and pain relief. I didn’t. Why take the chance when it’s clear that things aren’t going the way they should be? I’ll take a small abdomenal scar over death or a dead baby, thanks.

      • Melissa
        July 29, 2010 at 1:58 pm

        It sounds as though Dianne has a good point about a seemingly similar situation to Rita’s SIL’s birth, and thankfully a good outcome. However, I wanted to point out that a deflexed head is not totally undeliverable vaginally. I was born vaginally with a deflexed head–my mom won’t let me forget it!! (lol)
        It is always difficult to apply individual cases to overall shifts or trends in obstetrical care.

  8. July 27, 2010 at 3:33 pm

    I think it is great to have a conversation about indicated and unindicated c-sections. However, I think the frustration is that women are told they DO have an absolute indication for c-section (lack of progress, suspected macrosomia, previous c-section) and later find out that these were not a good assessment of the situation. Do you feel like it’s better for a woman to say, “I was told a c-section was indicated but I was lied to?” It’s an interesting idea for framing it, I’m just still kind of mulling it over.

    I also think that some of the “unnecessary” is talking about steps that were taken to get to the c-section. When someone feels like the reason for the fetal distress was being forced to stay in bed and get Pitocin, which then led to an epidural and then they couldn’t move around during pushing, and baby took a long time to descend and starting to have severe decels and they had to go for a c-section, they may feel that the c-section was necessary/indicated by the time it happened, but the things that caused it were not. So I think there might still need to be a way to work that aspect into the discussion.

    • July 27, 2010 at 3:49 pm

      Personally I take a bit of offense to the language “I was told a c-section was indicated but I was lied to.” I just don’t believe that happens. What happens is that the physician thinks the cesarean is indicated, and they make that recommendation to the patient. Lying implies that the physician felt it wasn’t indicated, but then for some perverse reason decided to represent something different to the patient. Unless the physician has a severe personality disorder, that doesn’t happen.

      I hate that women get this idea that somehow they were tricked into a cesarean. We can argue about indications, but if a physician is recommending a cesarean its because the physician actually thinks that its appropriate. That’s no trick.

      • mommymichael
        July 27, 2010 at 4:11 pm

        Have you read Gina’s (Feminist Breeder) VBAC story?

        At one point the physician was pushing a c-section.
        Then after her vaginal birth, made a comment about missing his daughter’s birthday. You may not *believe* that physicians could be so perverse, but that doesn’t mean that they aren’t out there.

      • Tamrha
        July 28, 2010 at 5:05 am

        Why do you take offense Dr. Fogelson? Her comment was not directed towards you and your personal practice. Are you choosing to take offense on behalf of your colleagues? If so, that’s an awful big undertaking, as well as one that you can’t possibly uphold as having no grounds because it is impossible for you to speak for every OB out there, or midwife even, in ever labor room, at every single birth. Until the day you can do that, and claim with 100% proof that a woman being lied to never happened, you cannot say that it has never happened.

      • July 28, 2010 at 8:05 am

        Who claimed 100% proof? I just said what I think.

      • Laurie
        July 28, 2010 at 8:29 am

        Then why do c-section rates increase at shift changes? I find it hard to believe that so many women show indication of the need for a c-section at exactly 4:45? I can respect that they don’t want to leave work for their colleague but to force an un-indicated procedure on someone seems extreme to me.

      • Stephanie R
        July 28, 2010 at 4:22 pm

        You may not lie, but my first OB did. “you’re pre-preeclamptic” “you’re spilling protein” According to my records I was NOT spilling any protein. “I’ll use low dose pit for your induction and wait to break your water” The pit was cranked (started at 6mu and was increased regularly despite a good ctx pattern) and he broke my water quite early under the auspices of seeing how dilated I was when we got started. when I was finally too exhausted to push any more “you just can’t push a baby that size out” My first vba2c was a full pound bigger, my second the exact same size. So yeah, my section may have been indicated, but only as a result of my OB’s lies that got me in that situation to begin with. And, let’s not forget the lie of omission of not telling women that late term ultrasound is notoriously wrong when they’re telling her that her baby is going to be over ten pounds and “he’s only getting bigger in there.”

      • Alex
        August 3, 2010 at 7:53 am

        This is really an attempt to answer the why section at shift change comment above.
        I work 12 hr shifts on Labour ward. I may have been looking after somebody all night, been in the room on multiple ocassions to check the trace / examine / see how things are going with the syntocinon / see how mum is coping. I

        f there is lack of progress, despite everything I have done to try and improve things, I like to deliver the baby myself – after all I have built a relationship with the couple. This is only the case with failure to progress, fetal distress is a whole different kettle of fish.

        I have usually given a few warning comments earlier on “things aren’t progressing as fast as I would like” and then have a conversation about how I think that a vaginal delivery is unlikely to occur soon (note, not impossible) and offer the option to continue or proceed to LSCS.

        I am present on LW anyway, performing a LSCS is not going to get me away any faster and I am offering an opinion of what I think the best option is, and letting the patient decide.

      • Renee
        May 18, 2011 at 6:50 pm

        I know for sure, 100%, that this DOES happen.
        I am an OB nurse, and I have seen Several instances where a woman was sectioned purely b/c the physician did not want to stay up all night, or get called in @ 2 am.
        One night, a particular physician stated to me after the section, “glad that’s over now, otherwise we would of had a 2 am delivery”–that is an admission of a true “Unecessarean”.

  9. July 27, 2010 at 3:43 pm

    I really appreciate this post – I have written about this issue and argued for the use of “preventable cesarean.” It’s not perfect, because we can never know if something was 100% preventable, but it at least allows us (unlike “indicated”) to look from the public health perspective and think about things like how our maternity care system is designed, disparities in access to care and education, etc. It also of course lets us look at actual care practices in labor or prior to labor (e.g., ECV).

    But here’s the line that is bugging me: “Does that mean that to not do the cesarean would absolutely injure either party? No. It just means that the risk/benefit of pursuing vaginal delivery is no longer in favor of it, to the best of our knowledge.” Because who decides when the balance has tipped? And whose “knowledge” counts? Let’s just assume that (virtually) no woman would refuse a cesarean if it was certain the baby would die without it, and that truly elective, patient-choice cesarean is still exceedingly rare. But between these rare extremes, women’s values, risk tolerance, and individual circumstances vary considerably. Their biology varies considerably, too. So what’s with the regimented idea that labor has to start, proceed, and end on rigid schedules or else a cesarean is “indicated”? (I know this is now how you practice, but it’s definitely what we see on the macro level.)

    I’ve been reading up on decision-aids/decision-support tools and the Ottowa Decision Support Framework. It seems to me that in every corner of health care, the stakeholders are beginning to wake up to the idea that choice of/consent for surgery requires a consideration of both medical and non-medical factors, and that the “right” choice won’t be the same for every woman, or even for the same woman at two different times. Maybe what the women with “unnecesareans” are saying, “If I knew then what I know now, I would have done something differently that might have avoided the cesarean, or accepted a different amount of risk in order to achieve a certain probability of benefit.” Those that are truly saying “my cesarean was completely unnecessary” have been churned out of a system that puts up unnecessary obstacles to achieving a safe vaginal birth.

  10. midwifemandi
    July 27, 2010 at 5:21 pm

    i have to agree amy – i feel that the reason so many women feel so strongly about the term “unnecesarean” is because they are not getting full disclosure of risks vs benefits – not only during the actual birth, but throughout their entire pregnancy (and honestly, throughout their entire lifespan). there is such a lack of informed consent in health-care; i have yet to meet a woman who has been given full information regarding the rationale, side effects, and risks/benefits (to baby and mom) of a pitocin induction or augmentation. instead, they arrive on the obstetrics unit expecting to hold their baby in their arms in a few short hours because that is what they have been instructed by their doctor – for whatever reason, they are to check in at such-and-such time on whatever date, because it’s time for their baby to be born.

    then, following what may likely end up being a longer and harder labor, and more likely a cesarean birth, many parents may start wondering, “Why?” As time passes, feelings of hurt, anger, betrayal, confusion, and fear continue to linger long after the postpartum period passes.

    i don’t think women are feeling that the *direct* causes of their cesareans (fetal distress, arrest of dilatation, malpresentation, etc) are avoidable – but rather that the lack of communication between provider and patient is responsible for the high rate of preventable surgical births.

    dr fogelson, thank you for a well-written and respectful article.

    • March 28, 2011 at 6:04 am

      I think you’ve nailed it – it comes down to true informed consent about the risks/benefit of interventions women may think they want in many cases. Women are under the impression that elective inductions and epidurals are “safe” otherwise the hospital/doc wouldn’t use them so often. They see it on TV all the time, all their friends are having one… Of course there are fantastic reasons for induction and epidurals can be an absolute Godsend, ultimately they should only been used when necessary. As far as comfort measures it would be much safer to educate women and families to use EA as the last resort in the bag of tricks and when one is indicated what type of care should be rendered to the mother in labor for “damage control”. There are so many women that are under the false impression that the medication in the epidural “doesn’t get to the baby” when the fact is that on the package insert it states very plainly that the medication “rapidly crosses the placenta”. Even having a true indicated need for an intervention doesn’t make the risks of that intervention disappear and they still need to be considered.

      And as far as those who think cesareans aren’t offered when they aren’t indicated – I was offered that “Unnecesarean” as much as I know you hate that word. I can’t think of another word that fits better. I was a homebirth transfered into the care of my OB at the hospital. I started having pushing contractions at 8cm which caused an anterior cervical lip that worsened into cervical swelling and regressed to 6cm due to the swelling. After we expended every method to get the baby into a more favorable position and to help progression we decided to make a non-emergent transfer (my vitals and the baby’s vitals were great) so I could get an epidural to relax and help me stop pushing. After a couple of hours all swelling was gone and I was 8-9cm. Me and baby are doing great. At approximately 4pm I was offered a cesarean because my doctor said that my baby was too large to come out. He told my husband he gave me a 1-2% chance to birth vaginally (and also that he had some conference he needed to go to) because I was so small. No fetal distress. I was doing fine (except for this massive assault on my ego). My contractions had stopped because of the epidural so after a little Pitocin I dilated to 10cm and pushed out a healthy (big) baby boy in 40 minutes.

      My OB did come to my room the next day and formally apologize to me and congratuated me on my obvious victory. As a nurse I’m not accustomed to doctors apologizing to me ever so I thought it was quite brave of him. But had an unnecessary surgery occurred I don’t think I would have felt the same about any apology. I’ll admit I thought about it before evicting him from my room and in retrospect found it unfair and manipulative given my circumstances.

      • August 13, 2013 at 2:35 am

        To me, this is an overly pedantic argument. All “unindicated” means is “unnecessary at the moment it was given.” Six to one, half a dozen to the other. I understand your line of thinking is that for women whose c-sections were unindicated, they could still have needed a c-section somewhere down the line, so we can’t say with any certainty whether *a* cesarean would not have been necessary at some point. The truth is, though, the c-section *I actually received*–not the hypothetical one I may or may not have received later–was not indicated, and therefore not necessary at that time. I could have needed a c-section later, but that would have been a different c-section for different reasons, and how I felt about that c-section would probably have been different.

        To me, unindicated is very unemotional, professional term that keeps the c-section purely in the realm of a medical judgment. I’m not a doctor, though. I’m a person who was cut open for no good reason. What I experienced–not what I hypothetically may have experienced–was not indicated, was not necessary. I shouldn’t have had to experience it. Unnecessary comes from a visceral, personal place, and I think that’s useful because these unindicated c-sections aren’t being carried out on mannequins, but real people who have emotional responses to things like how they are treated by medical staff, especially in the midst of an experience as important and life-changing as birth. Denying women access to this term because it is too messy, too imperfect dismisses a critical factor in this discussion and in the medical profession: the human factor.

        Unnecessary doesn’t just describe the c-section I received, but my entire experience at the end of my pregnancy up to the present, more than a year after my c-section where I’m still dealing with the physical and emotional fall-out. It describes not only the surgery itself, but how I was treated by doctors and nurses (horribly), the information I was and was not given by medical staff, and the decisions that my doctors, nurses, and I all made over the course of a week-and-a-half. I don’t understand the purpose in denying someone access to a term that, yes, is messy and imperfect, but perfectly encapsulates how I, a human being, felt coming out on the other side of a traumatic experience and realizing that none of it had to happen that way.

  11. J in the Lou
    July 27, 2010 at 5:25 pm

    My doctor pushed me to a cesarean. I was making progress, albeit slowly, but a long labor had left me drained to fight off his demands every 20 minutes – try relaxing enough to labor with THAT happening. At 1:30 AM I consented. The next morning his partner came in to check on me. I had no idea he would be taking over my care and had never met him before.

    What happened to my doctor? He left for a skiing trip that morning.

    Until the day I die, I will be convinced he gave me an UNNECESSARY cesarean so he could grab a paycheck before his vacation. To call it anything other than unnecessary is minimizing what happened.

  12. July 27, 2010 at 5:32 pm

    Most OB/GYN groups pool obstetrical and pay it out based on number of patients or number of call shifts worked. It is very unlikely that a physician in a group would financially benefit from doing a cesarean before he went off call. What does happen is that a physician that is convinced that a patient will not go on to deliver vaginally will do a cesarean before they go off call because they don’t want to leave the work for their partner who is coming on. When a physician who tends to do fewer cesareans works with a physician who tends to do more, it can seem to one that the other is leaving them work to do. This does, unfortunately, affect care in some cases.

    • J in the Lou
      July 28, 2010 at 3:49 am

      Given that he told me in the year before my delivery he missed 3 births out of 300, I cannot agree this applies here; he would have missed far more than 1% under your scenario. He told me the only time he missed a birth was if he was physically ill or out of town – and we can see that the latter didn’t actually apply to me. I would have been far happier if it had.

    • Rachel
      July 29, 2010 at 4:06 am

      “What does happen is that a physician that is convinced that a patient will not go on to deliver vaginally will do a cesarean before they go off call because they don’t want to leave the work for their partner who is coming on.”

      But what if the physician is wrong and all that is needed is more time, or the woman just needs to be told she can do it? That’s so thoughtful of you not leave work lying around for your partner, but what about your oath to do no harm??

      The hardest part of my cesarean was the recovery – that is the part that is upsetting to me about my experience. My body did not handle the combination of surgery recovery, detox from numerous medications, post pregnancy hormones, and sleep deprivation from newborn care in a pretty way AT ALL, 3 or 4 months later I still had issues. I don’t feel like that dr ‘did no harm’! If the team on duty that night would have been more encouraging and helpful towards a vaginal delivery I might have been able to deliver my 8lb son in a posterior position instead of having a cesarean for ‘CPD’. Leaves me wondering what might have happened if the Dr and CNM had told me “we know you can do this” instead of planting the seed of doubt “you’ve been here for XX hours, we think we need to talk about cesarean”.

    • D'Anne Graham
      July 30, 2010 at 4:00 pm

      ” What does happen is that a physician that is convinced that a patient will not go on to deliver vaginally ”

      Hubris. He has no way to know that–especially since he wasn’t there much, if atall, and has no idea what normal is, or what the woman’s story is–which is a huge determinate in outcome.

      “When a physician who tends to do fewer cesareans works with a physician who tends to do more, it can seem to one that the other is leaving them work to do. This does, unfortunately, affect care in some cases.”

      Sounds like good ol’ boy network screwing women–this is not quality nor SCIENTIFIC care. This is malpractice.

      You still in Waipahu? My worst birth was in Hawaii.

      • July 30, 2010 at 4:36 pm

        All my partners are women except noe, so not so much a good’ol boy network.

        I’m at University of South Carolina in Columbia, SC. I left Hawaii in 2008.

      • July 30, 2010 at 4:39 pm

        I’m not sure it isn’t scientific though. Women with particular labor patterns do have some predictable patterns of delivery, but only in aggregate, not as individuals. Women who have protracted labor do ultimately arrest more than women who labor rapidly.

    • J in the Lou
      September 15, 2010 at 5:51 am

      I’m curious if you saw this article, particularly the last 3 paragraphs. http://newamericamedia.org/2010/09/rate-of-c-sections-at-for-profit-hospitals-higher.php

      “Riverside County Regional Medical Center in Moreno Valley has one of the lowest C-section rates at 9 percent.

      Guillermo Valenzuela, vice chairman of obstetrics at Riverside County Regional, attributes his hospital’s low rate to doctors working in shifts. Shift workers have no financial incentive to hurry a delivery along: The doctor is paid the same and can end a shift regardless of whether he or she delivers 10 babies or simply monitors the early stages of labor. The system increases accountability, he said.”

      It seems to me when financial motivation is truly removed, the C-section rate drops dramatically.

    • November 19, 2010 at 11:27 am

      This “system” of finishing up one’s work before going off call just seems ridiculous to me! I understand the consideration factor of finishing what you’ve started, but we’re talking about people, not paperwork! This skewed perspective of caring for a laboring woman is very troubling.

  13. Jen
    July 27, 2010 at 7:06 pm

    The problem I have with the use of the word “indicated” seems to be the reason you prefer it. If a care provider feels a section is indicated, one would expect that to be based on the sum of his or her experience, training, and the beliefs the previous two things have created. The problem I have with that is that midwives, OBs, nurses, etc. are all human and prone to the occasional irrational thought or belief. If someone becomes convinced that vaginal delivery is dangerous and barbaric, it could be argued that having all expectant mother under their care agree to a scheduled section is indicated, but it would be difficult to argue that they were all necessary. Much the same can be said for a variety of situations where cesareans become indicated after a cascade of interventions, particularly if the cascade began with a routine intervention, not one that was indicated by the situation (routine pitocin augmentation is common in my area and comes to mind).

  14. Laurel Brant
    July 27, 2010 at 7:07 pm

    Well, Dr.Fogelson, you protest too much for me to think that you are any different from the vast majority of physicians providing maternity care. I am 63 years old and it has taken me many years to recognize medical propaganda with regards to childbirth and then to realize that doctors believe their own propaganda and now, sadly, so do most women.

    If you stopped being ‘tired’ of women speaking in the best way they can about their painful birth experiences; if you stopped being ‘offended’ by the reality of how many doctors practice; if you could stop justifying and defending; if you could show more courage and compassion, what would happen? I am thinking you would display your true sensitivity and your caring for birthing women.

    I have experienced forceps, elective cesarean section and 2 home births, in that order. I have spent years involved in birth work, teaching prenatal classes, doing labor support, sitting on committees, attending medical conferences and task-force panels. I have heard and seen such a blatant disregard for laboring women and their experiences that at times I have felt sick and despairing. PLEASE, I know physicians lie and if you are offended, too bad. My body was cut open and my baby removed because of lies – maybe you have another less offensive word for it – good for you. I am angry at your attitude. How dare you put up smoke screens – ‘indicated, not indicated, necessary, unnecessary’ – all the while women are being cut open and struggling to recover while caring for their newborns – you try it!!! Maybe you are the good doctor, if so, you would be doing something other than nit-picking over semantics. You would not be saying “a fair number of cesareans we do might be avoided”. You would be outraged at the 33% cesarean rate! You would be working to make changes to the medicalization of childbirth and you would be listening to what women are really saying.

    • July 28, 2010 at 3:37 pm

      Laurel, your work, and that of the women of your generation, are the agents of change that led to my successful birthing experiences. I hope that knowledge you’ve spread gives you comfort and has healed you from the great wrong done to you. Dr. Fogelson, frankly, I just don’t know how you can turn a term like birth rape into a brush off-able figment of the minds of irrational women looking for someone to blame. When someone is violated through their sexual organs, we call it sexual assault–rape, if you will. The strong language women use to recount their birth experiences has nothing to do with you, and everything to do with trying to figure out the real, devastating consequences of un-empowered birth (vaginal or cessarean). Don’t insult these women, sir, especiallyon behalf of your profession who has caused the violations en masse. Take the hint. Many of your clients are not satisfied, many are seeking home births in droves, and refusing test-based prenatal care in favor of relationship based prenatal care. The shocking thing is–the midwives are doing it better. And, don’t throw around high-risk. I was high risk accroding to the numbers, but my babies were fine, and came into this world with a mama fully equipped to heal efficiently and start her role as mother without any interference. That’s what unneccessarean is all about: the women who feel the start of their mothering experience was taken from them. Fine, do all the c-sections you want for the “indicated” 33%, but my God, man, stop separating mothers from the feeling of power that birth gives. Don’t stop them from nursing their newborn, don’t clamp their cords the instant the baby is out, and don’t justify your decision to her ever. Tell her why. The real, ugly why: I broke your water, and the cord got squashed. I induced you, and the baby was in the wrong position. The baby’s heart fluctuations were caused by the unnaturally strong pitocin contractions. I am only so hard on you, Dr. F becuase you have potential. You are talking about this. Do not join the side of the doctors, but advocate for the women you have given all of your free time to serve. Do your best in every labor to have every woman say “I did it on my own!” You are a defender of birth, not a protector. Keep searching. Your clients and their children and families will thank you.

    • MamaJessica
      July 29, 2010 at 1:43 pm

      Thank You Laurel! I have been reading these posts and am seriously appalled that this whole article is produced upon semantics. Our society needs more information-patients and doctors alike. I had the “joy” of a cesarean for the birth of my first child. It was the most HORRENDOUS thing I have been through. Let me add to that by saying I had cancer at 10 years old, that nearly killed me. I have had biopsies, tumor removal surgeries, hip surgeries, chemotherapy, radiation, and more! In comparison to all that bad in my life, when I found out I was expecting (I believed I was not fertile) I was looking forward to the memorable experience of childbirth. I was ready to endure the pain of labor for the magnificent end result. So much for that. If I had more encouragement and information, I am certain a vaginal delivery would have been possible. Have more compassion for your patients all you doctors out there!!

      • OB doc
        July 29, 2010 at 5:15 pm

        See above: when you sign a consent form for a surgery, you cannot allege “birth rape.” Sorry.

    • Alexandra Ryan
      May 18, 2011 at 9:34 am

      Laurel, those are the best words I have read thus far.
      Perfectly said.
      Thank you.

  15. Gretchen Malone
    July 27, 2010 at 7:51 pm

    I am just going to go down the list you gave for Indications for a cesarean. This isn’t an attempt to trash you or what you have written. It is an informed consumers experiences with the maternity world I live in.

    -nonreasurring fetal heart rate tracing remote from delivery. In most cases, this means a NICHD Category III tracing that cannot be resolved through medical treatment or expedious vaginal delivery.

    —–By what/whose reasoning? EFM is not an exact science and is totally dependant on the person/s reading the tape. When does the introduction of induction agents such as Pitocin and Cytotec factor into those readings?

    An elective repeat cesarean in a woman who after appropriate counseling chooses one.

    —-Really, What is appropriate counseling? If it is anything like the counseling I received while not even pregnant I can only imagine what it would have been like if I was actually expecting. The words explode, death, continuous EFM, required epidural line, I could go on but it is depressing. This was not just from one OB but 12. One even told me that the best part about a repeat cesarean was being able to pick my child’s Birth Day. Yeah solid counseling. Is this everyone, I hope not, but it is the normal in my neck of the woods.

    Arrest of dilatation
    —Again by whose definition? The Friedman’s curve is waaaay outdated. It is based off of information originally attained 50 years ago.

    Arrest of descent
    —-See Above

    Previous uterine surgery with high risk of uterine rupture
    —-What and who qualifies as high risk? and how high is that risk really? These were the question I wanted answered during my VBAC counseling and got 5-9% rupture rates. Truth is, evidence based information is hardly ever given to women. We have to seek it out for ourselves and then are told we have an angry tone or don’t really know what we are talking about becasue we didn’t go to medical school.

    Maternal pelvic reconstructive surgery with a desire to preserve the repair
    —-Valid Yes. Do I know women who have done this, again yes. I also know women that have had repeats to prevent further damage.

    Malpresentation of a singleton pregnancy
    —The only Malpresentation that I think really warrants a cesarean is a persistent transverse lie. Breech should not mean an automatic cesarean, but it usually does in the current model of care. This is mainly due to the fact that Breech birth is rarely if ever shown or permitted in medical school. So if there is no one showing what to do during a breech presentation how can anyone expect a OB in a hospital to know what the heck they are doing? Why should women be forced into an unneeded surgery because no one has been taught it happens and that surgery is not the only answer. There are maybe 1 or 2 OB’s that “allow” breech birth in my state. Yes State.

    Malpresentation of a subsequent baby in a multiple pregnancy, when breech delivery of the second twin is not feasible.
    —Why isn’t it feasible? So many women have been told because you are having twins you “have” to have a cesarean. Again why should women have to go through surgery because it is an inconvenience for the OB.

    Maternal request
    —-To this I know several women that have benefited from scheduled repeat cesareans. Previous Pelvic floor damage, previous birth trauma, sexual abuse. All very good reasons if the woman is truly choosing for herself. However, in the U.S. any cesarean not deemed and emergency is listed as elective and or at maternal request, because honestly are they really going to put

    “Primigravida was talked into a cesarean after 12 or more hours of labor, introduction of Pitocin because said primagravida’s labor was not progressing in a timely enough manner which fetus did not tolerate well causing decels/accels. Cutting off the pitocin and allowing labor to re-establish itself or would have been a waste of time and care-providers were going into a shift change.”

    That’s my breakdown and opinion on your list of reasons given and what most of the women I know have gone through when seeking a VBAC or trying to avoid a primary cesarean.

    • July 28, 2010 at 2:27 am

      Like I mentioned, the meanings of these indications are certainly up to debate, and many of your points are good. EFM is a bit of a sticky issue. It has not delivered on its promise of decreasing cerebral palsy, but it has reduced intrapartum stillbirth to near zero, at the expense of increased cesarean deliveries.

      What exactly is an arrest of labor is always up to debate. Friedman was clearly off. At the same time, there are certainly women who left to nature’s devices will never deliver a live infant, and may be injured themselves. Many folks doubt this, but one only has to look at countries with no access to cesarean to see the women who have been injured by terminally arrested labors. Argument about where the line should be is appropriate, and goes on in obstetrical circles all the time.

      Breech delivery of a singleton is not something that is done a lot in this country, mostly because there aren’t a lot of people trained in it. The feasibility of second twin delivery is usually related to to the availability of a practitioner trained in breech delivery of second twins. In my training program we did a fair bit of this and so I do it, but many OBs are not trained in this. There are some midwives that are trained in it and can do well, and also a fair number that aren’t trained in it but think they should still do it because they just think it will work out ok.

      All of these debates are great. My point was never that all cesareans are justified. My point is that to retrospectively call a cesarean unnecessary is unjustified.

  16. Alisa
    July 27, 2010 at 8:29 pm

    “The problem with the term is that we don’t know what would have happened if we hadn’t done the cesarean, and as such we have no idea if the cesarean was necessary. If fact, the true necessity of any cesarean can never be determined, as we will never know what the outcome of the alternative decision would have been.”

    Let’s use this analogy for other “since we aren’t sure what the outcome might be, we’d better just go straight to the worst possible scenario” shall we;

    Patient comes in with a papercut. “Owe, it stings doctor, what can you do?” Being that you don’t want this to come back and bite you in the ass, you’d better take some tests, and lots of them, spare no expense! Now someone with a papercut could potentially end up with an infection. I mean, 100 years ago people died if that papercut became infected.
    Tests come back inconclusive as to whether or not he will die from a flesh eating bacteria. You (doctor) have to make a tough decision. Wash the cut and slap a bandage on it and hope he is in the 99th percentile person who will not have any ill affects from this cut… or cut off his finger to prevent that .01 percent chance it becomes infected?

    I have to place a bet that if you were the patient with one less finger because of a “just in case” surgery, you would not be calling it your very painful, I can never get that finger back, “unindicated” surgery.

    • July 28, 2010 at 2:29 am

      Like I said above, my point was not to defend the cesarean, only to point out a more appropriate way to discuss why it was done. Lets argue what appropriate indications for cesarean are from a prospective point of view, not claim that we know retrospectively that a cesarean was absolutely unnecessary.

    • July 28, 2010 at 2:48 am

      Kind of a straw man argument don’t you think?

    • July 29, 2010 at 1:57 am

      With all due respect, I would argue that those same countries who do not offer access to c-sections and EFM *probably* do not offer adequate prenatal care, nutrition, or family planning services. By having babies too early in a body that is ravaged early by disease and malnutrition, it is not the lack of surgery that is going to kill those babies is all I’m saying.

  17. Stephanie
    July 28, 2010 at 1:57 am

    My first son was delivered by cesarean. I have since had to fight for 2 VBAC deliveries. At the moment that I was in the OR my cesarean was necessary and/or indicated. Not because any thing was wrong with me but because of the ignorant choices that I had made in the course of the previous 48 hours. It is our job as consumers to educate ourselves. Don’t just rely on the information you get from one source. You wouldn’t read one review for a car and run out and buy it based solely on that opinion and you shouldn’t rush into a medical procedure that way either. Unfortunately for me I did not realize this and let my eagerness to meet my child push me into an induction that my body just wasn’t ready for. After 18 hours labor (with Pitocin, flat on back, no wonder DS wasn’t presenting well) and no food for 30 hours I could not take any more. So it wasn’t the surgery that was unnecessary it was the entire course of events. If I had made the decision to wait and to just go into labor naturally and NOT be induced things may have turned out differently. But since we don’t have a time machine we will never know. Was I hurt yes, disillusioned, yes, and outraged when I was told I would have a repeat c-section. A lot of things need to change and some of it is just bringing birth back as a NORM in our society. With my subsequent VBAC deliveries people were astonished and then even more so when I went post date with my third child. As advocates and knowledgeable people we need to rational extort women to EDUCATE themselves and their families. When we use terms like unnecesarean we are just increasing the fear that pregnant women have. The term unnecesarean isn’t helpful to our sisters facing the “evil” OB poised behind the curtain with a scalpel waiting to pounce on them at the first decel. We as sisters, advocates, mothers, friends, doulas, midwives, educators, and fellow c-sectioners need to remove our selves from the anger and fear surrounding VBAC and C-section. Lets heal and not hurt. While I agree that you should call a spade a spade using terms that put people in a defensive frame of mind will not enable you to convince them that you are correct.

  18. Heather, RN, MN, PNC(C)
    July 28, 2010 at 2:28 am

    Arrest of dilatation? For how long?
    Arrest of descent? For how long?
    You know as well as anyone in the L&D unit that c/s are done unNECESSARILY for these reasons (amongst others) ALL the time even though fetal monitoring is normal (note the use of current terminology…”reassuring” is SO 2008). There is more going on in the birthing process than just dilatation and descent which is something that money-hungry and litigation fearing OBs seem to forget.
    Your use of semantics is disturbing and disappointing. By saying that “The problem with the term is that we don’t know what would have happened if we hadn’t done the cesarean, and as such we have no idea if the cesarean was necessary” reinforces the use of scare tactics to ensure women’s compliance with the “all-knowing” god of OB (who in fact just wants to ‘getter delivered’ before he/she goes home – aka, so he makes the money, not the OB taking over call in the next hour).
    You want to talk about linguistics…how about y’all stop saying “attempt” or “trial” of VBAC….how about you just say VBAC. mmm k?

    • July 28, 2010 at 2:52 am

      >> aka, so he makes the money, not the OB taking over call in the next hour

      See previous comments.

      >> You know as well as anyone in the L&D unit that c/s are done unNECESSARILY for these reasons (amongst others) ALL the time even though fetal monitoring is normal (note the use of current terminology…”reassuring” is SO 2008).

      No doubt this goes on. Lets just call them unindicated.

      • CountryMidwife
        July 28, 2010 at 5:34 am

        Well, unindicated is not actually a word in the English language :)

        On the argument of “not indicated” vs. “unnecessary” – potato, potatoh. To me, the real issue is why the language (or the feelings of women on this issue) bothers you.

    • July 28, 2010 at 3:02 am

      >> Arrest of dilatation? For how long?
      >> Arrest of descent? For how long?

      Great questions. I think the traditional idea of 2 hours without dilatation with adequate contractions identifies abnormal far too often. I think that waiting forever identifies abnormal far too infrequently. Somewhere in between is good.
      The same goes for the second stage. 3 hours without an epidural in a primip is traditional, but waiting longer will lead to more deliveries. Waiting forever in extreme cases will lead to injured infants and mothers. So somewhere in the middle is good.

      I would hope that folks are taking into account what the mother wants, and trying to get to that outcome in a way that she feels good about it. If they aren’t doing that, they should.

      Where would you draw the line on these issues?

      • PrecipMom
        July 28, 2010 at 4:46 pm

        Dr. Fogelson, I think that’s the crux of the issue: you hope folks are taking into account what the mother wants, but so frequently that is not the case.

        My 3 month old daughter had a 10 day NICU stay recently due to initial TTN turned presumed sepsis on the basis of CRP readings and in spite of negative cultures and a clinical course not really consistent with sepsis. I repeatedly asked the attending for how he was arriving at the duration of antibiotic treatment, to make sure that we were not spending longer in the hospital than necessary. I got literally screamed at by a towering male doctor while holding my crying newborn, and basically accused of not caring about my daughter’s wellbeing. All because I asked for the evidence showing that it was necessary for a nursing newborn with no symptoms to be treated inpatient for what amounted to 8 1/2 days past when she had all respiratory issues resolved.

        I really truly wish that an environment respectful of mothers and babies existed, but in so many instances, that is not the case. I have never had a c-section, and I agree that the term “unnecessarean” is unhelpful in coming to terms with a judicious use of technology. But I hear the profound disillusionment behind the word, and it feels awfully familiar after what we encountered. Bitterness leads to flippancy, even when flippancy is counterproductive, and there is something very wrong when so many women are so bitterly angry and disappointed in the maternity care they received.

      • July 29, 2010 at 3:57 am

        >> and there is something very wrong when so many women are so bitterly angry and disappointed in the maternity care they received.

        Yes.

  19. Rachel
    July 28, 2010 at 3:02 am

    I am so disappointed and saddened by this post. Being ‘tired’ of hearing about ‘unnecesareans’ and medical rape and just ‘not being able to believe’ that there are physicians who lie and coerce patients and playing around with words because ‘semantics are fun’– do not a case make. I’m sick and tired of hearing about environmental destruction and cancer rates and autism and [insert social ill], too, but calling it all a myth and mentally masturbating about truth and knowledge doesn’t make it go away, doesn’t help us do better, doesn’t improve the world. Plus it is a slap in the face to those who have been there. Maybe it is hard to look at ourselves and our professions critically, maybe it is easy to be defensive and wish it all away– I hope you choose better next time and help further the discussion rather than try to shut it down.

    • July 28, 2010 at 3:08 am

      Rachel – thanks for the reply. I want the discussion that you claim I try to shut down, but lets keep it prospective, about when and why we should do cesareans. We do too many. We’ll never know exactly which ones weren’t needed.

      So I ask you the same questions I asked Heather – When should a cesarean be done? By what criteria? You don’t like the criteria being used now – propose some better ones.

      • Rachel
        July 28, 2010 at 3:28 am

        I’m glad you want to have the discussion. But no, I don’t accept the burden of proof is on little ole me for expressing concerns about your post. You are well aware of the piles of blog posts and journal articles and mass media articles and books on this issue and how to get our c/s rate down to a safe healthy number. If you really want an honest and detailed discussion, pick a respected resource or writer and break it down with them. I’ll look forward to it.

  20. July 28, 2010 at 3:13 am

    My problem with this logic is that the OB always gets the benefit of the doubt- That they have the best intentions, truely believe in the neccecity of thier actions- and the burden of PROOF lies with the laboring woman? It’s ass-backward!!
    I birthed all 3 of my babies at home unassisted. I ask people who assume that Drs always put the best interest of the mother/baby first, who believe ‘at least you have a healthy baby so you shouldn’t be traumatized or question the neccessity of your C-section': Do you allow the same benefit of the doubt for my birth choice? Do you afford women the same assumption that she is always acting in the best interest of her baby and planned to birth in the safest possible way? Would you agree with the logic that I likely saved my or my baby’s life because we didn’t catch an infection from the hospital, or fall victim to fatal medical error? Were my unassisted births neccessary because the outcomes (including a posterior presentation) were wonderful? Were they indicated? I certainly think so. My OBs would probably disagree.
    The idea that OBs are the only ones intellegent enough to make these decisions is a HUGE part of the problem. If we continue to look at doctors like Gods, the lawsuits will continue because of the idea that they should be able to garantee a perfect outcome and should not be allowed the mistakes of a normal person. While the lawsuits continue, so will a rising c-section rate. The idea that when we walk into a hospital we should not have to take any responsibility for our own well-being is perpetuated by a system that tells us we ARE NOT QUALIFIED to do so.

  21. July 28, 2010 at 3:15 am

    I have another point to make. I can think of at least three different times an obstetrician tried to argue with me that a particular woman “should have had” a cesarean even in retrospect when there was a healthy mother and healthy baby and a vaginal birth. One of these cases – a woman who declined a cesarean for an abnormal tracing then went on to have a vaginal birth and was completely transformed in the process – led directly to the closure of my midwifery practice. (“Your patients ask too many questions and don’t consent to cesareans.”) Clearly in those cases a cesarean was unnecessary to accomplish the goal – a healthy mom and baby, and in fact may have been counter-productive to the goal of a healthy mom and baby, since we can’t look forward in time and know what kind of short- and long-term downstream effects that cesarean will hold for mother and baby.

    So yeah, a long hard look at the weird power dynamics going on among your professional colleagues seems like a better idea than declaring what kinds of words we all should start using.

    • July 28, 2010 at 3:53 am

      So in the situation you mention, we can say the cesarean is unnecessary because we chose not to have it and ended up with a good outcome in a vaginal birth. But are we ever in that situation when we did do the cesarean? Should we then say that the vaginal birth was unnecessary?

      A number of folks have taken umbrage to my focus on language and semantics, but I think these issues are important. Words are powerful, and the ones we choose are very important. To me, “unnecessarean” says more about the person’s feeling about their OB than it does about the situation that led up to the cesarean. It says that prior to the cesarean, there was a failure of the woman and the physician to really understand each other and come to a mutual decision.

      • CountryMidwife
        July 28, 2010 at 5:25 am

        A failure of the woman and the physician to really understand each other?

        If it weren’t so sad, I’d laugh. I would so love to expose the ugliness of “docs behaving badly” in some reality show (and watch the AMA flip a lid). I have a thousand stories to tell, as does every L&D nurse / hospital midwife / etc – and no, these docs don’t have personality disorders (just bad personalities). One of my top ten worst OB moments was when I was the L&D nurse to an NBA player and his wife and they were literally lied to about a c/section being necessary (following a single deceleration). Privately, I asked the doc why in the world we were doing the surgery. He said, and I quote, “he pays a lot of money for that nice piece of ass and I’m not going to answer to him when he asks why it now feels like he’s f’in a mayonnaise jar”.

        With respect, Dr. Fogelson, methinks you have a far rosier picture of your average OB colleague than is fairly warranted. I understand you are defending your tribe, and that’s natural to some extent. But remember that you are more progressive than, I’d say, oh, 99% of your average OBs. A huge percentage of docs I’ve worked with can’t recall the first name of a client they’ve just delivered. The sad reality is that there is really no “mutual understanding” or “dialogue” involved in the average OB / laboring woman interaction.

        I’m sorry to break it to you, but there are a hell of a lot of OBs out here who care more about expedience and personal convenience than the well being of mothers and babies. If you don’t agree with this, how do you really explain “daylight obstetrics” and cesarean spikes at certain hours?

      • Gretchen Malone
        July 28, 2010 at 6:07 am

        I have to completely disagree with you. Unnecesarean to me has nothing to do with how I felt or feel about the OBs who saw me while I was in labor with my son. The bitch slap in the face was when I got my operative report 3 years later showing that everything they had told me was a flat out LIE! The Procedure itself was Not Needed, I.E. Unnecessary based on the medical facts and evidence at the time.

        Women are counting on their care provider to be real with them and not BS them into believing surgery is the only option.

        You say it is a failure to communicate. Here is your communication; Stop Lying to yourself that you are the one who really cares what the women being cut open against their wishes will or should feel afterwards. Their is No communication from the doctor. It is “here is my policy and I am not moving away from it” Yeah really open line of communication.

        I think you need to take a read on another Blog of “My OB Said What!” Open your eyes more to what actually happens and not just what “you” have experienced. The world is a big place you should take a look around it sometime and broaden your perspective.

  22. Aria
    July 28, 2010 at 3:56 am

    I don’t think you should be practicing. If you really believe that anything other than a crown-down baby should be born via c-section, then you are lacking in your education. Breech-babies carry no higher risk than crown-babies, presuming the person catching the baby knows what to do, which is nothing! Hands off the breech. The risk to breech babies comes from YOU!! My own baby was CHIN-FIRST, sunny-side up, AND coming at an angle. According to you, c-section-time! Yet she was born 100% naturally at home, not even a minor tear. Laboring and delivering this way carried less risk, even for me with a medical history, than going and being cut open. C-sections may be routine these days, but they are still MAJOR abdominal surgery (that just happen to make YOU a lot of money).

    C-sections are usually only “indicated” or “necessary” to avoid liability for you doctors. Many inductions are the same. A doctor tried talking a friend of mine into an induction because he baby might have been “as big as 5 pounds and too big to deliver if we wait”. She waited instead, and had a healthy 6-pounder naturally. Often a doctor demands induction because it’s been 40 weeks to the day. Do you have any idea what the surfactant protein is? If you don’t, you need to immediately stop practicing. When fetal lungs are sufficiently mature to survive outside the womb with no problem, this hormone is released, signaling to the mother’s body that it’s okay for labor to start. Every induction prior to the release of this hormone risks immature lungs and NICU-time. But of course you make more money for the induction (50% ending in c-sections, more money for YOU), as well as any NICU-stay (again more money for YOU).

    Since you say no c-sections are ever unnecessary (yet also say a fair number could be avoided, yet you don’t avoid them), why are the most c-sections done around 5pm (dinner time) and 11pm (doctors want to go to bed instead of work all night)?

    Unfortunately for us mothers, the courts always see undesirable outcomes of c-sections as unavoidable, and anything undesirable with a vaginal delivery as avoidable with a c-section. This sends the message that c-sections have no risks themselves as the only problems were going to exist no matter what. This is moronic to the nth degree. Every surgery has risks, and this one is a MAJOR surgery that often carries more risk than a vaginal delivery. You know what my chance of surviving a c-section was? Just 50%, yet the OB/GYNs I originally as seeing were going to require a c-section. C-sections carry risks that vaginal deliveries don’t.

    You are worried more about what you perceive as YOUR liability rather than the health of the patient. You’d rather slice someone open and call it “indicated” and leave the burden of proof about it being unneeded on the woman, riding on the mistaken belief that doctors are gods who can do no wrong and never decide wrong. You need to be smacked down a few pegs as do all doctors. You are NOT perfect, and quite often do make mistakes. Hundreds of thousands of deaths in the US every year are due to doctor error, then called “unavoidable.” Are you really gods who always know better than the patients?

    Doctors like you, who sit there claiming you never do wrong, are sickening, and you should be ashamed of your conceited self.

  23. Aria
    July 28, 2010 at 4:07 am

    Lia Joy, doctors claim that people who birth without them are taking dangerous risks. The risks, according to them, are in not being in a bacteria-and-disease-filled hospital where the are waiting to pump narcotics into us and cut us open at the slighted “indication” like not “progressing” a full centimeter an hour (my 14-hour labor, which started right off with contractions 4 minutes apart, would have been too long in a hospital). Hmmm, being at home, safe, comfortable, with a midwife who spends more of her time actually in the delivery of babies, or in a hospital where we are a chart number. A midwife, who cares about us as whole people, or a doctor who sees us for a minute, two if we’re lucky, at the end of an appointment. A midwife who recognizes us years later, or a doctor who has no idea who we are.

    We’re really safer leaving out medical decisions in the hands of someone who doesn’t know who we are without glancing at a chart than we are making decisions for ourselves, at least according the the doctors who are paying for their luxury cars on our dime. We’re really supposed to be safer leaving the decision to someone who doesn’t even know our named, and are supposed to trust they can remember all of our medical history and all else that factor into delivery.

    A woman who is empowered is the biggest threat to doctors. We affect their bottom line. The more we move toward being responsible for our own choices and choosing to deliver without them, the less money they stand to make from us. They rather we put our lives and our babies’ lives in their hands blindly and feel too weak and powerless and stupid to decide anything for ourselves. Say no to anything they want, and we’re harming our babies. Really, WTF should I have had my baby given the hep B vaccine right after birth when I don’t have it and her risk of getting it is nil? Why should I have drops smeared in her eyes when I have no diseases? Much of it comes down to a doctor’s bottom-line.

    I wonder how many doctors are smart enough to realize that making women feel that we shouldn’t be responsible for our births is part of why medical malpractice suits are as high as they are. It’s true that sometimes birth injuries are unavoidable, no matter what, yet many women are quick to sue because we’re told that the doctor is the one 100% responsible and we should just hand our choices over to the doctor. So if something goes wrong, it must be the doctor’s fault. Try educating women about our choices in an HONEST want, and help empower us, and watch the rates drop. Give us choices, let us take the responsibility. All-around WIN.

    • July 29, 2010 at 5:30 am

      Aria claims: “doctors claim that people who birth without them are taking dangerous risks.” and “A woman who is empowered is the biggest threat to doctors.” These sweeping attacks add nothing to this discussion.

  24. July 28, 2010 at 4:41 am

    It interesting how the comment thread has gone from a discussion of the terminology we should use, which was the point of the post, to a discussion about how OBs do too many cesareans (which I already agreed with), to personal attacks….

    Aria >> I think maybe I’m serving as your OB in effigy here.

    • July 28, 2010 at 4:55 am

      While I understand the intensity of emotion involved, I have to agree that the personal attacks aren’t productive.
      However, I think the conversation has gone in this direction because many of us feel that terminology, the way this problem is discussed, and the way women’s experiences are considered irrelevant (you know, the women who feel their experience amounted to rape- some of whom have also experienced the violation of sexual assault and know of what they speak) are all RELATIVE to the # of C-sections occuring. If we, and the words we choose to use to describe our experiences, are not listened to in RETROSPECT, how can we trust they will be listened to during labor? We can’t. And that is at the root of the empidemic of c-sections AND lawsuits.

    • Aria
      July 28, 2010 at 5:46 am

      You said, and I quote, “I have never seen an unnecessary cesarean delivery. In fact, no one has.” So you are saying that all c-sections are needed. You, Sir, are a liar and a double-talker. Either you believe that some c-sections are avoidable, and so are not actually needed (unless a doctor fails to assist in avoiding one or created a so-called need), or you believe that all of them are necessary because you claim to have never seen an unnecessary one, and somehow magically know that no one else has either through some magical power you have to know what everyone else has ever seen.

      • July 28, 2010 at 6:05 am

        If you read my post I discuss what the word unnecessary means, at least to me. If it means something else to you, then obviously the conclusions will be different.

        To be fair, I have used the term previously in the same way you are using it now.

        Me (last year) -> “Believe it or not, Obstetricians realize that many cesareans are unnecessary all by themselves. The problem is that within our model, we don’t have a good way of determining which are truly necessary, within an identified high risk group.”

        http://academicobgyn.com/2009/11/08/protracted-

        The question comes down to the difference between what is prospectively avoidable and truly unnecessary.

        Now I admit I am being a little hyperbolic when I say there are no “unnecessary” cesareans. Clearly if the doctor is telling an outright lie for some ridiculous reason, as noted by CountryMidwife”, then its prospectively unnecessary. If doctors act in bad faith, then that is a problem. And sadly, it does happen at times, and that is bad.

        But mostly we have cesareans that the physician, in good faith, thought was indicated. In those case, calling it retrospectively unnecessary seems wrong to me.

        Often in court cases that involve a damaged infant the plaintiff attorney claims that a cesarean should have been done. In many of these cases, the signs that indicated the cesarean just were not there, and prospectively there was no reason to do a cesarean. Nonetheless, the physician is held to a standard of seeing the end of the story before it is told. It seems to me that to retrospectively claim that a cesarean is unnecessary, rather than arguing the indications of the cesarean, is doing the same thing in reverse.

        And Aria – be chill. You’re getting very personal and it isn’t justified that’s just unnecessary. HAH!

  25. Augusta
    July 28, 2010 at 5:28 am

    Dr. Fogelson, I’ve been a fan for a while of most of your posts. I like that you seem open to reasonable discussions about maternity care. I genuinely believe that you care about the current state of maternity care and that you care about your patients.

    But I do not agree with this post at all. You are saying that you’re trying to engage in a debate with people about what should constitute proper c-section indications. I feel like that’s really insulting because you’re already an OB. If anybody comes up with other suggestions, you can easily dismiss them because you, of course, know better. I think that’s the root of the problem which many women are responding to here. You’re asking us for our suggestions, but then calling them simply a matter of uniformed opinion. And minimizing what are for many women real experiences.

    There ARE unnecessary c-sections. You admit that yourself. To call them otherwise is to me a manipulation of the truth which suits your profession, but does harm to your patients. I personally have seen obstetricians lie to pregnant and laboring women. LIE. You may not believe it happens, but it does. Many other birth workers and childbearing women can attest to the same thing. It is about a power differential in which OBs always have the upper hand. Until that changes, any quidelines and suggestions which do not treat women as equally included in the process of making decisions in their health care are essentially useless. And I’m sure the c-section rate will continue to climb if this stays the status quo.

    • Aria
      July 28, 2010 at 12:37 pm

      No, he doesn’t actually agree that there are unnecessary c-sections. To quote him, “I have never seen an unnecessary cesarean delivery. In fact, no one has.” Therefore all c-sections done are, according to him, necessary.

      My own OB/GYN used her weight as a doctor to try instilling fear into me, outright telling me that most homebirths end in death. The truth is there are fewer deaths among among natural, midwife-attended births among otherwise low-risk mothers than there are doctor-attended hospital-births among among otherwise low-risk mothers.

  26. July 28, 2010 at 5:40 am

    I always get such a kick out of reading the interaction in the comments section. Good stuff!

    I cannot say that I agree with you on this issue, but it looks like you are getting clobbered by the comments, so I won’t join in! I will just say that I really appreciate your respectful tone and your willingness to engage in thoughtful conversation. I always enjoy your blog because of your kind tone, your willingness to ponder opposite points of view, and your readiness to engage in calm and considerate conversation. I always learn a bunch from reading! Keep it coming!

    • Krista
      July 28, 2010 at 7:02 am

      I agree with you Diana. I see where you are trying to go with this Dr. Fogelson but I respectfully disagree that there are not plenty of OBs who manipulate patients for their own benefit and convenience. Not all, and hopefully not most, but they do exist. Many comments echo my thoughts better than I can put in words so I’ll leave it at that. I received “counseling” by 2 separate OB practices regarding my decision as a healthy pregnant woman to have a vaginal delivery vs. a cesarean and it was very, very skewed in favor to agreeing to a cesarean delivery while skimming over the risks that accompany major abdominal surgery. I think factual, unbiased education for maternity care consumers AND OBs that practice evidence based medicine would greatly lower the cesarean rate in this country.

      While we disagree, I appreciate that you are open to further discussion with your readers.

      • July 28, 2010 at 8:19 am

        But is that lying? Its a physician explaining the risks and benefits as they see it, given their experience and training.

        If folks want OBs to look at pregnancy as a completely low risk event that will always go well, maybe they’re being a little unrealistic. Most OBs see risk in pregnancy because they spent four years of residency working with very complicated pregnancies and seeing a lot of bad outcomes. In a lot of ways this biases their view (an mine in some cases.) I agree with Sharon (commented down lower) that a system where midwives work with low risk patients and have OB backup can work very well, and with many patients is preferable to primary OB care.

    • Rebecca B.
      July 30, 2010 at 9:07 am

      Diana is spot on. Don’t completely agree with the post, but love the nads required to lob this grenade out into the birthing community. :) And totally appreciate Dr. Fogelson’s willingness to engage in ensuing discussion at length. Kudos!

  27. Sarah
    July 28, 2010 at 6:13 am

    While I’d agree that unnecessary is not a scientific term that can describe a medical event as a mother and 2X patient in the maternity care system, it moat definitely describes my treatment concerning my birth process. It is downright unnecessary to walk into a womens room and tell her the baby will die if they don’t do a cesarean. That the TIME LIMIT of pushing had expired. (2.5hrs in my case even though I pushed for 3.5 with my VBAC w a midwife) just to echo anfew comments, I might not know if my first was indicated medically but I do know for sure that my second birth might have “indicated” surgery yet It would have been unnecessary. If i would have just scheduled a repeat cesarean then it too would be unnecessary. I think i will use both terms when helping moms discuss safe birth as it will also help those whove had unmecessary surgery to see theirbirth theough an OB/GYN eyes who only seesthwm as a peice of organic matter to be researchedand analyzed. There is no way you can take Unnecesarean out of the discussion in general.

  28. July 28, 2010 at 6:40 am

    >> There is no way you can take Unnecesarean out of the discussion in general.

    Based on the comment thread, clearly not! :)

  29. July 28, 2010 at 6:43 am

    Ceseareans are like breast biopsies; most are unnecessary in retrospect. When a woman finds a lump in her breast, the odds that is breast cancer are quite low. When a mammogram detects an abnormality the odds that it is breast cancer are quite low.

    Therefore, applying the reasoning that commenters are applying to cesareans would mean that the rate of breast biopsies should be cut dramatically. In most cases, watchful waiting is all that is necessary to demonstrate that the lump or abnormality was not breast cancer.

    Think about how much money we could save! All those mammograms and biopsies cost a fortune; just waiting to see what happens costs nothing.

    Think about women’s experiences! If we did far fewer breast biopsies, women would not have permanent scars on their breasts. And the recovery would be so much easier. No need for pain medication, dressing changes, etc. if you just watch and wait to see what happens.

    Sure some women would die preventable deaths with a policy of watchful waiting but those numbers would be very small when compared to the number of women spared from having unnecessary biopsies.

    Of course if you think that a policy of watchful waiting is inappropriate for breast lumps and mammogram abnormalities, considering that most biopsies are unnecessary, why would you think a policy of watchful waiting is appropriate for C-sections simply because many of them are unnecessary in retrospect?

    • July 28, 2010 at 6:59 am

      I was wondering when you de-lurk :)

      • July 28, 2010 at 8:42 am

        “I was wondering when you de-lurk”

        I was following the thread but didn’t have anything to add until my comment about biopsies. What NCB advocates fail to grasp is that C-sections are preventive care and it is the nature of preventive care for the majority of it to be unnecessary in retrospect.

        Preventive care exists to prevent bad outcomes whether those outcomes are colon cancer, heart attacks or neonatal deaths. The overwhelming majority of colonoscopies are unnecessary, most people who undertake steps to prevent a heart attack would not have had one anyway, and most C-section do not save babies’ or mothers’ lives.

        Preventive care is not defective or unnecessary just because we find out later that it wasn’t needed. People seem to understand that reasoning when it comes to colonoscopy, mammography, lowering blood pressure, etc., but when it comes to C-sections, some people fail to understand that the reasoning is the same.

    • July 28, 2010 at 7:06 am

      Amy, Are women being bullied into biopsies? Are the risks/benefits being clearly communicated to them? Are they being told “you WILL die of cancer if you do not submit to this proceedure” – and most importantly, would you respect a woman’s choice to decline, and opt for watchful waiting? THAT, as I see it, is the real issue. When women are coersed, lied to, belittled or given false information they are much more likely to get angry about the lack of (or percieved lack of) ‘neccesity.’ Given all the correct information, evidence based practice, and the RESPECT of her role in the decision, most women will agree in retrospect “it may not have been neccessary, but it was still the right choice.”

      • July 28, 2010 at 9:35 am

        Honestly Lia Joy, that’s not far from what would be said. If a woman had a suspicious breast mass and she didn’t want it to be biopsied, you can sure the physician is going to tell her that this decision could lead to her dying from a treatable cancer, and that would be documented all over the chart. Nothing less would suffice if she later sued for failure to diagnose a treat cancer in a timely way. Even then it probably wouldn’t suffice.

    • Aria
      July 28, 2010 at 7:38 am

      Wow. Are you on drugs? The risk of a breast lump biopsy are so tiny compared to the risks of someone’s abdomen being cut wide open to remove a baby whose lungs likely aren’t completely mature.

      Cutting biopsies prevents risk to women. The risks are so infinitesimally small. Now with c-sections, unnecessary ones cause a lot of harm. But your reasoning, why not deliver all babies by c-section?

      Have you never notices how the US has the highest rate of maternal mortality among the developed nations, and we also have the highest rate of c-sections? Even in this country, hospitals with lower c-section rates, which, ironically, are usually the poorer ones, tend to have better maternal and infant outcomes than hospitals with higher c-section rates?

      • July 28, 2010 at 8:54 am

        “Cutting biopsies prevents risk to women. The risks are so infinitesimally small. Now with c-sections, unnecessary ones cause a lot of harm.”

        Really? Well why don’t you tell us exactly what percentage of women have complications of biopsies compared to number of lives saved and tell us exactly what percentage of women have complications from C-section compared to the number of lives saved. The statistics are what matter, not personal impressions.

    • Dana
      July 28, 2010 at 8:26 am

      If reason is given to perform a breast biopsy, then no matter what the outcome, malignant or benign, the biopsy was necessary. I, as a woman, would rather have a scar on my breast than wait while constantly wonder, “Is cancer growing inside of me?”
      Your comparison of breast biopsy to C-section is not very fair. Most women, who feel they have been put under the knife without good cause, do not feel their OB was watchfully waiting through their labor at all. I had one doctor strip my membranes without any warning or discussion. The nurse later told me he does that routinely to “get things going”. Then when contractions did become constant, another doctor broke my water and started the pitocin because it would “really get things going”. The doctor then moves on to his other responsibilities with other patients. He is not there while you are laboring; or when the nurse tells you it is time to push; or when the nurse tells you what great progress you are making and the head is rocking back and forth. You feel this incredible high that you are about to deliver your first born child. That is, until the doctor returns. You have pushed for 2 hours and haven’t made enough progress, it is time for the C-section. When doctors are MIA for the majority of labor, then arrive and quickly decide it is no longer worth waiting watchfully, it is easy to wonder if he had been a little more open-minded, or thoughtful of my situation, would he make the same decision again? And that is why it is easy for a woman to wonder, sometimes aloud, if her cesarean was “necessary”. When a doctor does not use his or her mind to make a decision or take the patient’s situation into consideration and solely follows protocol or his/her own standard routine, there are bound to be surgeries that were preventable at some point in the labor.
      A breast biopsy does not require a six week recovery while you are trying to care for a newborn and your hormone levels are dropping like a ton of bricks. Nor does it risk obstructing your bowels/bladder and increase your chances of hysterectomy in the future. I, and I’m guessing most women, feel that if there is evidence that the infant is in any danger, a cesarean is indicated. Just as if there is any evidence for risk of breast cancer (a lump) a biopsy is indicated. I would never expect my OB to wait watchfully while it was clear that my unborn infant was going to die inside of me, but I would expect my OB to always give me full disclosure and never put me in a situation that could raise the risk of a C-section just to “get things going”.
      Women can handle a good deal when it comes to labor and delivery and many are preparing themselves more than ever before. Too many doctors do not think highly enough of their patients, as evidenced by your weak analogy of biopsies to C-sections.

      • July 28, 2010 at 8:55 am

        “Most women, who feel they have been put under the knife without good cause, do not feel their OB was watchfully waiting through their labor at all.”

        How much do you think that has to do with the fact that NCB advocates are telling them that their C-section was unnecessary whether it was or not?

    • Dana
      July 29, 2010 at 8:59 am

      Re: Amy: “How much do you think that has to do with the fact that NCB advocates are telling them that their C-section was unnecessary whether it was or not?”

      I really can’t speak to that since I am not a NCB advocate. Also, I do not believe my cesarean was unnecessary, unindicated, or whatever. There does appear to be a growing body of women, (some who you may think are quite nutty, but most are probably very reasonable), increasing the “demand” for less cesareans. Therefore, I think it is the medical community’s responsibility to adjust “supply” accordingly. That is not by performing less cesareans and allowing neonatal deaths to increase. Rather, it makes more sense to me that research be done to determine the best ways to lower the risk of C-section, and also to practice current known methods that lower C-section rates more often.
      Many OBs should realize that it would benefit doctors, who are aware of a woman’s fear of cesarean, to discuss that with her, and tell her the steps they can take together to limit risk of surgery. More OBs should realize the benefit of spending a little more time with such a patient. If she feels she has been in a safe environment from the start, she is less likely, in my opinion, to feel her cesarean was unnecessary. I have a mother who has suffered and deteriorated from a disease of 27 years. I have accompanied her on appointments to doctors of rheumatology, infectious disease, endocrinology, orthopedics, ENT and other surgeons. She has never once been rushed out of an appointment or not given the time she needed to ask questions. I truly believe a patient should trust her doctor. And with 9 months full of appointments there is no reason why more questions should not be asked and answered to reduce later regrets.
      If, on the other hand, women pushing a discussion about unnecessary cesareans is only annoying noise to the OB, then that professional cannot be surprised if that noise only gets louder. There needs to be more discussion and less noise and both parties have a hand in that.

  30. July 28, 2010 at 6:58 am

    One thing I take from a lot of the commenters is that a lot of cesareans are happenening after a patient is involved in a labor process that does not optimize the opportunity to deliver vaginally. This I cannot agree with more. There are a lot of things we do that increase our cesarean rate. Induction is probably the biggest issue. I have seen so many infants get stuck in pelvices with their head nearly sideways after unfavorable inductions. I almost never see this in sponteneous labor. A recent study showed induction in primiparous women to double the risk of cesarean delivery.

    In some cases, induction is for medical reasons, and some of these reasons are arguable. Most OBs like to get folks with hypertension delivered by 39 weeks, but it likely that we have to do this many hundreds if not thousands of times to prevent one stillbirth, and we do it at the cost of many cesareans that might have been avoided with spontaneous labor. On the other side, there are many patients that are very anxious to be done with their pregnancy, who absolutely want to be induced. In some cases, they even switch doctors because their physician won’t induce them.

    So about this issue of obstetricians lying to patients –

    I think a lot of what is being perceived as lying is a physician using their platform of authority to express their opinion, when another party believes differently. That, my friends, is not lying, its just one of many examples of how people don’t agree on how we should do things. If one physician tells a patient with abdominal pain that he needs an appendectomy, and another says that the appendix is fine, neither is lying. One of them is just wrong. Being wrong isn’t the same as lying.

    On the other hand, if a physician actually knows X and willfully tells a patient Y, for some alterior motive, then that is lying and is reprehensible. I have seen it happen a few times, but it is by far the exception and not the rule.

    • Krista
      July 28, 2010 at 7:20 am

      Very good points. Re: lying physicians- In my personal experience and those of many women I’ve come in contact with, it seems like untrue statistics are often used to “scare” women into agreeing with their doctor. I was told that “research” indicated that refusing an induction at 41 weeks and remaining pregnant for the next week instead, would 150x increase the chance of my son being stillborn (surprisingly he was born very healthy at 42w, 2 d). Of course when I asked for the study to back-up this conclusion the DR had none. I’ve also had a friend who was informed that as a normal, healthy pregnant woman seeking a VBAC, there was a 10% chance she would experience uterine rupture. And the examples go on and on. That to me, Dr. Fogelson, is flat-out dishonesty that surely happens on a daily basis. If a Doctor is not sure of the statistical number they are quoting, there is NO harm in saying- “Ya know, I’m not sure on that. Let me get back to you when I have more information.” I’d respect an OB like that.

    • Aria
      July 28, 2010 at 7:45 am

      The first two paragraphs are spot-on.

      The rest…how often have you been a patient of an OB/GYN? Exactly. Zero. Two doctors coming to different conclusions about what is medically needed without their own motives getting in the way isn’t lying, no. But you’d be surprised at how often doctors do blatantly lie to pregnant women. They know our desire and desperation to have healthy babies can make us robotic yes-women who don’t question those who are supposed to know better, and this is an abuse of authority. Almost half my friends have been induced or had c-sections because their doctors made them so scared their babies would outright die if they weren’t induced for reasons such as the baby might be a whopping 5 pounds already (that mom was only 35 weeks along), to saying that it’s been 39 weeks, but it’s possible the conception date was a week off and so might actually be 40 weeks. You MUST understand that these reasons are VERY COMMON to the point of expected. When inductions aren’t done, c-sections are.

      You don’t know what your colleagues are saying to women when in the rooms with them. At best, you’re going to be getting a re-telling by them, and they’re probably going to want to leave out the bits that don’t look so good to them. If you were to wiretap rooms, you’d probably be pretty shocked at what you’d be hearing. Blatant lies are unfortunately very common.

      • OB doc
        July 29, 2010 at 5:33 pm

        I am interested that in the discussion of how Dr. Fogelson must be an “outlier” but that a majority of OB doctors are just lying in wait to cut women open, no one mentions the other side of the wishes of the patient. I cannot tell you how many requests for induction I get on a weekly basis–many of then prior to 39 weeks for women who are “tired of being pregnant and my last baby was born at 36 weeks so how can this be a bad idea?” I won’t do them, but I have actually had women go to other practices b/c my partners and I would not consent to this. What about the women who call in asking for pain meds for normal, pregnancy-related back pain? Or who want a note for time off from work b/c “it’s just too hard.” Pregnancy is hard, I’ve done it, don’t get me wrong. But to pretend that all women would PREFER no medical interventions at all, including induction, and would happily work and submit to continuing a pregnancy to and beyond 42 weeks is just as bad as stating that no obstetrician would ever section a woman for personal convenience, at least.

      • Melissa
        July 30, 2010 at 12:10 pm

        Agreed, OB Doc. There are plenty of women out there that are asking for the 37 week induction, the epi, the pit, the elective c-section…but they are also more likely to get it…if not from you then another OB out there. They aren’t having to fight for what they want…they may just have to wait a few weeks to get it.

        Meanwhile, the woman who says she wants a natural childbirth has an uphill battle to get what she wants. And the stress from having to be her own advocate, rather than her OB supporting her, often will cause her to have a prolonged labor and end up in exactly the situation she does not want.

    • D'Anne Graham
      July 28, 2010 at 5:06 pm

      Re: Physician and lying–is actually a well known and studied element of medical culture. I refer you all to Lying: Moral Choice in Public and Private Life by Sissela Bok. She writes: “Until the day comes that patients can be assured that they can trust what doctors tell them, is there anything they can do to improve the chances for themselves? How can they try to avoid slipping into a dependent relationship, one in which they have no way in trusting what anyone tells them? Is there anyway they can maintain a degree of autonomy, even at a time of great weakness?”
      I would also point you to the Clay Pedestal by Thomas Preston, MD.

      You have a stereotypical rose colored glasses view of your profession. And I can attest to the hubris supporting those glasses. As a teen-ager I made cocktails for the docs that came over to our house and heard them talk about how stupid the non-MD world was and their next money making venture. Did they help some people. Of course they did–and if they were human, think about how much more they could have done.
      The distorted power relationship between practitioner and patient/client and the air of entitlement of absolute power endemic within the medical profession is at the root of the Unnecesareans epidemic, malpractice (where only 1 out of 7+ verifiable acts of malpractice are litigated and physicians overwhelmingly win–Harvard study) and a bloated over-prescribed,fragmented medical business.

  31. July 28, 2010 at 7:25 am

    “Amy, Are women being bullied into biopsies? Are the risks/benefits being clearly communicated to them?”

    Have you seen or heard of anyone successfully refusing a breast biopsy. I haven’t.

    • Lucia
      July 29, 2010 at 2:02 pm

      Actually I have. http://www.webmd.com/breast-cancer/news/20031014/does-mammogram-risk-outweigh-benefit I would have to do more research about the effects of removing tumors in animal studies but they suggest they may prevent cancer from forming just as certain bacteria inhibit the growth of more pathogenic bacteria. Breast cancer is one of those currently untouchable subjects, women are uninformed about their risks and many believe that their risk of death from breast cancer is higher then that of other disease processes such as heart disease and even higher then lung cancer, Both of which are more common. Using breast cancer is not exactly a fair comparison either as one is a destructive abnormal force and the other is a biologically normal process. I certainly hope you’re not insinuating that a fetus is a tumor or a cancer and thus in need of the same drastic method of removal. Judging from your blog and the constant disparaging remarks about women and organizations who advocate natural childbirth, it’s hard to tell.

  32. July 28, 2010 at 7:44 am

    There has been great discussion all around on this, many commenters stating what I would state if I had not been so delayed in commenting, so I will just make a couple of other points if I may.

    I believe that women need to be seen/attended by a midwife unless she risks out of midwifery care, at which point she gets “kicked up” to an OB for the care that she needs. Of course, OBs feel that every cesarean surgery was indicated/necessary/needed (call it what you want!) at the time the decision was made to do the cesarean.

    OBs so rarely have the opportunity to observe “normal” physiological birth that of course every potential indication looks like a menace lurking in the corner ready to snatch mother and baby to the underworld! The beauty of the midwife is that they enter the room believing birth is normal, happens best when left to take it’s course and are able to attend birth with this belief. And it is the rare physician who does the same. When we set up a system that saves the OBs for the needed cesareans, then all our cesareans will be needed and attended by skilled and competent physicians who are indeed saving the life of the mother and/or baby. But when we ask OBs to attend normal birth, it rarely works.

    OBs are not evil or driven by forces that make them act so cautiously, they just don’t know any better, they must bear the fear of litigation and the pressures of their institution, all which work directly against normal birth. They respond as they are trained. We should not criticize this, we should use them for what they are trained to do and leave normal birth to those who are trained in normal birth.

    Research supports the fact that comparing *low risk* women cared for by midwives and l*ow risk* women cared for by OBs, the outcomes (less interventions, cesareans, nicu stays, etc) are better with the midwives.

    This country needs to change the way we conduct our “obstetric business” building on cooperation and collaboration between midwives and OBs, and making OB care available to those for which there is a true medical need, leaving normal birth to those that do it best! Then and only then will truly be no “unnecessary cesareans.”

    • CountryMidwife
      July 28, 2010 at 11:26 am

      Amen, Sharon.

    • Statler&Waldorf
      July 29, 2010 at 7:21 am

      I agree Sharon!

    • Melissa
      July 30, 2010 at 8:30 am

      Me too!

  33. Alisa
    July 28, 2010 at 7:48 am

    “Kind of a straw man argument don’t you think?”

    But you have a finger, not a uterus, yes? I would think it would be difficult to truly understand where a childbearing woman comes from without a way to ever experience that for yourself. That is an analogy, a substition for something you can not fathom.

    But you want to discuss terminology and what makes a c-section unnecessary, so here you go:

    http://www.kevinmd.com/blog/2010/03/vbac-rates-obstetricians-blame.html/comment-page-1

    The comments left here have a lot of MD or Dr. titles in them. And alot of these Doctors are talking about litigations and malpractice and why they will go for a c-section first over being sued. You’ve said that most doctors don’t lie to their patients or perform c-sections unnecessarily. But here is a long list of OB/GYNs who do just that. These c-sections, being performed for insurance reasons, are not unindicated, they are lies.
    Since when did “Do no harm” become “Do no harm, unless it benefits me first, all else is secondary.” How can women not be upset and use the terms “rape” or “unnnecesserean” when they are being unfairly operated on? It’s money over safety and health, and it’s sick!
    I truly hope Dr. folgesen, that you can see the problem with this and why it stirs so much passion in a person. Terminology is not a fix for the problem, it’s just something to hide behind.

    “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” Excerpt from modern medical oath

    • July 28, 2010 at 8:01 am

      >> But you have a finger, not a uterus, yes? I would think it would be difficult to truly understand where a childbearing woman comes from without a way to ever experience that for yourself. That is an analogy, a substition for something you can not fathom.

      Honestly this is an argument I cannot get down with. Female urologists do not have penises, yet they can provide excellent care to men with urologic issues. Most oncologists have not had cancer, and most gastroenterologists have not had severe GI disease. The knowledge of medicine and how to practice it comes not from empiric personal experience, but from years of studying the work of those that have come before us, and years of training integrating that study into practice.

      I think I understand that from a certain point of view, pregnancy and childbirth is looked at as something different, and not amenable to the medical way of study. Most OB’s look at it as a physiologic process. Most of the time it works, occasionally it doesn’t, and we try to head off the problems. Sometimes we cause a few ourselves. Our experience working in high risk centers shows us that terrible things can happen in pregnancy, and these experiences do affect our outlook.

      No part of that depends on an OB/GYN being a woman. I know plenty of female OB/GYNs that are far less progressive than I when it comes to labor management.

  34. Sarah N.
    July 28, 2010 at 8:20 am

    As a former NICU nurse, I find your indications for c-section appropriate, as long as they cater to the individual’s situation and desires, which I’m assuming you attempt to do. However, in my experience I have seen unnecessary c-sections performed. When there is no proper indication, and no distress of mother or baby, I call it unnecessary.
    I was told to prep a warmer for a woman that would be c-sectioned for “a big baby”. “Is there any distress” I ask? “No.” I am called back 1/2 hr. later saying that the woman doesn’t want the c-section and wants to push. “So we’re not doing it then?” “Well, she says that she’s already had three normal vaginal deliveries, and those were all big babies too.”
    So an hour later, her fourth *normal* SVD happens. It just happens to be a week after another woman had a scheduled c-section for breech when ‘oops isn’t that funny your baby isn’t really breech he’s vertex, why didn’t we check for that first.’

    quote- “So in the situation you mention, we can say the cesarean is unnecessary because we chose not to have it and ended up with a good outcome in a vaginal birth. But are we ever in that situation when we did do the cesarean? Should we then say that the vaginal birth was unnecessary?”

    Yes, typically at the time of the cesarean it is necessary. However many times the circumstances that led to it could have been knowingly prevented, reducing the overall c-section rate. You can say vaginal birth was unnecessary if you’d like, but in what situations is vaginal birth “unnecessary” for childbirth? Certainly not for the 32% of women that are getting cesareans. Maybe for transverse babies and complete previas, and circumstantial cases that would probably bring the overall rate into the WHO guidelines, around 15%, or less.

    • July 28, 2010 at 8:24 am

      “You can say vaginal birth was unnecessary if you’d like, but in what situations is vaginal birth “unnecessary” for childbirth?”

      Its a theoretical argument only.

  35. Alisa
    July 28, 2010 at 8:21 am

    That is true, it’s not a man thing, but much more a control issue.

    • July 28, 2010 at 8:23 am

      You’re right we’re all control freaks. Part of becoming a doc.

  36. July 28, 2010 at 8:22 am

    >> The comments left here have a lot of MD or Dr. titles in them

    Gosh – Amy Tuteur is the only doc that has posted on this thread except me. When it comes to birthing topics, the comment threads are 90% natural birth and midwifery folks, maybe 95%.

    A lot of docs read the threads but never comment. You may think this is nuts, but a big reason they don’t comment is that they don’t want something they wrote to be read back to them in court out of context.

    • Aria
      July 28, 2010 at 11:37 am

      I’m thinking a lot of doctors who read this blog read it to laugh and don’t think you’re worth their time.

    • OB doc
      July 29, 2010 at 5:36 pm

      Well, I’ve added one more :)

    • Melissa
      July 30, 2010 at 8:33 am

      I think that poster was referring to the blog link they posted and not your thread with that statement.

  37. Alisa
    July 28, 2010 at 8:25 am

    But what about lawsuits? I’m curious to hear how that benefits the woman and child, and not the doctor?

  38. Sarah N.
    July 28, 2010 at 8:27 am

    I forgot to mention, but thank you for writing this, and thanks for keeping a line of communication open. It’s an emotional topic for many women, but one that desperately needs to be discussed, that we might possibly understand each other’s point of view.

  39. Alisa
    July 28, 2010 at 8:29 am

    “The comments left here have a lot of MD or Dr. titles in them”

    refering to the comments on the link I posted. Mostly docs, not many naturalists

  40. July 28, 2010 at 8:51 am

    “Cutting biopsies prevents risk to women. The risks are so infinitesimally small. Now with c-sections, unnecessary ones cause a lot of harm.”

    Really? Well why don’t you tell us exactly what percentage of women have complications of biopsies compared to number of lives saved and tell us exactly what percentage of women have complications from C-section compared to the number of lives saved. The statistics are what matters, not personal impressions.

  41. Laurie
    July 28, 2010 at 9:02 am

    At one time I thought my c/s was unnecessary but over time and with a lot of reading I have decided that, at the time it was done – it was necessary. But that was mostly because of the ridiculous rules of the hospital I was delivering at. GBS+, water breaks – instructed to come in immediately (which now I know is unnecessary). It took 8 hours to get a contraction pattern established (no pit, but the MW gave me blue cohosh) – no food the entire time…..no fluids either (admittedly didn’t ask for them). Forced stadol shot so that I could “rest”…Purple pushing on my back for two hours, after 20 hours of labor the baby got stuck? NRFHTs – c-section…I was doomed to failure from the start.

    But one of the commenter made a good point about educating ourselves. I am no longer angry about my c-section because I have since educated myself and I am a better consumer. What I’m mad about is that I didn’t know I NEEDED to educate myself the first time around! I’m mad at the midwife who told me I didn’t need a doula in a hospital with an almost 50% c/s rate. And mad that I thought a weekend long birth class was enough the first time. Its like I went into the biggest exam of my life having just glanced over the Cliff Notes. As a college educator I find this appalling! I gripe at my students all the time about not doing their homework and not studying! How could I have done that?

    I’m also a little angry about how I was treated during my VBAC pregnancy. My primary care provider was a midwife and she was very supportive, but her OB group was not. One OB said “if I were her patient” she would section me at 39 weeks if I had not gone into spontaneous labor by 38 weeks – how is that a fair shot at a TOL? My response to her was “I’m glad I’m not your patient”. When I hit 40 weeks you would think I was a ticking time bomb by the way they acted. I had to go for NST – baby was great, MW said go home and gestate in peace. At 41 weeks I saw an OB in the practice who informed me that I had very low fluid levels and claimed that I was “endangering the life of my child” if I didn’t just walk over to the OR and submit to the repeat at that instant. He even told me this lovely story about a patient of his who delivered a dead baby :) However, I knew what normal and low fluid levels were and while my levels were on the low side of normal, they were still within the normal range. He didn’t like it when I told him as much and so noted it in my chart that I was strongly advised to have a repeat c/s. That same doctor discharged me from the hospital after my wonderfully successful VBAC and all he had to say was that he was “glad I got what I wanted”. He was visably uncomfortable with being in the room with me. Now, I wonder why that was? I had a perfectly normal VBAC delivery at 41 weeks and 6 days gestation but I had to fight for it the entire time. Not only that, I couldn’t exactly gestate in peace for fear of it being taken away by an OB for no good reason.

    My suggestion for lowering the ridiculous c-section rate in the US: Make VBAC a REAL choice for women. EDUCATE (or re-educate) OBs on the practice of attending VBAC births and how to really inform patients of the true risks/benefits. Don’t skew it either way – you are a doctor, not a salesman. Give the risks of c-section (and multiple c-sections) along with the risks of VBACing. No ever told me the risks of repeat c-sections, but boy did I ever hear about the risks of uterine rupture during my pregnancy. And I loved the dead baby story I got at my 41 week check up.

  42. Melissa
    July 28, 2010 at 9:05 am

    Nicholas Fogelson :But is that lying? Its a physician explaining the risks and benefits as they see it, given their experience and training.
    If folks want OBs to look at pregnancy as a completely low risk event that will always go well, maybe they’re being a little unrealistic. Most OBs see risk in pregnancy because they spent four years of residency working with very complicated pregnancies and seeing a lot of bad outcomes. In a lot of ways this biases their view (an mine in some cases.)

    When I read this I hear “Why bother with/practice based on the evidence when we have anecdotes?” Do you see how that could be?

    I think that frustrates a lot of women–to be subject to a one size fits all approach to maternity care based on fear of being blamed for a bad outcome rather than on what the body of evidence indicates is helpful or harmful.

    • Heather
      July 28, 2010 at 7:35 pm

      If OB’s in training are only seeing high risk births, with maybe a few low-risk hospital births that are intensively “managed” thrown in, of course their perceptions of the risks are skewed! However, this is NOT a reason for women to “understand”. Too much is at stake. What needs to happen is for OB training to include a good slice of “hands-off” labor and delivery–requiring them to observe a few home births (and I do mean, sit down, shut up, and OBSERVE!) would be ideal. But even birth center, or non-interventionist hospital births would be an improvement. Additionally, we desperately need a maternity care system in this country where OB’s are caring for the women who require an OB’s skills and midwives are caring for the women who do not. No, I am not at this time a health care professional, although I could see taking doula training when I am done having small children, but I am a mother. I have had one hospital birth and one home birth, with midwife-based prenatal care for both, as the hospital-born baby was supposed to have also been born at home, but was risked out because a car accident broke my water & sent me into labor at 35 weeks. Any more babies that we have will be born at home. And the biggest reason is the one women here have been saying over and over and over, in various ways. A midwife works with me and for me with the goal of having a healthy mama and baby at the end of labor with as little intervention as possible. An OB/hospital combination expects the mother to conform to their routines and desires, often without explanation or evidence, and with bullying and scare tactics. My hospital birth was fairly non-interventive, for a modern hospital birth–BUT I was a very well-informed mama going in (when I was in the car wreck, I was on my way home from the state capitol after lobbying the state senate to legalize CPM’s in our state–and everyone at the hospital knew it. It was a hot political issue at the time, and our state capitol is not a big place), and I am a person who is not afraid to stand up for myself. And my husband was there, and I knew I could count on him to be in my corner, if I could not be. Even so, my homebirth was MUCH less stressful, because I knew for sure that the midwife wasn’t going to try to do things I didn’t want done.

      • OB doc
        July 29, 2010 at 5:44 pm

        People: If this is really your experience, I urge you to go to a different hospital. Or a birthing center attached to a hospital. Not going to get into free standing BC or home birth debates here, b/c that’s not my thing. But do realize that there are doctors and hospitals out there that support women’s wishes and will do everything possible to achieve a safe, vaginal delivery. I do not infrequently sit with a patient while she pushes 3-4 hours. Much as my midwifery colleagues will attest, I find that most women push most effectively with their provider in attendance. Plus, it lets me see how things are *really* progressing. I think that fact that our clinic is connected to labor and delivery makes a HUGE difference. I am not across town trying to manage a labor on the phone. When faced with “cancel a whole afternoon of clinic or just call the section b/c someone has been pushing for 3 hours,” I guess I’m not surprised that the Friedmann curve is adhered to far too stringently. Someone commented earlier that as long as the baby and mom are doing well (and I would add progress is being made), what’s wrong with pushing for 4 hours? Well, nothing, that’s what. Research your options for delivery–and that doesn’t just mean your doctor, but also your hospital. If your hospital doesn’t look kindly on your ideal plan (assuming all things are equal and you are a low risk patient), consider a different hospital. There are OBs out there (and certainly midwives too, but I’m just responding to the OB-bashing) who will explain things to you and answer your questions, and treat you with respect. Leave the rest of them to wonder why their patient numbers are dropping like flies :)

      • Heather
        July 29, 2010 at 6:56 pm

        @OB Doc: The problem is, lots of women don’t HAVE other options! In an urban/surburban area, women MIGHT have available to them hospitals and OB’s that actually have different mindsets. Or all the hospitals and OB’s in a given area might be doing things the same way. Freestanding birth centers? They’re a pretty rare bird in many parts of the country. The St. Louis area, where I live, has _one_ and it only just opened up (or maybe I jumped the gun & it’s not quite going yet). The entire state of MO has 2. In a rural area, the options are to use the local hospital (others are likely too far away) or a midwife. If she’s not already booked solid.

      • Melissa
        July 30, 2010 at 8:41 am

        I agree with Heather that there needs to be extensive NCB training for OB’s…it would change the face of modern obstetrics.

  43. courtney
    July 28, 2010 at 9:07 am

    Ah, so the doc. will only come out to play if we follow his rules.

    Semantics ARE important. I just put you on the defense by the words of my reply. Doctors are very good at controling their patients feelings and reactions through the words they use, tone, gestures, sighs, nods, etc. I am sure that you know how to get a woman who wants a trail of labor to give up. . . You induce her, restrict her water, food, movement, and then wait until labor hormones have got her out of her thinking brain. . . and then you come in frowning with the bad news. A woman in labor just sees “DANGER” and that is the end of that. . . you make your Tee time, Mom gets post-partum depression and bonding issues, Baby gets asthma and thrush.

    I would love to hear what you have to say. I would love to have a real conversation about a VERY important topic. But frankly, I am not willing to let you control the words I use or the topics we limit the discussion to.

  44. Aly
    July 28, 2010 at 9:41 am

    Well, let’s see what Dr. F has to say: putting aside the benefits for the time being, are the risks to breast biopsies and cesarean sections the same, short and long term?

    I have to agree about lying. While I’m sure a few do it, most obs genuinely believe they are doing the right thing by performing unindicated cesareans. Isn’t uterine rupture in subsequent pregnancy, not just labor, a risk of cesarean section? Don’t uteruses rupture without labor, or in premature labor, or before arrival to the hospital? Why can physicians go nuts about the risks of vbac and uterine rupture, and fail to realize that the first cesarean is the ultimate cause of a thinned out uterus? Why is the risk of amniocentesis glossed over? What’s with the cognitive dissonance? And why can’t they just let it go that not all women share the same philosophy? Is it the control freak thing? Are obstetricians really minor players in the whole decision making game, and it’s the administrators who call the shots? And why are facilities that can’t perform an immediate cesarean delivery doing births at all?

    On the other side, the natural/normal birth advocates bother me because they can’t admit that most women can be fully educated and still prefer the control/technology associated with a repeat cesarean. There’s nothing wrong with that, and the movement could sure move forward if it emphasized choice rather than ideology. That’s why I like Dr. F.

    I’d also like to know your opinion of the role of cEFM in unindicated cesarean.

    • July 28, 2010 at 10:01 am

      The analogy to breast biopsies is a good one, but I can’t quote data on the risk/benefit profile. The idea that one can’t judge the indication for a procedure based on the result is appropriate I think.

      A lot of great questions. I really think that malpractice litigation has a huge part to do with it. OBs can’t let it go because we get can get nailed hard for bad outcomes, even if it seems like the patient wanted that course of action. Its very hard to get sued for delivering a healthy baby by cesarean. Maybe that’s not right, but for now it seems to be the case. Docs that have been through the litigation process will go to great ends to not end up there again. There’s no question that a great deal of medicine ignores evidence under the idea that that particular path is less prone to litigation.

      >> And why are facilities that can’t perform an immediate cesarean delivery doing births at all?

      There’s actually a great deal of talk about reducing cesarean rates in the obstetrical literature, particularly in the editorials. OBs realize that this is a problem, and some are really trying to improve the situation.

      • Aly
        July 28, 2010 at 11:16 am

        “There’s actually a great deal of talk about reducing cesarean rates in the obstetrical literature, particularly in the editorials. OBs realize that this is a problem, and some are really trying to improve the situation.”

        Is it possible that academic ob/gyns such as yourself and non researchers view the subject differently? Because I read the literature and see concern about the high c-section rate, then I read comments from run of the mill obs that basically propose that all deliveries should be cesareans, and that there is little risk to cesarean. People like Dr. Amy on one side and midwife Gloria Lemay on the other who are seemingly incapable of seeing any kind of grey area. Seems like a contradiction. Then I read WHO reports quoting a triple maternal death rate from cesarean… what is one supposed to think? Someone linked to the asthma risk in c-section babies, I’m assuming thrush could be related to the antibiotics sometimes required for wound infections.

        I’ve also read that the number one way to reduce the 32% number is to increase access to vbac, because these 2,3,4 cesareans make up the most significant portion of the total.

  45. July 28, 2010 at 9:44 am

    >> But frankly, I am not willing to let you control the words I use or the topics we limit the discussion to.

    Nobody’s controlling anything. Its just an opinion. People can say or write whatever they like.

    >> You induce her, restrict her water, food, movement, and then wait until labor hormones have got her out of her thinking brain.

    Wow – sounds sinister.

    C-section -> asthma and thrush? I’m unaware of any data that says that. I’d love to see it.

  46. Heather
    July 28, 2010 at 9:58 am

    Semantics. If a lifeguard “rescues” a swimmer showing no “indication” of needing rescued, that rescue was “unnecessary.” A rescue may become necessary later, obviously, but if the rescue wasn’t indicated at the time, than it wasn’t necessary at the time.

    • July 28, 2010 at 10:03 am

      In truth, I’m less against the use of the term unnecessary cesarean, which I’ve actually used on this blog in the past, than I am against the term “Unnecessarean”. Its catchy and punny, but it links the words unnecessary and cesarean in a way that implies that cesareans are inherently unnecessary, and that I do not agree with.

      • CountryMidwife
        July 28, 2010 at 11:35 am

        While acknowledging the extremists that exist, I think you are either overreacting or underestimating “natural child birth advocates” on this one. If there’s anyone out there who thinks ALL cesareans are unnecessary, they are, I think we’d agree, idiots. But I don’t think that’s the case for the majority. Question, Dr. F — what do you think is an appropriate national cesarean rate?

      • July 28, 2010 at 12:55 pm

        Its a good question, and I’m not really sure. The 15% number that the WHO presented was admittedly just made up.

        This is just opinion, but I think if we made a real effort to reduce elective inductions and support VBAC, we could probably achieve a rate of 15-20%. Maybe better.

      • Aria
        July 28, 2010 at 6:34 pm

        Unnecessarian refers to those c-sections that are unnecessary, and many c-sections are unnecessary c-sections. What would you prefer to call them aside from what they are? Joy rides?

  47. July 28, 2010 at 10:05 am

    >> but if the rescue wasn’t indicated at the time, than it wasn’t necessary at the time.

    So then here is a another question. When we consider the decision for cesarean, shall we only consider what is going on at the time of the delivery, or what the eventual outcome is? To me “indicated” is all about what is going on at the time the decision is made, and the events leading up to it. Necessary, when used in retrospect, to me implies something that is more based on the outcome. Clearly others may use in in a different way. It is semantic, but hey it led to this interesting dialogue.

  48. July 28, 2010 at 10:13 am

    Nicholas Fogelson :Honestly Lia Joy, that’s not far from what would be said. If a woman had a suspicious breast mass and she didn’t want it to be biopsied, you can sure the physician is going to tell her that this decision could lead to her dying from a treatable cancer, and that would be documented all over the chart. Nothing less would suffice if she later sued for failure to diagnose a treat cancer in a timely way. Even then it probably wouldn’t suffice.

    Saying the decision ‘…could lead to death from treatable cancer.” and saying “You are going to die if you don’t have this proceedure done.” are 2 different things…. Regaurdless, If giving a woman accurate and complete information about her c-section (or biopsy) is not enough to protect drs from lawsuits, isn’t THAT the problem? I don’t see the OBs as monsters here (though some of their actions/words are pretty horrifying) I think it is a system (and general public (ie potential jurors) consensus that Drs are magic and anything less than an ideal outcome is because they didn’t perform that magic as it was OWED to the patient. Drs (& MWs) who fully inform and empower thier patients help break the cycle, and women who speak out, and INSIST on taking responsibility for thier births and the outcomes help to break the cycle.

  49. Melissa
    July 28, 2010 at 10:13 am

    Only one thing to say about the Amy Tuteur comments…pregnancy is not a disease…apples & oranges. Try coming up with comments actually related to the topic. You want statistics? How about the c-section rate across the U.S. is a whopping 32%…meanwhile Ina May Gaskin’s Farm Midwives have a 1.2% overall rate. When Ob/Gyn’s have those kind of results, then they might get my business…but it is highly unlikely to ever happen.

    Unindicated or unnecessary…the wording is pure semantics. I can tell you from personal experience that I avoided 2 unnecessary c-sections. How did I do this? By having home births for both my sons…the first because he was 10lbs 12oz and the other 11lbs 12 oz frank breech. In my state, in any hospital, I would have been forced into c-sections, because no one will vaginally deliver a baby over 9lbs or a breech baby***.(***Mainly, because Ob/Gyn’s aren’t trained to deliver breech babies safely…which involves *gasp* keeping your hands off!) They were both born very healthy at home with no issues.

    The problem I see is that Ob/Gyn’s think THEY are “necessary” for the outcome of the birth to be positive. Ob/Gyn’s should only be necessary if there IS a problem. 80-90% of women don’t need anyone to deliver their babies…they need to be educated, so they aren’t afraid of it. The major difference between NCB care and an Ob/Gyn is that one is there to provide support “if needed” and the other is taught to “manage” birth. I don’t need my birth managed, it will happen on its own with or without you…if Ob/Gyn’s would allow birth to happen and step in only when necessary, their c-section rates would drop like a rock. The problem, IMO, is how Ob/Gyn’s are taught to approach birth. How can you say that NCB is an option in your practice if your entire education is spent on controlling birth and performing c-sections? You are trying to improve on Mother Nature and failing miserably…so you can keep your machines that say “PING” and continue to say unindicated and I will continue to say unnecessary safely at home.

    • July 28, 2010 at 10:42 am

      “the c-section rate across the U.S. is a whopping 32%…meanwhile Ina May Gaskin’s Farm Midwives have a 1.2% overall rate.”

      And they also have a whoppingly high rate of neonatal death. In the only study done outcomes at The Farm (Durand, 1992) the death rate is 10/1000, approximately 3 times higher than the death rate for comparable risk women during the same time period. That’s why the author didn’t compare The Farm death rate with the hospital birth death rate. Instead, he compared it a national database of births that deliberately oversample high risk births (because the database was collected specifically to investigate high risk births.

      This is a perfect example of the fact that most of what homebirth advocates think they “know” is factually false. There is a truly outstanding amount of misinformation being passed around by homebirth advocates who are then baffled as to why no one follows “the evidence.” Obstetricians follow the evidence; homebirth advocates don’t really know what the evidence is.

      • Aria
        July 28, 2010 at 11:44 am

        The Farm does NOT have a death rate of 1 our of every 100 babies. They would be shut down so fast and likely charged with murder if that were the case. Multiple studies have shown that, factoring out the high-risk hospital-births that would skew the statistics, midwife-attended births have a slightly lower neonatal death rate. Now add in those high-risk births and deaths and the stats skew far in favor of midwifery, but midwives don’t see most high-risk patients, so it’s not fair to count them.

        Also who counts as “high-risk” is often wrong. I was considered high-risk, but found a wonderful midwife who realized my risk was only high because of doctors concerned for their own liability (the OB/GYNs I saw were demanding a c-section, and instead I had a homebirth and am damned glad I did).

    • July 28, 2010 at 12:47 pm

      You are right that OBs and midwives have a different approach to labor. As for improving on mother nature – unfortunately mother nature does lead to fetal and maternal deaths, and we have done a good job at preventing these things. Go back a few hundred years and the number one and two reasons for maternal death were hemmorhage and infection. With modern antibiotics and blood banks its nearly unheard of. We have also converted an extremely painful experience to a nearly painless one, which to most people is a very desireable change. So many things have improved with modern obstetrics. With that has come too many cesarean deliveries and inductions of labor.

      >> Mainly, because Ob/Gyn’s aren’t trained to deliver breech babies safely…which involves *gasp* keeping your hands off!

      This is really not true. Every OB is trained to deliver breeches, and most have done some in their residencies. Many continue to deliver breech second twins. The technique of not touching the infant until it has delivered to the scapulae is quite well known, and described in any OB textbook. It is a shame that term breech has gone away, because it is largely safe in many cases. The Term Breech Trial, which had big methodologic problems, really nailed the coffin on that. Fortunately there are some new data that may reverse the trend. There is a pendulum to all of these things, and it likely will swing the other way in time.

      • July 28, 2010 at 4:11 pm

        Well, running a marathon hurts a lot, but you do it better if you can feel your legs. Women don’t become scared of childbirth pain all on their own. The misinformation that we pass on to each other is uninformed, and based on in-hospital experiences shared with devastating effectiveness. A water-assisted labor, massage, relaxation techniques, etc. are all less new-agey when a patient OB encourages them. But, that’s pretty labor intensive in a busy hospital, and when the pharmacy or anesthesiologist is just a comfortable call away, women feel they are in bed and out of options. Let’s find a way to support women to embrace childbirth pain when possible! Honestly, it’s not the worst pain I’ve ever been in–it’s just the most all-encompassing, intense pain I’ve ever been in.

      • Jennifer B.
      • Jennifer B.
        July 29, 2010 at 8:42 pm

        I assume it is you who posted “justathought”… THANK YOU if that is the case.

      • Melissa
        July 30, 2010 at 4:34 am

        Infections? Are you talking about childbed fever, which was directly related to the “doctors” not cleaning up between patients or cadavers before attending a laboring woman…or like anti-biotic resistant staph and similar infections which you can still get in a hospital today? I have never heard of a HB mother getting an infection after delivery. I have heard plenty of stories of c-sectioned mothers having problems with infection & healing, including my own sister-in-law. Hemmorage is just as much of a risk during a c-setion as it is in a vaginal delivery and even more so after surgery 3,4 & 5. The U.S. does not have highly impressive maternal & infant death rate for a developed country and the highest number of OB’s…begs the question if we are doing things that are good for women & babies.

        I am not saying that ALL c-sections are unnecesary…there will always be those cases where a c-section can save either mother or babies life. What I am saying is that it should be medically indicated for THAT mother or child, not because you experienced xyz with patient xyz or I am not delivering in the right time-frame. OB’s have my respect for being highly skilled surgeons…but as a PP stated, they should not be attending normal low risk births, IMO.

        I personally don’t feel it is necessary for a surgeon to attend my natural delivery, because that is not what you are trained to do. (While I am sure you may have seen a “vaginal” delivery…I am highly sceptical anytime an OB says they have attended a natural birth…as they are not the same thing in my book.) When I need a surgeon I will go to one…when I deliver my child I will go to someone trained in natural childbirth.

        Regarding breech birth & training…I am on a mainstream birthboard of 10,000 pregnant women and pretty much every single mother whose baby is breech still at 36 weeks is being told they will have a c-section at 39 weeks, if baby does not turn by their next appointment…so if OB’s are trained…then most are not using their training in order to give their clients a choice in how they deliver. These women are all being told that it is dangerous to deliver breech and a c-section is the only way to go. So are they being lied to? Or just manipulated?

      • July 30, 2010 at 4:53 am

        OB’s are trained on how to do breeches, but they are also trained on how to read the literature. The Term Breech Trial, despite its flaws, did show a substantial difference in neonatal death rate between labor and cesarean for breech delivery, in favor of cesarean. This trial had some methodologic issues, as most large trials do. Not surprisingly, those that thought already that breeches were safe pan the trial, and those that think it is dangerous quote the trial. Happens with every big study on any topic.

        Given that the trial exists, however, it is way off base to suggest that an OB/GYN who tells a patient that a breech vaginal delivery is more dangerous for the baby than a cesarean is lying.

        What I think we deal with here is anecdote vs data. Lots of people have delivered breeches successfully. I have done a few. Some midwives have done more. Some midwives have also tried to deliver breeches and had head entrapments leading to fetal hypoxia and long term disability (I know two in fact.) They thought it was safe before that happened, and then then realized that it wasn’t so safe.

        If something terrible only happens 1 in 50 times, you can think its safe for a long time until that 1 in 50 hits. The fact that it has always worked out ok wasn’t skill and it wasn’t fate, it was just luck.

        The idea that a breech delivery would be as safe as a cesarean for the baby is just logically irrational. The baby’s head is the biggest part of the body. If the vagina and pelvis are just big enough to accomodate the body but not the head, it’s going to get stuck. Sometimes this can be relieved quickly, and sometimes it takes too long and the baby gets hurt.

        That’s no lie, nor is it manipulation. Its a presentation of the data we have. The other side is presenting their anecdotes of delivering breeches safely. I have those too, but I don’t have real data to back up a belief that breech delivery as a whole is as safe as cesarean.

      • July 30, 2010 at 4:54 am

        Melissa I’d be happy to send you a PDF of the term breech trial for you to read.

      • PrecipMom
        July 30, 2010 at 5:06 am

        Quick question: is a history of shoulder dystocia a known contraindication to vaginal breech birth? My comfort level is such that I would choose elective c-section with my history of shoulder dystocia if I had a persistent breech, but I don’t know if there has been any official evidence or recommendation regarding that risk factor.

      • July 30, 2010 at 5:15 am

        Not all all, but we do have statistics that show what the recurrence rate is. Women with a shoulder dystocia with no risk factors (like a baby > 4000 grams or maternal diabetes), have about a 10% recurrence rate. Given that only 10% of shoulder dystocias lead to fetal injury, and only about 10% of those are permanent, that’s still a pretty low risk of a long term problem. As such, you have to do a lot of cesareans to prevent those injuries, though you need fewer to prevent a non-injurious shoulder dystocia.

        Diabetic women with macrosomic infants with a history of shoulder dystocia, on the other hand, have a very high rate of recurrence, some studies say 50%. Cesarean in those cases seems justified to me.

      • Melissa
        July 30, 2010 at 8:48 am

        “Breech delivery of a singleton is not something that is done a lot in this country, mostly because there aren’t a lot of people trained in it. The feasibility of second twin delivery is usually related to to the availability of a practitioner trained in breech delivery of second twins. In my training program we did a fair bit of this and so I do it, but many OBs are not trained in this.”

        I am confused…either they are trianed or they aren’t…your words, not mine. LOL

      • Melissa
        July 30, 2010 at 9:42 am

        No thanks on the TBT trial PDF…I already know it can be done safely…remember, I birthed a frank breech. I am sure I won’t be surprised by the conclusions they come to.

        Interesting to note that Canada recently decided to begin retraining their OB’s in breech delivery in order to reduce unnecessary c-sections and give women a choice. Ironically, in looking for a link to Canada’s reversal on breech delivery I found this article that mentions the TBT study, which was a Canadian study…and that it was flawed.

        “When TBT outcomes were looked at more closely, most of the death or harm inflicted on vaginally delivered babies turned out to be explainable by causes other than the delivery method.”

        http://network.nationalpost.com/np/blogs/fullcomment/archive/2009/06/19/colby-cosh-new-thinking-on-breech-deliveries.aspx

      • July 30, 2010 at 10:28 am

        Being trained to handle a high risk situation does not remove the risk, it just part of optimizing one’s chance of a good outcome.

        The fact that you had a successful breech delivery says nothing about the underlying safety of the practice. Nobody, and no research, suggests that breeches cannot be delivered safely. We only think that in aggregate, there will be more fetal injuries and deaths with babies born via breech vaginal delivery than by breech cesarean delivery.

        The Term Breech Trial does have some methodologic issues, but in no way do those issues negate the trial in total. If anything, they suggest that breech deliveries be carefully selected, and that many women shouldn’t try. One of the biggest issues with the trial was the heterogeneity of the practice locations. Some centers were in developed countries where ultrasound and CT and Xray pelvimetry was available, while other centers were in third world countries where they had nothing. There were some anomalous babies and some babies that died prior to labor, but they were present in both groups, not just in the breech group. Of only 16 fetal deaths in the whole trial, 13 were in the breech vaginal delivery group, and 6 of these were clearly attributed to a difficult vaginal delivery with likely fetal hypoxia. A 7th was also difficult, but may have been an anomalous infant as well. One important point, though, is that overall there were very few deaths in any group, and which demonstrates a large level of safety for either method.

        I agree that the trial is overinterpreted to some extent, but to say that an obstetrician who feels that breech delivery is more dangerous than cesarean is lying is just ridiculous.

        The fact that you have formed your opinion on the term breech trial without reading it, and still have no interest in reading it, is too bad. Of course you already know that it says breech delivery is more dangerous than cesarean. That’s obvious. The point is how they did the trial, and the details of what happened in it. It takes a lot of training to work through all of that, but if you don’t do that work, you are working from a place that will never effect any change.

      • Melissa
        July 30, 2010 at 1:22 pm

        While I appreciate your concern with my beliefs on the subject, I am not a HCP, so I don’t see a need to read the study. I come from the other side of the spectrum from you, so I believe that birth is inherently safe with occasional anomalies that require intervention. I don’t base my decisions off what may have occured with 1 other woman with another set of circumstances…or your 1 in 50 example…you are basing your care off of the 1 anomaly rather than the other 49 who had no problem. So basically, fear based medecine.

        Canada reversed their stance on its findings, saying that even if there is a slightly higher death rate amongst the vaginally delivered that it is not statistically significant enough to rule out giving women the option and in some cases would be better than performing a c-section. Also, I never said that OB’s are lying about breech delivery…I said OB’s are forcing c-sections in breech cases and saying it’s because it is dangerous…and I asked you if they were lying or just manipulating. If the danger is statistically insignificant by Canada’s standards, then why aren’t women in the U.S. able to choose for themselves?

        I am not advocating breech delivery for everyone, mine was a surprise breech or I would have attempted to turn him. I was given my options by my HCP and because I felt comfortable with the risks involved, I chose to deliver my son vaginally. A lot of women are not being given the option, because either the OB is not trained or will not deliver a breech vaginally. To me that is taking away the woman’s choice.

        I believe that the ACOG came to a similar conclusion in regards to VBAC and uterine rupture risks being overblown. My SIL is going to attempt a VBAC only after I gave her the statistics that compared VBAC risks with C-section risks…something her own OB should have done. What did he tell her about VBAC? He gave her a “# in a thousand women rupture and end up having a hysterectomy and the baby dies” story. (I can’t remember the exact number he used, but knew it was not accurate, which is why I gave her the real stats) When she confronted him with it, he reversed his stance and said he supports VBAC’s (as long as she follows his strict criteria) and he just didn’t want to sway her with his influence. : P I am rooting for her, but will be very surprised if she gets her VBAC.

        There are inherent risks in all birth…no matter where or how it is done. No matter what you do, you will never be able to eliminate all those risks. And by trying to eliminate those risks are OB’s creating a different problem? I believe that the childbirth decisions need to be made by a truly informed mother, which is not always or often the case.

      • July 30, 2010 at 2:01 pm

        >> If the danger is statistically insignificant by Canada’s standards, then why aren’t women in the U.S. able to choose for themselves?

        Maybe because in the United States a breech delivery with a fetal death is a near guaranteed out of court settlement.

      • Melissa
        July 30, 2010 at 7:50 pm

        “Maybe because in the United States a breech delivery with a fetal death is a near guaranteed out of court settlement.”

        Thank you for being honest about it…and that is exactly why we have the term Unnecessarian…because women should not be “forced” into a c-section, because their OB is afraid of litigation or for any other reason, other than immediate medical need.

        The facts should be presented, risks discussed and the choice should be left to the parents to make the best decision for them. I am sure that there are great OB’s out there who do practice this way, but the problem is there are plenty out there who don’t.

  50. courtney
    • July 28, 2010 at 12:32 pm

      interesting. Its case control, not prospective, which hurts validity to some extent, but its interesting.

  51. July 28, 2010 at 10:34 am

    Let’s be honest here. Both obs and midwives lie to women and coerce them into choices that suit the practitioners. I’ve worked in hospitals in the UK where certain midwives would have an epidural set up with 10 mins of meeting a woman and obs would ask you to turn up the synt and get her to theatre before the end of the shift. This is why I can’t work in hospitals any more.
    Also I think that obs often do not see the aftermath of c-section. Instead the women fall apart in the community and it is family and later the midwife they choose for a homebirth who have to provide the support required to come to terms with their previous birth.
    We need more education and access to a range of maternity services. Women need to think about what kind of birth they would like to experience and choose an appropriate practitioner:
    OBs = a surgeon who has an inbuilt fear of physiological birth and no experience of it
    MW = experience of supporting a physiological birth and dealing with the occasional complication
    It is such a shame that it is only after their first birth that women then go on to do the research and choose appropriate care for the next baby.
    Some will always choose the surgeon as the ‘safest’ option due to their definition of ‘safe’.

    • OB doc
      July 29, 2010 at 5:51 pm

      We need more education and access to a range of maternity services. Women need to think about what kind of birth they would like to experience and choose an appropriate practitioner:
      OBs = a surgeon who has an inbuilt fear of physiological birth and no experience of it
      MW = experience of supporting a physiological birth and dealing with the occasional complication

      Statements like this only add to the “us versus them” mentality, regarding MW and doctors and providers and patients. If I said “all midwives are inherently inferior to all OBs because they have less formal training,” what would you say? I don’t happen to agree with that statement at all, having known and worked with many fabulous midwives, but it’s similar in tone and intent. I think most reasonable people would agree that the truth lies somewhere in the middle (oh, that people could see this in other walks of life…politics comes to mind as well.)

      • Melissa
        July 30, 2010 at 7:55 am

        Comparing midwives & surgeons is like comparing apples & oranges…a midwife is a highly trained NCB provider & an OB is a highly trained surgeon. They do different things, which is why their approaches are different. They both serve a purpose and provide a needed service. How often the OB is needed in his role as a surgeon is the question.

        I would like to see women having real choices no matter where they deliver. I choose HB for myself, but understand that it is not for everyone…but there should be no reason that they can’t have the same type of birth in the hospital. What prevents a mother from having a NCB in a hospital setting and having the reassurance that emergency care is there if she really needs it?…why is it harder to get that type of care without staying at home or going to a birthing center? It’s not because it’s being offered and women aren’t choosing it…for the most part the women who get that at a hospital have had to fight tooth and nail in order to get it and a lot of them are unsuccessful, which is why they turn to HB.

        There is a completely different approach in how women are “allowed” to labor & deliver in both settings and that is where the breakdown is. In the hospital, it is assumed that all women want or need pain relief, induction at 39 weeks, progress on a pre-determined timeline, need pitocin to help it along, need constant fetal monitoring, can only deliver 8 lb babies, need to be told when to push or what position to deliver in…in short that something is inherently “wrong” or broken with these women when they are unable to deliver their babies within the limiting guidlines put upon them.

        It’s kind of like telling a marathon runner that they can do it on their own, but they have to run backwards with a weighted pack…eventually they’re going to give up, because you are putting an unfair burden on them…whereas if left alone they probably would have finished the race.

  52. Mom2Four
    July 28, 2010 at 10:45 am

    Why get all hot and bothered about wording? You know it’s true, you just don’t want to admit it. I’m expecting my fourth sometime this Fall. I’m one of the lucky ones that has no had a csection but have came close during my 2nd pregnancy. Let’s just say that they wanted to induce when it was good for them and scared me into it. They said I had low fluid and I was not borderline, but they fibbed up the papers and admitted me. This lead to me being on pit for hours and hours with no cervical dilation … so let’s crank up the pit and start manually dilating my cervix. Oh wait, babies heart rate is going crazy and mom can’t breathe .. hmmm .. let’s go ahead and give her some drugs (I wanted to go natural, but obviously couldn’t after they manually dilated me) .. oh, and while we are at it, let’s break the bag of waters. I came so close to having a csection and met the OB on call that would be doing it. I was scared out of my mind but luckily, my son was born vaginally. I have a lot of anger about the way things went. I’m still angry about it and this was five years ago. I can’t imagine someone having a csection and trying to deal with those emotions. They tried inducing me with my third son because of “high” fluid this time .. but I flat out said no and ended up going into labor on my own, labored for the majority of it at home in peace, had no interventions, and delivered a perfect baby. This time I wised up and am choosing a home birth midwife. I’m sick of all the inductions and stuff that is NOT NECESSARY. What nurses/OB’s do in the hospital is what causes “Unnecessary Cesareans” .. let’s not forget to add in the fact that if you don’t pop out a baby in six hours then .. well, let’s just say things are not progressing and wheel her off to the surgical room. It’s SICKENING.

    We need more education out there for women to avoid this stuff. STAY AT HOME AND LABOR. Do your OWN research. Check into your HOSPITAL’s records and stats for csection rates or induction methods. You would be very surprised. Look at the research on all the induction methods out there, it’s SCARY. Out of all three of my births so far, I only had one person sit down with me while I was in labor and really explain the RISKS with the epidural. Look at what it can do to YOU in labor, but most of all, look what all of those things can do to your BABY. That precious baby you have been waiting for for 9-10 months. And just remember, a due date is ONLY an estimate. Let your body decide when it’s time to birth. Don’t let people scare you into things.

    So choose wisely! Listen to your heart, your mind, and your soul. Women need to take a step back in time. Mother Nature knows best, not some silly machine.

  53. July 28, 2010 at 10:52 am

    OK, I started writing a reply last night and since then the comment section has (predictably) exploded. Some of the vitriol and name-calling is very disappointing to me. Dr. Fogelson is trying to engage in an open, respectful discussion which I really appreciate. The “lying doctors” discussion has become prevalent and I hope that’s not (solely) attributable to my original comment about patients being lied to; I believe it’s very attributable to the feeling many women have (well-documented in the comments) that they WERE lied to.

    With that comment, I honestly didn’t mean to offend; I was thinking about many of the situtations documented here, where people feel that they were not given good information on what the “indication” for c-section was. Suspected macrosomia and automatic repeat section are not on your list of indicators, but there are many women out there being counseled that they should have a c-section just because they had one before, or because baby is measuring very large, etc. Some of them, later, when they find out that those are not evidence-based indicators, feel lied to. They don’t understand how the evidence, ACOG, etc. could say one thing and their doctor would say another.

    “I think a lot of what is being perceived as lying is a physician using their platform of authority to express their opinion, when another party believes differently. That, my friends, is not lying, its just one of many examples of how people don’t agree on how we should do things. If one physician tells a patient with abdominal pain that he needs an appendectomy, and another says that the appendix is fine, neither is lying. One of them is just wrong. Being wrong isn’t the same as lying.”

    I think this is an excellent point, because it is hard for me to believe (just as it is for you) that hordes of evil obstetricians are lurking with scalpels behind their backs knowingly fabricating statistics to scare their patients with in order to exert a godlike sense of power (off to golf course!) They are giving their professional opinion as to how they think this mom/baby will have the healthiest outcome, and every clinician practices at least slightly differently, because no one has the exact same assemblage of experience, personal biases, differences in training, different readings of the research, etc. etc. That’s just the nature of things. But that does not excuse any healthcare provider, IMHO, from saying “Now, many people in my profession/current practice guidelines/current research evidence don’t agree that [x] is a good indication for [y]. I disagree with them because [personal experience, issues with the research, etc.]. Here is more information about this topic.” Not “You need [y] because [x]! Or you’ll die!”

    A possibly helpful parellel I could draw to this is domperidone for milk supply. I know many lactation consultants who disagree with the FDA’s ban on domperidone and want to give patients the infomed option of ordering it from Canada, particularly if there are concerns about a history of depression (the alternative, Reglan, can cause depressive symptoms). But it’s probably not a good idea, given that it is after all BANNED in this country, to just tell a woman “You need to order domperidone from Canada if you want to get your supply up, because I am very concerned that you could develop severe postpartum depression if you use the alternative.” Instead, a good LC talks about the research behind its lack of availability in this country, the flaws she sees with that research, the risk/benefits of using Reglan, what precautions to take if mom does use Reglan, the process that would be entailed in ordering domperidone, etc. Contrast this with typical consents for Cytotec, which has a black box warning against use for labor induction – I can tell you, at least where I have worked there is no informed consent for Cytotec. I have heard plenty of drs. and midwives say “I think Cytotec is an excellent drug used appropriately and the research and warnings against using it are flawed/don’t apply in certain cases because xyz”. But I have never once heard them say that to a patient, because they have never even discussed what the pill IS with a patient. I hear them say that when defending Cytotec use in outside forums, when criticized.

    …Whew. I hope I’m making myself a little clearer. The issue is not outright lying-through-the-teeth “I know this isn’t true but I’ll tell her anything to convince her”, which I’m sure happens, but rarely. The issue is “I think this, so I’ll present it as gospel”. That’s when people feel lied to.

    • July 28, 2010 at 1:01 pm

      >> The issue is not outright lying-through-the-teeth “I know this isn’t true but I’ll tell her anything to convince her”, which I’m sure happens, but rarely. The issue is “I think this, so I’ll present it as gospel”.

      I agree with you – docs should present it as their opinion based on their training and experience. I try to do that.

      But you do have to understand that not all patients want that. A great number of patients aren’t interested in participatory medicine. Though there are outliers throughout, I think that there is a strong association between educational background and desire to participate in medical / healthcare decision making. People who use the internet tend to be educated, so you’re going to get a relatively biased sample here. I take care of a lot of women who haven’t had a lot of educational opportunities, and a lot of them have trouble making medical decisions for themselves, even when one takes the time and effort to try to explain all the reasons one might choose one thing over another.

      • Jennifer B.
        July 28, 2010 at 7:31 pm

        That’s right… most women just want BIG DADDY to take care of them… riiiiight… it is insulting to say that women aren’t educated enough to make choices.

      • July 29, 2010 at 3:06 pm

        There are huge cultural differences in what various groups want in their relationships with physicians. Your background may make it hard to believe that any woman could act that way, but it is the truth in some cases. I can’t tell you the number of times I’ve tried to educate patients and give them choices and heard the reply “You’re the doctor”. The best any doctor can do is to try to be the doctor that each patient needs.

      • Jennifer B.
        July 29, 2010 at 8:37 pm

        Thanks for your response, I can understand that. I guess I just can’t EVER see putting all my care in anyone else’s hands… no matter what degree they hold. I can’t fathom a woman in America doing that, I guess it does happen.

        I would like to hear your thoughts on my later posts on my experiences with unnecessary cesarean vs. a very necessary one.

        Nicholas Fogelson :
        There are huge cultural differences in what various groups want in their relationships with physicians. Your background may make it hard to believe that any woman could act that way, but it is the truth in some cases. I can’t tell you the number of times I’ve tried to educate patients and give them choices and heard the reply “You’re the doctor”. The best any doctor can do is to try to be the doctor that each patient needs.

      • July 30, 2010 at 11:45 am

        And I have worked with a lot of those patients myself. But I feel like it becomes an easy excuse for care providers (and I don’t except myself from this temptation) making a snap judgment about a woman’s educational/cultural background and giving her only the information they assume she wants. Or getting impatient because 99 patients shrug and say “You’re the doctor” and don’t

      • July 30, 2010 at 11:52 am

        And I have worked with a lot of those patients myself. But I feel like it becomes an easy excuse for care providers (and I don’t except myself from this temptation) making a snap judgment about a woman’s educational/cultural background and giving her only the information they assume she wants. Or getting impatient because 99 patients in a row shrug and say “You’re the doctor” and the 100th comes in and asks for more information when making a decision.

        And really, the examples we’re discussing of women upset about their c-section counseling are not of women who didn’t want participatory medicine (although they deserved honest information and options counseling whether or not they were interested in using it). It’s about women who DID want it, thought they were getting it, and found out that wasn’t the case; or wanted it and were belittled and/or ignored.

      • July 30, 2010 at 2:02 pm

        Absolutely. The default should be education and choice, but we can’t force that down somebody’s throat if that’s not what they want.

  54. CountryMidwife
    July 28, 2010 at 11:14 am

    But is that lying? Its a physician explaining the risks and benefits as they see it, given their experience and training.

    For example, I have collected current VBAC consent forms from three area hospitals. NOT ONE lists “increased risk of complication in future pregnancies and deliveries due to abnormal placental growth or location” on it. Not a single woman I know is counseled about this. But you know as well as I do that every OB knows that information is true and correct.

    • July 28, 2010 at 12:30 pm

      You’re right. That data should be included, as it is a known long term risk.

  55. CountryMidwife
    July 28, 2010 at 11:21 am

    Of course if you think that a policy of watchful waiting is inappropriate for breast lumps and mammogram abnormalities, considering that most biopsies are unnecessary, why would you think a policy of watchful waiting is appropriate for C-sections simply because many of them are unnecessary in retrospect?

    But that is the very nature of public health, is it not? The good of the many exceeds the value of the good of the few. Clearly gray zones exist and expertise and evidence guide us in appropriate use of technology and intervention. But realistically if almost 32% of ALL women having clinical breast exams, for example, had breast biopsies, yes, I think both you and the general public would object.

    • July 28, 2010 at 11:26 am

      “But realistically if almost 32% of ALL women having clinical breast exams, for example, had breast biopsies, yes, I think both you and the general public would object.”

      100% of women who have abnormalities on exam or a mammogram have biopsies. That’s the equivalent of 100% of women with any indication for C-section being persuaded to have a C-section.

      You can’t have it both ways. If it is acceptable to do lots of breast biopsies that were unnecessary in retrospect, why isn’t acceptable to do lots of C-sections that were unnecessary in retrospect?

      • Aria
        July 28, 2010 at 11:40 am

        A biopsy isn’t a major surgery cutting the body wide open, cutting through many muscles, then cutting through a major organ.

        Tell, me, Amy, if you had to make the decision right now, and it would be written into law, would you require that all babies be born via c-section since you see it as nothing more than a minor form of preventative medicine?

      • Washi
        July 29, 2010 at 1:51 pm

        “100% of women who have abnormalities on exam or a mammogram have biopsies”

        Really? Sorry, no. First hand experience, that’s a lie.

      • July 29, 2010 at 3:02 pm

        Is it a lie, or is it just wrong? I’d say the latter.

  56. July 28, 2010 at 11:42 am

    “A biopsy isn’t a major surgery cutting the body wide open, cutting through many muscles, then cutting through a major organ.”

    You don’t cut through any muscles in a C-section.

    • Aria
      July 28, 2010 at 11:49 am

      Only for women who qualify for a certain type of incision. If you don’t know that there are incisions that do cut through muscles, you are definitely not a doctor qualified to talk on the subject. The type of incision they wanted to do on me was going to cut through many muscles.

      But you’re avoiding answering my question. If c-sections are such safe “preventative medicine,” if you have to make a call right now, would you make it a law that c-sections are the default childbirth method?

      • July 28, 2010 at 12:29 pm

        Yeah… – you’re just not right here. Its fascinating how a non-surgeon who has never done a surgery thinks she knows a surgery better than someone who has done it hundreds of times. Blows my mind.

        Cesareans are done via two incisions, either low transverse or vertical. Both approaches separate the rectus abdominus muscles. Neither cuts the muscles.

      • Aria
        July 28, 2010 at 12:34 pm

        The OB/YN I had went over the plan for me in detail, which included cutting muscles. Or are you going to claim to know my medical history and what the OB/GYN I had said?

        You aren’t refuting that c-sections cut through a major organ. Yeah, let’s prevent the possibility of surgery by just doing it.

        About about you, Mr. Foglson? If given the decision right now, since you think c-sections are such mild surgeries and are mild preventative medicine, if you could make c-sections the default delivery method, would you? If not, why now?

      • Aria
        July 28, 2010 at 12:35 pm

        Also you are displaying a major part of the problem, doctors who pull the “I’m a doctor and you’re not” card to try making others feel stupid. Well, it’s not working. It’s showing that you’re conceited and have let some letters after your name go to your head. You do not always know best, yet think you do. This is dangerous. You are a danger to your patients.

      • July 28, 2010 at 12:48 pm

        Honestly I think you must have misunderstood. There is no cesarean approach that cuts any muscles.

      • July 28, 2010 at 12:49 pm

        As I mentioned in my post, I think the cesarean rate is a big problem. I certainly wouldn’t support a widespread policy of cesarean deliveries.

      • Aria
        July 28, 2010 at 6:27 pm

        Listen, asshole, you weren’t in the room. I was concerned about my muscles being cut when they’d been cut before. She said they would be again. So unless you were there, you need so shut your stupid mouth and stop presuming to know all.

      • July 29, 2010 at 1:45 am

        New one on me then. I suppose if you’re referring to cutting through the uterus as cutting through muscle.

    • July 28, 2010 at 3:16 pm

      “Yeah… – you’re just not right here. Its fascinating how a non-surgeon who has never done a surgery thinks she knows a surgery better than someone who has done it hundreds of times. Blows my mind.”

      – Blows my mind that obstetricians who have never actually attended a homebirth (or a physiological birth) think they know birth better than someone who had done it hundreds of time.

      • July 29, 2010 at 1:50 am

        When did I say I know better? Everybody has a right to their own opinion.

    • Washi
      July 29, 2010 at 4:30 pm

      People who make up statistics to suit their own side of an argument and present them as facts are liars in my book. You give her too much credit. :)

    • July 3, 2011 at 4:33 pm

      Amy Tuteur, MD :

      You don’t cut through any muscles in a C-section.

      Um, excuse me, “Dr” Amy, who went to Harvard… the uterus IS a MUSCLE, more specifically smooth muscle known as the myometrium.

      • July 6, 2011 at 1:56 am

        Yes… and there is smooth muscle everywhere as well, so you could say that if you cut through the bowel you are cutting through muscle as well….

        I think its pretty standard when people saying “they cut through the muscles” they are referring to striated muscles that are under somatic (conscious) control.

        In the standard approach, there are no muscles that we use to control our body cut through in a cesarean delivery.

  57. CountryMidwife
    July 28, 2010 at 11:48 am

    Retrospective “indication” is the unreliable part. We are talking about 100% of people with a condition having a 32% chance of intervention. 100% of pregnant women have a 32% chance of a c/section. 100% of women who have clinically examined breasts do not have a 32% chance of biopsy. “Palpable lump” is a heck of a lot more reliable than “suspected macrosomia”, in example.

    • Aria
      July 28, 2010 at 11:59 am

      These “do no harm” doctors don’t understand this. They are trying very hard to skew things.

  58. Allison
    July 28, 2010 at 12:06 pm

    What a great thread. Very nice hearing from MDs for a change – I am a doc but spelled with a Ph :) I wish more MDs would more seriously consider all sides of this discussion.

    I think the rates of un-indicated INDUCTION need to be addressed BIG time!!! Progress in this area is coming SOOO slowly, it seems. Out of the maybe ~100 inductions I have second-hand knowledge of (from talking in detail with a few OBs, L&D nurses, friends and family) and the one I witnessed personally (my mother) – I do feel MOST women are NOT allowed INFORMED consent on being induced. Most I know WERE “bullied” into it by 40 weeks. Even the very nicest doctors and nurses have some bias towards early induction for no evidence-based reason. These women were NEVER told how often (statistically) the induction actually resulted in a rapid, uncomplicated vaginal labor – and NEVER told how many times more often the induced patients got c-sections over those not induced. WHY on earth would a healthy mom with a normal, healthy baby at ~40 weeks gestation be ENCOURAGED heavily once or twice a week by her Dr to be induced just to “speed things up”?? It really gets my blood boiling… I have heard (can you tell me if it’s true) that hospitals/practices waiting until at least 41 weeks to induce a healthy mom/baby have drastically lower c-section rates? Let’s get the word out!!!

    I think the emphasis here should definitely be on informing patients FULLY of the likely outcomes of these decisions. I have talked with SO many women (friends and acquaintances) who were planning to be induced until I mentioned that there was an increased risk of c-section. “Really? My OB never mentioned that!” Granted, most of them never ask, and some of them ask for the procedure to start with, but either way it is the OBs JOB and RESPONSIBILITY to inform them of the most likely outcomes of the procedure before allowing them to consent.

    I do see other factors that are likely contributing to c-section rates besides induction. BUT – to Dr. Fogelson – does evidence now show with good certainty that early induction (that is, induction which is NOT medically INDICATED) is a cause of increased c-section rates? If so, then more hospitals and doctors (and the ACOG) claiming that they want to lower the c-section rate need to SERIOUSLY start DOING something about it!!! Especially because (in my widely varied experiences) it is almost always the OB who recommends the induction that is NOT INDICATED, and perhaps even CONTRA indicated due to the evidence of increased risk.

    That said, I went into labor spontaneously at ~42.5 weeks gestation (according to my OB) and had a very healthy 9 lb. 7 oz. baby at home. I do wish he had come earlier…but glad I waited :)

  59. July 28, 2010 at 12:37 pm

    Aly :

    “There’s actually a great deal of talk about reducing cesarean rates in the obstetrical literature, particularly in the editorials. OBs realize that this is a problem, and some are really trying to improve the situation.”

    Is it possible that academic ob/gyns such as yourself and non researchers view the subject differently?

    There’s a wide variety of practice patterns, which doesn’t necessarily track along with academic / non-academic practice locale. No question that some are more concerned with the cesarean rate than others. I think docs who cover the office while covering labor and delivery are less likely to make efforts to reduce cesarean rates than those who are solely responsible for labor and delivery.

  60. CountryMidwife
    July 28, 2010 at 1:49 pm

    I totally agree. And a great reason for 24/7 midwife coverage and OBs mostly doing surgery, your expertise. Why do you feel there is such national OB resistance to 80-90ish percent of women being attended by midwives and 10-20 percent risked out to OBs? Because there are too many OBs. I still don’t get why an OB wants to do a normal, vaginal delivery. It’s like calling a brain surgeon for a headache. If there is one saving grace to the (dreadful) malpractice crisis – it’s that we’re likely to have fewer OBs in the future. In this day and age, I honestly think it’s the only answer to the problem.

    • July 28, 2010 at 1:53 pm

      Here’s something that will blow your mind. In academic circles, sometimes the MFMs imply that it is only they that have the qualifications to manage pregnancies, and that us simple OB/GYNs don’t have the chops. We’re all good friends so it goes up an back, but that sentiment is in there sometimes. Suddenly an OB/GYN is only good enough to take care of a low risk pregnancy, and it takes an MFM to manage chronic hypertension, gestational diabetes, or pre-eclampsia.

    • July 28, 2010 at 1:54 pm

      >> If there is one saving grace to the (dreadful) malpractice crisis – it’s that we’re likely to have fewer OBs in the future. In this day and age, I honestly think it’s the only answer to the problem.

      Don’t be so quick in looking forward to that day. If that happens the lawsuits will starting hitting the midwives.

  61. CountryMidwife
    July 28, 2010 at 2:00 pm

    I feel you. One of my recent frustrations is that when I consult my group of collaborating physicians for ANYTHING – they say, send them to MFM. Period, end of discussion. I care for a 75% Plain, self-pay families and a single MFM visit with ultrasound is $1100 and so few will go, and we’re left with no advice or guidance. Your comment helps me realize that they’ve been disempowered to this point. But I also know my friend, who sees their group, was referred to MFM for a “family history of incompetent cervix”. She is a primip who has an aunt who had a preemie baby and this is the result of that disclosure on intake!!! The whole thing is ridiculous. Hyperthyroid – send to MFM! AFI of 24 – send to MFM! Placenta 2.5 cm from cervical os? Send to MFM! I do have to wonder – is the OB becoming redundant? Are midwives and perinatologists the proper model? Perhaps fodder for another post…

  62. CountryMidwife
    July 28, 2010 at 2:05 pm

    I don’t look forward to that day! Perinatologists work 100% from a liability perspective and can’t care for their clients rationally because of it. Hence a recent client with an afi of 9-11 throughout her pregnancy who had *22* WEEKLY MFM visits and ultrasounds and decided on no more testing and an out of hospital birth specifically in reaction to this over reaction. I have to think she had good insurance. By the way, they never once counseled her to stop drinking 3L of Pepsi and start drinking more water.

    • Lucia
      July 29, 2010 at 1:09 pm

      I disagree, My own MFM stayed constantly positive even though I knew my risks with identical twins and I felt compelled be ready in case they showed signs of twin to twin transfusion. She stayed ever optimistic that it wouldn’t happen. She specialized in gestational diabetes and although I had it with my first I did not have it with my twins and she was incredibly impressed at how well I was handling my blood sugars with diet and excersize. When my blood pressure started skyrocketing she immediately transferred me to my Midwife’s care because she knew how much I desired a vaginal birth and if I stayed at her hospital she would have been forced to section me then and there. At least at the other hospital I’d have a chance of vaginal delivery. I absolutely respect MFM and the work they do and I don’t think they’re all in freak out mode all the time.

      • August 5, 2010 at 6:49 am

        Lucia, I had twins with TTTS & a vaginal birth. <3 to you.

  63. July 28, 2010 at 2:15 pm

    Aria :
    The Farm does NOT have a death rate of 1 our of every 100 babies. They would be shut down so fast and likely charged with murder if that were the case. Multiple studies have shown that, factoring outI glad did).

    Read the study. That’s exactly what it shows.

    • Lucia
      July 29, 2010 at 1:42 pm

      Could we have a link. I’d hate to be thought of an uneducated natural child birther. My understanding of the the farm’s mortality rates were mostly as a result of congenital abnormalities that would have resulted in death no matter the method of birth nor the location. I know one was an anencephalic baby. There’s no good outcome with that situation. In this time screening would have most likely lead to termination but in the 70’s there weren’t routine ultrasounds that I know of. I’m curious to see if the compared apples to apples.

      • July 30, 2010 at 8:08 am

        “My understanding of the the farm’s mortality rates were mostly as a result of congenital abnormalities that would have resulted in death no matter the method of birth nor the location”

        And the hospital neonatal mortality is mostly the result of congenital anomalies. Nonetheless, the Farm’s neonatal mortality was triple that of comparable risk hospital births. You can read the entire paper on Ina May’s website.

      • Melissa
        July 30, 2010 at 9:57 am

        If both groups show infant mortality as “mostly the result of congenital anomalies” then shouldn’t they be statistically similar? And if not, then wouldn’t you just be proving that The Farm had a higher population of babies with congenital anomalies and not actual deaths attributed to delivery method. Hmmmm…maybe this is peaches & prunes…LOL

      • July 30, 2010 at 10:26 am

        “If both groups show infant mortality as “mostly the result of congenital anomalies” then shouldn’t they be statistically similar?”

        No, of course not. There were excess deaths in the Farm group, deaths that were related to anomalies not incompatible with life, and deaths from entirely preventable causes. Read the paper.

      • Melissa
        July 31, 2010 at 4:07 am

        Here is the link to the Farm study.

        http://www.thefarm.org/charities/mid.html

        Out of 1707 births on the Farm, there were 0 maternal deaths & 17 infant deaths…6 of which were due to congenital anomalies, 4 due to complications related to prematurity, 2 due to death in utero before onset of labor, and 1 each: due to neonatal sepsis, abruption, respitory distress, cord prolapse, and suspected child abuse (not sure how that last one is attributed to the Farm). Anyways…this adds up to 1% as compared to a hospital rate of 1.33%. I don’t see how those numbers would be considered high, especially as most of those deaths could also occur in the hospital and are not related to delivery method. You also have to keep in mind that these births occured between 1971 & 1989…this is not recent research, but a retrospective study.

      • July 3, 2011 at 4:42 pm

        Can we please stay on the topic of indicated vs. not indicated cesarean section.

        Leave it to “Dr” Amy to skew this lively discussion towards her agenda to discredit home birth. Go back to YOUR blog, Amy,
        OR stay on the topic.

  64. July 28, 2010 at 3:14 pm

    I think it’s just a lot of semantics. If the section could have been avoided by a handful of variables…then a section was done unnecessarily…b/c someone somehwere didn’t have the forethought/patience/whatever you want to call it to decide to let the labor continue. I was *told* my baby was dying. That *I* was dying. I didn’t feel like I was dying, but then, I’d never died before…so what did I know? I trusted my doctor’s expertise enough to think that he wanted what was best for me. Not that he wanted to get me delivered before the weekend (yeah, I said it). My doc had been pushing for a section since about 5 a.m., my daughter was eventually delivered that way at noon. I left the doctor’s practice b/c he would not continue to care for me after I voluntarily cut off my insurance. I had the money to cover well-care, but he said that I would have to find another doc. Three years later (when I had insurance again) I wanted another type of care for my newest pregnancy, and had to get a copy of the operative report. The operative report gave all the stats of myself & my baby just before the surgery. I checked with a friend of mine (Nurse Practitioner) b/c I was curious what some of the info meant. She deciphered the details and said, “…elective cesarean after failure to progress…” Seems to me like I unnecessarily had a section. I wasn’t dying, my baby wasn’t dying…my doctor didn’t want to wait on me to labor through the weekend. Awesome.

    • July 28, 2010 at 4:27 pm

      Sounds like the indication of non-reasurring fetal status wasn’t there. I’m sorry that happened to you. I teach my residents to not use the term ‘failure to progress’ as it doesn’t really mean anything specific. It encompasses legitimate indications for cesarean, but in many cases is just a slow labor.

      • July 29, 2010 at 12:32 pm

        Yes, I have discovered it just takes me a long time to have a baby. And I am okay with that. I just wish my care providers were okay with that. B/c of the less than helpful attitudes I have received when trying to wait on things, I have decided if/when husband and I have another child, I will simply go unassisted. I can’t handle the pressure of being told I’m laboring too long, or that I will need to be restrained to keep me in bed. My husband is a combat medic…he’s seen it all, I’m sure handling a delivery will be a nice break for him. I just wish I didn’t feel like I was being forced into doing it with so little professional help.

  65. Stephanie R
    July 28, 2010 at 4:51 pm

    Stephanie R :
    “you’re pre-preeclamptic”

    Just to clarify, he clearly said “pre-preeclamptic” He did not stutter. I even repeated it back to him to be sure I heard correctly.

  66. Jennifer B.
    July 28, 2010 at 5:50 pm

    I understand that you are saying that AT THE TIME OF THE INCISION a doc thinks it is necessary… I respectfully submit that when “recommending” cesarean at 38 weeks to a generally healthy primigravida at 5 months who’s only health concern was that PRIOR TO PREGNANCY she suffered from seizures and that she is currently obese, is simply and blatantly a cover-your-ass maneuver NOT a medically indicated cesarean. Especially when said “recommendations” come with threats of a dead baby if not complied with because, and I quote: “YOU ARE TOO FAT TO DELIVER VAGINALLY”

    Further, there is substantial medical evidence that obesity doesn’t cause any problems with delivery itself, although lifestyle choices that contributed to obesity may cause problems like hypertension, pre-eclampsia, gestational diabetes, macrosomia and other pregnancy concerns… NONE OF WHICH I HAD. These lifestyle choices can cause similar issues in non-obese women. I did begin having hypothyroidism, but was well managed.

    Finally, weighing the risks of major abdominal surgery on an obese person, which I am certain you are aware carries more extreme risks to the mother – including increased risk of infection, heart and kidney failure, need for more anesthesia which carries it’s own risk, blood loss, etc… – against “allowing” her to come to full term and have a vaginal delivery which carries minimal risk to a person in my situation as outlined, and you have created a situation where, without further indication, you are looking at a VERY unnecessary cesarean.

    Perhaps you would like to consider reading http://myobsaidwhat.com/ and looking at the experiences of the women there before making such sweeping statements.

    I did end up having a cesarean because, after firing that first doctor, I ended up with a doc who didn’t get all my records from the previous doctor. Because of my weight, with no other indication – in fact with COUNTER EVIDENCE by testing done BY HIM, he wrote in my chart that I was gestational diabetic and pre-eclamptic, and that a LATE ultrasound showed a macrosomic baby (13 lbs it said). Then he went on vacation and left me with a Dr. on call who refused to listen to me when I told her I was NOT suffering from those conditions… because I am fat, I MUST have those conditions. She insisted on inducing my early labor and then when she came to break my water to “speed things along” baby wasn’t engaged… et voila… cesarean. And of course if we don’t have a cesarean RIGHT NOW, baby will die from cord prolapse… My PERFECT APAGAR 9lb baby was born at 4:12pm… just in time for shift change.

    • Jennifer B.
      July 28, 2010 at 5:59 pm

      Conversely, there ARE very necessary cesareans. My daughter was born by cesarean four months ago because, after working toward a VBAC with a VERY AMAZING doctor, the placenta failed. Shown on ultrasound as completely calcified, and 5 days later when the cesarean was preformed, almost completely detached. VERY NECESSARY.

      Believe me, I can tell the difference.

      • Lucia
        July 29, 2010 at 12:59 pm

        Agreed. I was in a similar situation with my first, although the ultrasound showed a perfectly normal placenta and he was very active. When the placenta finally came it was completely white and purple. The converse is the mother who’s placenta is completely calcified according to the ultrasound and it comes out red and healthy. I suspect your baby gave some other warning of distress warranting a c-section. My very nessisary cesarean was for monozygotic twins in a breech vertex presentation and my own mild pre-eclampsia. Ironically I felt more violated with my induction there I did with my c-section. There is alot to be said for bedside manner and respecting the patient’s wishes. I felt my OB did everything to ignore every one of my requests right down to mutilating my genitals with episiotomy and attempting to use forceps on my son which I had previously told her she was not to do. She never even considered a vacuum which is what I requested at the time. My midwives, OB and MFM all did EVERYTHING in their power to ensure I could have vaginal delivery with my twins and in the end, even faced with my skyrocketing blood pressure they told me their recommendation and left the decision to me. No lies no schedule just true concern for their patients. I think far less women would feel violated if Drs were honest and truely did what they could to respect the mother’s wishes AND did what was best for the mother and baby’s safety. I think too many women feel that they cannot trust the medical profession, esp among the homebirth natural birth crowd. I know I certainly am skeptical of Drs and of medicine in general as a result of my own traumatic experiences.

  67. Shawn B.
    July 28, 2010 at 6:47 pm

    As my wife stated we have had one that was unnecessary and one necessary section. The fact that a doctor SAYS that what they are doing is necessary but that doesn’t mean it is law. Not everything has to be done the fast way so you can do your thing. Yes, you might have spent all those extra hours in school doesn’t mean you should scar people’s births just to get rich quick. Sections should only be done if EITHER the mother and/or the unborn child(ren) lives are in actual danger. A possible problem isn’t good enough. The hard facts need to point to a definite problem. If mother and baby are both all right then there shouldn’t be a problem with going on and trying a vaginal birth. If baby get distressed ON IT’s OWN…meaning no pit to distress. There are very good OB’s out there. They are very far and in-between but the rest can learn from them by screwing their heads on straight and give women a chance. They deserve it!

    • July 29, 2010 at 1:53 am

      We get paid the same to do a cesarean as a vaginal delivery in most cases. Maybe $100 difference with some insurers. Not enough to influence decision making in any case.

      • Lucia
        July 29, 2010 at 12:41 pm

        You must be getting short changed! My insurance was charged $15,000 for my first son’s induction with epidural, $60,000 for my twins c-section and $7,000 for my youngest son’s un-medicated vbac. At least this is what I received in the bills sent from the hospitals. I’m sure it varies state to state, insurance to insurance but the same payment is not a universal and some Drs do have motivation.

      • July 29, 2010 at 3:01 pm

        Unfortunately for us, what is charged has _nothing_ to do with what is paid. The contracts that insurers and hospitals are hugely complex, but believe me that the insurers pay what they want, with complete disregard to what is charged.

        The level of service does effect payment, though, and the insurer probably does reimburse the hospital more for a cesarean than a vaginal delivery, as there are more costs involved. This pay differential does not carry through to the physician – so yes we are getting short changed. Happens all the time.

  68. Alayna
    July 28, 2010 at 7:17 pm

    Once there was a woman who was happy and excited.  Someone came to her and convinced her, against her better judgement, to follow them. They led her to a dark room and the torture began. They shoved things into her urethra, they shoved hands into her vagina and she felt them scratch her insides.  She cried and begged them to stop. They laughed.  She was cold and not allowed to eat. She had to urinate on herself.  After 26 hours they took her to another room where they drugged her so she couldn’t move but felt pain.  One of them took a knife and sliced her open.  She could feel everything.  She could feel their hand inside of her body and the pain overwhelmed her.  If felt as if she were on fire.  Nobody cared. Her lungs started to gurgle and she couldn’t breath.  She coughed and she was yelled at.  Nobody cared.  Finally darkness consumed her.

    Hmmm. The story of a woman tortured by a sick monster or a birth story? Hard to tell the difference…birthrape exists.

    When the doctor tells you that you have preE and low amniotic fluid so your induced which turns into a FTP cesarean and then you get ahold of your medical records and find out your blood pressure, blood work, urine, and amniotic fluid were NORMAL…that’s an unnessecarean.

    • July 29, 2010 at 1:57 am

      An awful image for sure.

      • Alayna
        July 29, 2010 at 3:17 am

        It’s not an awful image. It’s what happend to me. I was treated lie shit by hospital staff, anesthesia awareness, IV fluid overload which caused my intestines and lungs to stop working. I was in a coma for the first three days of my daughters life and can’t ven remember the 4th because I was so drugged. I have PTSD and my marraige is probably over because I can’t forgive my husband for not “letting” me have a homebirth.

        Doctors and hospital staff lie. When they aren’t lying they are bullying.

    • July 29, 2010 at 3:51 am

      I’m sorry that happened to you.

  69. July 29, 2010 at 2:01 am

    I deleted several comments from Aria as they crossed the line from discourse to abuse, even more than some of the comments that are already there.

  70. Augusta
    July 29, 2010 at 2:05 am

    Just a snarky comment for the record. I guess uterine muscles which are cut through during a cesarean don’t count.

    • July 29, 2010 at 2:11 am

      Well it isn’t a striated muscle. Humans don’t have control of what their visceral muscle does. People in the medical community don’t refer to cutting through visceral muscle as “cutting through muscle”. Every organ has some visceral muscle. The entire uterus is visceral muscle.

  71. July 29, 2010 at 2:19 am

    Nicholas Fogelson :
    But is that lying? Its a physician explaining the risks and benefits as they see it, given their experience and training.
    If folks want OBs to look at pregnancy as a completely low risk event that will always go well, maybe they’re being a little unrealistic. Most OBs see risk in pregnancy because they spent four years of residency working with very complicated pregnancies and seeing a lot of bad outcomes. In a lot of ways this biases their view (an mine in some cases.) I agree with Sharon (commented down lower) that a system where midwives work with low risk patients and have OB backup can work very well, and with many patients is preferable to primary OB care.

    While it may not be lying, it is certainly spinning the story by omission. It is not, then, fully informed consent.

    • July 29, 2010 at 3:09 am

      While I can see why you might say that, I would disagree. Its not a lie of omission, its a different perspective. When one explains what one thinks about an issue, and somebody else happens to disagree with that point of view, the first person isn’t lying. There are all kinds of folks out there that want to minimize the dangers of uterine rupture in a VBAC. Many OBs disagree with this. Neither party is lying, they just think differently.

      • July 29, 2010 at 3:36 am

        That’s pretty dicey, man. When you’re going over a risk/benefit analysis with a patient over a proposed procedure, leaving things out because of your “perspective” is underhanded. I would argue that offering ALL the information and THEN your perspective based on your professional history is fine.

        The simplest example I can give is the glossing over that almost every single woman I know has been given over how “simple” a c-section is and that it is not major surgery with very real risks. It’s one thing to sit in front of someone and explain that it is major surgery, there are risks before, during and after, including loss of life for mother and/or baby, but HERE is why I think it is necessary. To the contrary, this conversation *simply doesn’t happen.*

      • July 29, 2010 at 3:45 am

        Obviously I can’t speak for other docs, but in my experience women are always informed that cesareans are major surgeries with real risks, both verbally and in writing. As for what every doc in the country does, it will certainly vary.

  72. Vanessa
    July 29, 2010 at 3:14 am

    “It just means that the risk/benefit of pursuing vaginal delivery is no longer in favor of it, to the best of our knowledge.”

    Have you read ANY recent studies on the risks of cesarean? This excuse is absolutely bogus in most cases. Considering the 50% increase risk of maternal and/or infant mortality in a cesarean, it’s stupid and silly to use this excuse instead of trying a vaginal delivery first in MOST of these cases.

    Seriously, as you call yourself a professional, I challenge you to actually sit down and look at the risks of each possible route in delivery. The risk of a uterine rupture during a VBAC is LESS than 1%, and that very rarely means life or death for the mother or infant. Even the National OBGYN board has changed it’s official position on VBACs. Please continue to go down the list of each “indication” of a cesarean and look at the risks. The risk of a cesarean often far outweighs the benefits of a vaginal delivery.

    • July 29, 2010 at 3:22 am

      50% increase in infant mortality in cesarean? Not true at all. Show me the data, controlled for indication for delivery. If you pick mothers that are having cesareans for terrible fetal heart rate tracings, of course you will see a higher infant mortality rate.

      >> The risk of a cesarean often far outweighs the benefits of a vaginal delivery.

      No doubt there.

      >> The risk of uterine rupture during a VBAC is less than 1%..

      Absolutely. Read some earlier posts and you’ll see that I’m quite in support of VBAC. The risk of uterine rupture is very low, but when rupture does occur, the risk to infant and mother are high. This is why some OBs who have managed uterine ruptures have a dim view of VBAC. They have a PTSD of their own to deal with.

  73. July 29, 2010 at 3:21 am

    I, too, fall into the camp of a kinda long-time reader of your blog and someone who has been buoyed by your willingness to engage in discussion and, quite frankly, that you seem like an OB I’d actually stick with if I ever decided to switch from midwifery care. I’m not a frequent commenter. This was the first entry I’ve read of yours that has made me gasp and clutch at my chest in a, Who is this man??!!! kind of way. ;)

    I am totally with you on the idea that words count. Not only WHICH words are used, but that ALL the words count. When words are omitted – as I pointed out above – it leads to one or both parties involved not having the full story. Without the full story, a woman cannot give full and informed consent. It’s that simple. And sure, you could argue that a consumer should be educated and can do her own research – but there are countless docs out there who not only actively encourage their patients to “stay away from the internet,” who roll their eyes when the idea of a doula is broached, and who give the secret hand signal to prep the OR at the first sound of the shuffling of papers called a Birth Plan.

    Add to that that from a very young age, our girls are taught that their bodies are shameful, that they are to be for man’s pleasure, that development in puberty and menstruation are “dirty,” AND SO ON, and already there is a foundation of institutionalized misogyny before she ever needs prenatal care. The majority of American women are NOT sexually empowered, are NOT fully knowledgable about their bodies, do NOT understand the anatomy & physiology of pregnancy. They ARE taught that doctors are experts who ARE to be trusted and NOT to be questioned, and they ARE shown that labor and birth is always a rush, almost always dangerous, and extremely painful.

    When you say that you are offended by the language, doctor, you are saying it from a point of authority as a white, male medical professional. You automatically have the power. Any conversation that you have with a patient BEGINS skewed in your favor. I don’t want to diminish the hard work of unpacking racism, but I believe that this fight is somewhat similar. Aside from FOX News reporters, I would hope that white people don’t cry “race card” and tell someone who is of color that they are not experiencing racism just because the white person doesn’t see it. Similarly, there are things that you are not going to see because you are not a woman, you are not pregnant, and you have been educated within the very system that you are (admirably, if not fully) questioning. Does that make sense? When one blows off the idea of birth rape, when I read the comments on an article written by a woman who suffered PTSD after a traumatic birth calling her a crybaby and a whiner – it is all victim-blaming, and it is disgusting.

    Disclosure: I have never had a cesarean. It is only in retrospect that I see how lucky I was with my births – that I understand now how I advocated for myself and my babies even as I didn’t see it at the time. My oldest = midwife attended in birth center. My youngest = midwife attended in hospital. My middle girls are twins who suffered TTTS in utero. Our first high risk practice wanted to go in and reduce fluid volume by amniocentesis on a weekly basis, starting immediately. The doc practiced at a very well regarded hospital and was highly decorated. His idea of what was indicated – I am fairly certain – would have left me without those babies. I was able to get out of his office without a needle in my belly pretty much by sneaking out.

    Because of his power and his prestige, it was REALLY HARD for me not to believe that what he wanted to do was not the best course of action. He DID tell me to stay off the internet. But the internet is where I found my way to the TTTS foundation and to a whole host of other information and where I was able to get 2nd and 3rd opinions and where I found the practice I switched to – the one that I called and said, “Help me, I have a high risk situation but i’m used to giving birth in a tent in my backyard and making placenta art.” (I was kidding, of course, but they understood what I was going for.) As a result, I did consent to more frequent monitoring – something that parts of the natural community would vilify me for – but they were also willing to work with me to adopt a nutritional plan to see if it would help. IT DID.

    Although they did pressure me when they wanted induction at 34 weeks, they didn’t pull the dead baby card and they were supportive of giving me time to think and research and “ask the babies” and prepare us all for this too-soon upheaval. And THEN, the doc at the induction and delivery was respectful and kind and at one point offered to let me go home and come back the next day. He gave me time to consider AROM after suggesting and explaining it. During the delivery, he would have let Baby B come breech if she had flipped. Maybe this was all because it was done at a teaching hospital, with lots of other people around to witness and learn.

    To the contrary, as a nursing student last year I did my OB rotation at a local hospital that does the birth center transfers. I put out a little “wish” ahead of time “to see what I needed to see,” and to make a long story short, I saw a woman putting full and complete faith in her doctor who was an absolute prick.

    I saw my own ability to change the atmosphere in the labor room from fear to anticipation with simple, soothing words and by teaching her mom to do some light foot massage and by getting the dad involved as well. And then I saw it all shot to hell when the doc – who had already stayed an hour past shift change – came back in, said, “who keeps letting her sit up? you need to be laying down” as he put her bed back down, gave her a vicious internal exam, *jabbed her fundus* as he told her she wasn’t working hard enough and wasn’t strong enough and there was no way this baby was coming out – and then left the room to call the c-section as the family behind him shed tears.

    Later, I discovered that this very same man is the medical director for the freestanding birth center. So my deep down wish that this was an isolated incident is probably not the case.

    The OB nurse I was learning from – with 20+ years experience – said that the birth center clients liked to bring in their birth balls to “extend” the labor for their own benefit, because they like the pain, and that “everyone” knows that if you throw a mom into lithotomy position that the baby “just comes out.”

    This is what we are up against, Dr. Fogelson. These are your colleagues who practice in a major city, where firing LPNs and not hiring RNs without a BSN in favor of earning Magnet designation is more important than the Baby Friendly Initiative, where status and recognition is more important than things like making sure that long-term breastfeeding rates or neonatal health are optimal. Maybe that’s not the case where you are, but I’m pretty sure that things are different state to state by law, let alone by individual practitioner preference.

    Personally, I am not offended by the term Unnecessarian, and that’s not just because I have an intellectual boner for Jill. The reason I support the word is because it gives mothers – laypeople, if you will – a cracked open door. A door for discussion. A door to a safe space, where the doubts and fears they have had, where the pain they experienced – emotional and physical – is recognized, honored, and accepted. The word Unnecessarian may be unnecessary and offensive to you, but like most other doctors, you will always have another patient. There will always be a full appointment book. Many of us don’t know if we will ever have another birth. There are women – lots of women – who would have more children, but know they would be unable to handle the trauma that they’d gone through before.

    I urge you to take some more time to be on the listening end of the conversation. Sneak into the back of a local ICAN meeting. Suggest that your hospital hold a focus group of previous c-section patients. Really open yourself without defense to what women are going through at what is the most vulnerable and transformative time of their lives. Listen to the language that these women use – and I guarantee you, you will have no shortage of participants. I forget who said it – but ask any woman about her births and she will likely be able to provide tiny details you wouldn’t believe. As her what she had for breakfast yesterday and the chance of her remembering is like 40%.

    Thanks again for your work and your writing.

    Be well,
    Kathy

    • July 29, 2010 at 3:41 am

      Kathy – thanks for your comments, and the effort in writing them. I am very interested in what people have to say, which is why I reply to comments.

      But let me ask you this? Is it not ok for the other side to have a different opinion? Throughout many posts I have expressed different opinions than many commenters, yet I rarely have outright attacked others, despite the many personal attacks made towards me.

      There is no doubt that birth in this country has some problems. We do too many cesareans. We have created a system where a big percentage of labors are induced, which is not in the best interest of mother and baby. In some cases, OBs are not completely respectful of a woman’s desires of how she wants to labor. The system as a whole is not very supportive of women who want to birth in other environments, which is a problem.

      As a single doctor, I don’t have a lot of power over this, other than to try to practice the best I can and influence some younger doctors to do the same.

      I’m not offended by the term “Unnecessarean”. I do, however, think it does nothing to promote the cause that the people who use it want to promote. It does quite the opposite, by instantly offending many of the people you would want to influence. The same goes for a website called “My OB Said What?”, which instantly creates a bias that OBs must say terrible things. I go throught at site from time to time. Some things are pretty crazySome things are inappopriate things to say, and but a lot of things to me seem completely appropriate but misinterpreted, or taken out of context. This doesn’t demonstrate some fundamental defect in obstetrics, it just demonstrates the difficulty in communication between groups of different backgrounds. Heck, we’re arguing above about whether a cesarean cuts through muscle, and apparently to Aria thought that cutting through the uterus counted counts as cutting through a muscle. Depends on how you look at it – difficulties in communication.

      The same goes for the entire basis of this post – Does one care about the language, or just the underlying message? No where in my post did I say that all cesareans are justified, only that I would love to see different language used.

      Thanks for your comments

  74. July 29, 2010 at 4:20 am

    I am with you on this: I don’t believe that attacking the person whose mind you hope to change will ever help to change it. Putting someone on the defensive only serves to help them figure out a stronger defense.

    And I understand what you’re saying about loving to see different language used, but it’s almost like the music theory professor I had early on in college who had perfect pitch and was a composer – she simply couldn’t break it down for us to the building blocks of music theory. She was so steeped in a higher level of thinking and of speaking that she was perplexed when we just didn’t “get it.”

    My own interpretation of “Unnecessarian” isn’t the language I use if I’m talking to medical folk or writing a letter advocating change. But for women who are lost, who are hurting, and who have genuine difficulties forming an attachment with their child because of their own trauma and/or unnecessary separation from their newborn, the word, again, offers that open door to discussion. And it also offers a call to action to those who find themselves on the shorter, more disempowered end of the stick after what very well could have been a non-indicated surgery. Keep using medical terms with these women and you will continue to alienate them and make them feel like their pain isn’t valid.

    I don’t know. It sucks pretty hard to be put into a place of fearing that you’ll kill your baby if you (don’t induce, want a VBAC, don’t monitor every second of labor, go past your due date) and it sucks even worse to realize after the cytotec + cervadil on an unripe cervix, after pitocin, after an epidural, after sucking on sponges, after giving up and giving in to surgery you never wanted to hear that if only you’d made different choices along the way that there could have been different outcomes. I don’t mind giving someone who has been through all that a word like unnecessarian as a tool to work through it all, and if it gives her the power to speak up and the ability to change the direction of the conversation she has during her next pregnancy, then its job has been done.

    You know, I just went to the trouble of actually going to theunnecessarian.com and in her info page, she states: “The Unnecesarean is a patient advocacy Web site that pulls back the curtain on the practice of prophylactic cesarean surgery for suspected fetal macrosomia and illuminates the experiences of women who have been harmed by the aggressive practice of defensive medicine. The site provides information about preventing an unnecessary cesarean and resources for making fully-informed decisions about childbirth while offering an irreverent take on the maternity care crisis in the United States and beyond.

    The most recently released data from the CDC on childbirth showed that 32.3 percent of U.S. babies in 2008 were born by surgery. This is the twelfth year in a row that the rate has risen. Rates of severe maternal morbidity have increased, yet maternal and infant mortality have not seen a decline with the aggressive use of this life saving surgery. ”

    Obviously, the word has taken on a life of its own, and even the site itself is no longer simply talking about suspected macrosomia. But how wonderful! How wonderful that now we are talking about induction prior to 39 weeks often being dangerous, unnecessary, and not indicated! How wonderful that more people are talking about the links between intervention and managing labor leading to cesareans that could have been avoided! How wonderful that we are becoming aware! How wonderful it will be if we can move to a place where birth is honored and celebrated, and not treated as a procedure!

    Am I too glass-half-full? I think there’s a lot of opportunity in the word for the medical community to perk up their ears and take heed. My husband is in advertising. Brand management. Social media & the easy accessibility to information are in the consumer’s favor, and medicine has become a commodity. Your consumers are speaking to you, you know?

    • July 29, 2010 at 4:38 am

      >> “non-indicated surgery”. Keep using medical terms with these women and you will continue to alienate them and make them feel like their pain isn’t valid.

      Thats probably true.

  75. July 29, 2010 at 4:37 am

    Thanks again for the good discourse. I truly think that to achieve these changes there needs to be some fundamental changes in the way obstetrics is practiced, or a big move towards combined midwife/ob care. A lot of OB practices are moving towards using OB hospitalists that do not have any responsibilities outside of the hospital, which over time could have a substantial impact on cesarean rates. The downside of course is that the doc you work with throughout the pregnancy isn’t the one to be there for the delivery. Midwifery is again a good way to address this, in good collaboration with OBs.

    A lot of OBs do care about this. I just saw one in an interview with John Stossel talking about how many unindicated cesareans are performed. Sadly, some do not, or allow other pressures to be more important that this issue. Believe me, there are a whole lot of pressures involved, from malpractice, to office conflicts, to hospital administration and risk management, etc…

    A great deal of the problem is not on the doctor side. _many_ patients request induction of labor, or even outright cesarean. Even after being counseled that elective induction increases their risk of cesarean, they still want that. It depends very much on the patient/client population one is working with. I have very few patients that want to VBAC, despite what I would characterize as a very pro-VBAC informed consent process. Many feel scared of labor, and don’t have the support they need. Often their mother influences them against a VBAC. A lot of it is cultural differences.

    • July 29, 2010 at 4:44 am

      No, thank YOU. I’m not sure what it says about me that this has been a welcome diversion from breaking up fights, switching the laundry, and figuring out why my new cell service bill is so damn high.

  76. July 29, 2010 at 4:38 am

    Amy Tuteur, MD :
    “I was wondering when you de-lurk”
    I was following the thread but didn’t have anything to add until my comment about biopsies. What NCB advocates fail to grasp is that C-sections are preventive care and it is the nature of preventive care for the majority of it to be unnecessary in retrospect.
    Preventive care exists to prevent bad outcomes whether those outcomes are colon cancer, heart attacks or neonatal deaths. The overwhelming majority of colonoscopies are unnecessary, most people who undertake steps to prevent a heart attack would not have had one anyway, and most C-section do not save babies’ or mothers’ lives.
    Preventive care is not defective or unnecessary just because we find out later that it wasn’t needed. People seem to understand that reasoning when it comes to colonoscopy, mammography, lowering blood pressure, etc., but when it comes to C-sections, some people fail to understand that the reasoning is the same.

    My wicked google skills are failing to find me information that backs up cesareans being considered preventative care. Honestly, you just blew my mind with that idea. If you have anywhere you could point me to that continues that line of thinking, I’d greatly appreciate it.

  77. Abbey
    July 29, 2010 at 4:47 am

    I have given the term “unnecesarean” a lot of thought and arrived at the same conclusion that you did. How do I know that my cesarean was unnecessary? I don’t, I can never know. That’s what happens when you make a decision, you can only know the effect of that decision, not the others.

    What I do know is that the way I was treated after I arrived at the hospital was unnecessary. I wanted to get up and walk around during labor. I was hurried to back to bed anytime I tried to get up. If I tried to discuss anything about my care in the beginning, the risks were trivialized and they simply wouldn’t take no for an answer. I eventually just decided that my best option in this situation was to lie quietly in bed. Being ignored was a better option than trying to seek the “help” of those who I had entrusted my care to.

    Later the doctor came in and looked at my ticker tape and told me that my contractions weren’t strong enough. I tried to tell her how they felt and that I wanted to get up, but she just cut me off and walked out.

    After I had been there for 9 hours, the doctor broke my water and shortly after told me that I could get up and walk around if she installed an internal fetal monitor. She also told me that she might put in on my son’s eye and blind him for life. At this point, I didn’t trust these people. They didn’t care about me or my son or doing their job well. I didn’t want their involvement. I didn’t want to give them permission to permanently disfigure my son when they wouldn’t even care if it happened.

    So they continued on the same course. More pitocin, and ignore. The doctor came in and told me that my contractions weren’t strong enough and that she was going to turn up the pitocin. I told her not to. She just walked over to the machine and punched the buttons while I quietly pleaded for her not to and then walked out.

    Later they wheeled me in for a cesarean. I asked the doctor if everything was going to be okay and her immediate reaction was to say yes. Once they were loading my body onto the table the doctor looked at me said, “You know outside when I said things would be okay? That’s not true, you could die. Did you understand the papers that you signed.” I started crying rather forcefully and a nurse rolled her eyes at me and told me to stop crying. Then the doctor and nurses that didn’t care if I was sad, scared, human, alive or dead, continued to talk and laugh and ignore me while they held my life completely in their hands with my completely present consciousness.

    I understand that you want to believe that doctors want to have an “intelligent discussion” with their patients. I understand that you want to believe that a doctor would never lie to a patient. I understand that you believe that doctors have the patients best interest at heart when they make their decisions. I understand that you want to believe that a doctor would not do harm. The patients want to believe this too, but our experience has taught us differently. Some doctors are selfish, some doctors make their decisions based on what they believe they can teach an ignorant jury (including that if you or your baby die in surgery there was nothing more that they would do, which is true, so they push for surgery), some doctors are cruel. Defending the actions of these doctors and trivializing the pain, suffering and life shattering effects that patients on here try to share does not help the conversation that you say you want to have. Doctors are people and people aren’t perfect. The problem is that some doctors have been taught and that some doctors believe that humanity has no place in what they do and this is the part that is the unnecessary and devastating part.

    Did I have an unnecesarean? I did. The way I was treated was cruel and unnecessary. Does that mean that there wasn’t mechanical failure on my part caused either by my treatment or unknown causes? No, by the time I needed surgery, I needed surgery. The problem is that I am not a machine so the term “mechanical failure” should not apply to me. The way I was treated was unnecessary. I had an unnecesarean.

  78. July 29, 2010 at 6:55 am

    I love arguing semantics. Perhaps that’s perverse, but I’m not so sure you knew what you were getting into when you wrote this post.

    I absolutely believe I had an unnecessarean. And while I can rail against the OB who performed the surgery as much as I like, it was actually a midwife who started my journey in that direction. Playing the blame game and the guessing game are, however, not productive at this juncture.

    What is productive is discerning the reason behind your dislike of–and denial of–the term.

    I understand that you’re tired of hearing about it, especially when referred to in terms like birth rape and various other terms with obviously negative connotations. It is bad for business, and can certainly be used as a “Scare tactic” for the “other side.” Honestly, I’m tired of it too (though for different reasons). That doesn’t make it untrue. It does make it a sad commentary on the current system.

    One point that I have seen again and again in the comments, which I have not seen any MDs respond to, is that what the OB said and what the medical records contained are often at odds. Personally, I have not requested my medical records yet, and will not until I have someone with the know-how to read them available to me, but those who I’ve spoken with have seen serious discrepancies. So then, is the OB lying? Or the documentation?

    And to get back to semantics, I think you’ve riled up many of these commenters by calling unnecessary (or unindicated, if you prefer) cesareans a “myth.” The word myth denotes fantasy, something false and untrue. It connotes that the women using this term aren’t smart enough to tell fact from fiction. What is true, then? Fact = there are more cesareans performed than should be. Fact = some OBs (despite your protests – and note that I say some, not most or all) perform cesareans because it is the most convenient to them, and not because it is medically indicated (or they force the circumstances in order to make it medically indicated, ie “pit to distress”). Fact = some women are unhappy with the c-sections they have been subject to, and upon review of their medical records see a clear distinction between what they were told and what was recorded. Fact = some women suffer PPD and PTSD as a result of said cesarean delivery (including myself), with symptoms and reactions similar to those of rape victims.

    But in the end, it seems to me that your argument is not so much regarding whether or not certain cesareans are necessary (or medically indicated), but that the term unnecessarean is too emotionally-charged and doesn’t leave room for medically necessary cesareans. Forgive me for stating the obvious, but birth will always be an emotionally-charged issue, in no small part because of the hormones released in the process. Find a way to turn those off, and then maybe we can all be clinical about it. Until then, emotionally-charged language that describes how an event FEELS is unequivocally necessary. Unless convinced of the earnestness on the part of women, this industry will not change. Grassroots movements need a rallying cry. Women who have had a cesarean that they did not want and possibly did not need must have a term that aptly describes their experience. Thanks to Jill and others in the community, they have just that.

    So leave the term alone, and let it be what it was meant to be: part of the process of healing and recognizing that, while the past cannot be changed, steps can be taken to improve future journeys.

    • July 29, 2010 at 8:05 am

      I think the conversation has been good, and has shown me a little better how the term is helpful to some. In that way, it is probably a good thing. I do appreciate the stories here. Though I defend my tribe to some extent, it is awful that so many people have such negative experiences, and a shame that the obstetrician involved wasn’t able to meet the needs of their client.

      In a lot of these cases, what was needed was better communication, and more patience on the side of the OB.

      Here’s an example of how one of these issues can go better, from my own practice, if only to give a story of something good:

      A 26 year old primaparous women labors at home with a midwife for about 36 hours. She transfers to the hospital with her midwife. On arrival the strip looks fine. The estimated fetal weight is 9-10 pounds. She has a blood sugar of 160, indicating that she has undiagnosed gestational diabetes. She says her midwife did a fasting blood sugar earlier in the pregnancy which was normal, which not surprisingly did not diagnose her diabetes (fasting are less sensative than a challenge test which is routine for OBs). She doesn’t believe us that she has diabetes, which we let rest for the time being. She is completely dilated, and we are told she has been complete for about 4 hours. There is a great deal of molding and the head seems asynclitic. We discuss with her that the baby is quite large, and given where we are now there is a good chance the baby is not going to deliver vaginally – but given that she has tried so hard to achieve a vaginal delivery and the strip looks great, lets give it a bit more time. She continues to labor for several hours after getting an epidural at her request, and there is no further descent. At that point she feels ok that she has given her best in trying to deliver the baby vaginally, and with the idea that a cesarean is likely the best course. We go ahead and do the cesarean and deliver an 11+ pound baby. Though she hoped for a vaginal delivery, she felt good that she gave it her best and delivered a healthy child. We counseled her that she is at risk for gestational diabetes in future pregnancies, and it would be worthwhile to do a challenge test in the next pregancy to rule this out. This cesarean was necessary, and despite the patient’s initial strong desires for a vaginal delivery, I don’t think she looks back at it as an unnecessarean.

      • July 29, 2010 at 8:18 am

        Your example is an excellent illustration of a necessary cesarean, absolutely. Something I did not mention, but in my local ICAN chapter, several of the women have had medically indicated c-sections. One even had a partial rupture (first pregnancy) following a home birth attempt, but both mom and baby were fine after hospital transfer and crash c-section. So while I agree that much of the online discussion isn’t about these circumstances, yes they do exist. Perhaps the anti-unnecessarean community could do a better job of illustrating that.

        I have noticed an interesting trend from women who believed their cesareans were unnecessary – many were for OP positioning. The hospital birth culture isn’t entirely friendly to “mal-positioned” babies. Recognizing that OP presentation isn’t, on its own, a c-section indication would go a long way in eradicating the unnecessarean.

      • July 29, 2010 at 9:20 am

        It’s certainly not, but it does contribute to arrested labor. Many babies will turn eventually, but some won’t. I know some folks may hate this idea, but its a great time for a vacuum delivery, facilitating rotation to an OA position and effecting delivery. Waiting a long time is also an option, which is some cases will lead to a delivery. At the same time, sitting with a fetus in mid-pelvis for hours on end without progress likely contributes to long term pelvic disfunctin such as pudendal neuropathy.

      • July 29, 2010 at 9:24 am

        To add a corrolary to that story I told.

        The woman had gestational diabetes that her midwife failed to diagnose, which certainly contributed to the size of her child. The fingerstick blood sugar her midwife chose to use as a screening test is far less sensitive to the glucose challenge test used routinely by OB/GYNs. Had this patient been cared for by an OB/GYN, she would have been identified as gestational diabetic and her blood sugars would have been treated. Her baby would have been substantially smaller, and she very well may have gotten the vaginal delivery she wanted because of it. In a lot of ways, her choice to work with the person she worked with contributed to her getting the cesarean she wanted to avoid.

  79. Melody
    July 29, 2010 at 7:01 am

    Sorry, I’d say that the thousands of cesareans done in the name of the ancient “once a cesarean” rule were pretty damned unnecessary. Obviously, a percentage of those women would not have been able to have a VBAC. But those who would have succeeded, whichever ones they were, but were cut because the hospital policy required it, had very, very unnecesareans. The term is perfect.

    And yes, sometimes doctors lie because they are human and humans do that. Sometimes, doctors are really good people who inform their patients well, even if the patients weren’t expecting or wanting to be participatory in the care.

  80. daniel h. chappell, M.D.
    July 29, 2010 at 7:17 am

    This has been a painful but informative read.
    You have been flogged for just being an OB.
    I see many complaints from people that had Caesarean Sections and no thank you’s others for saving mom or her baby from a prolonged labor and vaginal delivery that could have resulted in permanent injury. Too many wish to ascribe no risk or injure to vaginal delivery. All vaginal deliveries have some injury as a result. Most heal just fine but some, not many, have horrendous results that are debilitating to baby or mom.
    I have to admit, I am OB, too.
    I have to tell my patients the risks of Caesarean but I don’t have to tell them the risks of vaginal delivery until I need to compare the choices. And I tell all my patients that surgery is always “CHOICE” and not a requirement. I tell them “as I see it” this is the situation. And I tell them “As I see it” these are the choices. And I tell them “as I see” this is my reccommendation, based on my education and experience which includes more than a few thousand deliveries, good and bad. I do the best I can do, I succeed most of the time I rarely fail and I have to live with the failures, too. I am not stuck in my ideology that says DO THIS OR YOU ARE A FAILURE. (like some concepts of Lay Midwifery) I have been to the Frontier School of Nurse Midwifery (I was there when they fired their doctor and they tried to hire me to replace her.) I, for the most part, agree with their philosophy. But, to take a hard and fast rule that THIS IS THE ONLY WAY, just leads to mistakes and failures with injuries or even deaths. To deny them is wrong. To attribute these deaths and injuries to the method, just makes them a “cost of doing business”. They should, each, be rather thought of as a failure and an opportunity to improve the system to prevent more in the future.
    How about someone relating a success story, here. I see a lot of those.

    • Abbey
      July 29, 2010 at 8:41 am

      In refernce to: “I see many complaints from people that had Caesarean Sections and no thank you’s others for saving mom or her baby from a prolonged labor and vaginal delivery that could have resulted in permanent injury.”

      Dear doctor (mine, not you),

      Thank you for saving my vagina! I don’t know what I would do if any truama had come to it from pushing a baby out of it. It was so much better to endure hours of mental torture until time for the cesarean. I can’t tell you what a comfort it is to live in a mental hell 3 years after the birth of my child because you couldn’t muster a little human decency when spending about 15 minutes of the 15 hours that I was at the hospital talking to me. At least I can go in to my therapist tomorrow and tell him that I’m completely cured because I realize that my vagina is A-OK. Thanks again, doc!

      ——
      Once again, I can’t know for certain, but I am fairly certain that the way I was treated would have been damaging even if I had a vaginal birth.

      When are doctors going to realize that the trauma doesn’t come from an “indicated or unindicated cesarean” most of the time? The trauma usually comes out of doctors not listening to patients and not treating patients with respect or choice in their care, and carrying out their care in an insensitive manner. Is this all doctors? Absolutely not, but there are a good number of doctors out there that are abusive. The obstetrical community needs to recognize that abuse is rampant in their community and start trying to fix it instead of blaming the patients for using the wrong word when they try to describe their trauma. It is important that a patient have a basis of trust in their care provider. It is important that a patient feel that they are cared about and being given the best that those caring for them have to offer. Simply, being alive without a traumatized vagina isn’t a high enough standard.

      I will say thank you to Dr. Fogelson and the others that genuinely seem to care about opening up this dialogue. This isn’t about flogging all OBs. This is about women who want their voices to be heard. They don’t want to be told that what they experienced was “good practice” or that their doctors just had trouble communicating. These women are saying that their lives have been profoundly damaged by the birth of their children because the way that they were treated. They want the medical community to say that abuse should not be part of their “standard of care”. Doctors need to start reading and understanding what these women feel. They need to start finding new ways to communicate and make this better.

      • Alayna
        July 29, 2010 at 10:34 am

        I completely agree Abbey. If I had been treated with any kind of empathy and respect I wouldn’t have the anger that I have today. I own a support group for traumatic births and the common thread between cesarean/vaginal and OB/midwife is that if the woman is treated horribly it will be traumatic for her.

    • July 29, 2010 at 9:21 am

      A doc! tell your friends to come :)

    • CountryMidwife
      July 29, 2010 at 1:00 pm

      All vaginal deliveries have some injury as a result

      I don’t understand this. You are saying you’ve never seen an intact bottom without so much as a bruise or a skid mark?

      Thanks for the kudos to Frontier, who does a really good job of preparing CNMs but with a much more holistic bent than university programs.

    • Jennifer B.
      July 30, 2010 at 1:53 am

      You must have missed my post where I talked about having a very necessary cesarean with an amazing doc…

    • sara
      August 18, 2010 at 6:45 am

      “All vaginal deliveries have some injury as a result”

      I know I’m late to this discussion, but this just simply isn’t true. I birthed my first child after a fast labor and only 15 minutes of pushing in the hospital- no head molding and no tears to me. I would have been happy birthing at home but planned a hospital birth for insurance reasons. I stayed healthy and active during pregnancy and labored at home in a tub, and had no damage…so it is possible.

      It’s never a good idea to make sweeping statements like that, and it seems like a doctor would know better..

      • August 18, 2010 at 7:49 am

        Certainly it isn’t true that there is not always a mucosal injury to the vagina, but it may be true that other structures under the mucosa are regularly damaged. Lots of women have pelvic floor issues later in life despite lack of any vaginal lacerations in birth (though many of these issues can be ascribed to pregnancy in general rather than just the delivery). I’ve seen many deliveries where the baby would not descent through the soft tissue of the vagina and then suddenly its moving down through, without any visible tear. I strongly suspect that some of the structures in the anterior vagina have just torn in these situations, making the room for the descent just witnessed. We see these injuries all the time when we go back and repair peoples prolapsed bladders 30 years later.

        But in terms of mucosal injury to the vagina – clearly not everybody has an injury.

  81. Nicole K
    July 29, 2010 at 7:32 am

    I had an unecessesarian. Actually, breaking my water was unnecessary, the epidural was unnecessary and pitocin was unnecessary…and the pitocin quickly put my baby in distress, which then made a cesarian necessary. However, the interventions were absolutely unnecessary. Getting patients in and out of the hospital in a “timely” manner is important to the hospital. Epidural slows progress. Pitocin stresses the baby. Epidural + Pitocin = Cesarian.

    • July 29, 2010 at 8:16 am

      Not in disrespect Nicole, but did you not consent to getting an epidural? Did you benefit from the pain relief? Epidurals slow progress a bit, but average increase in total labor time is about 20 minutes, and in cohort trials there isn’t a measurable effect on cesarean rates. As for epidural + pitocin leading to a cesarean, that hard to support given the hundreds of thousands of women who deliver vaginally each year with both of those things going on.

      That all said, I’m sorry you didn’t have the experience you wanted.

      • Alayna
        July 29, 2010 at 11:02 am

        Have you ever been in excrutiating pain and then told to read AND comprehend something?

      • July 29, 2010 at 1:47 pm

        I’m not sure I get the point of this question. It seems we all want informed consent, but you are suggesting that its not right to have informed consent because you are in pain. So which is it?

      • Alayna
        July 29, 2010 at 3:15 pm

        My only point is why is the patient always blamed?

        You don’t know how her consent form was presented to her.

      • Washi
        July 30, 2010 at 8:50 am

        “Have you ever been in excruciating pain and then told to read AND comprehend something?”

        I have. I was told I HAD to sign their consent form and I HAD to have antibiotics unless I signed a release form … which I had already done months in advance, no good did it do me for they were forced upon me anyway. When I was ordered to sign a form I presume was a release for them to do whatever they pleased I wrote something other than my signature on the dotted line, a plea to the woman holding the form that I was being abused. No one took notice that it wasn’t a signature. Their hands left many bruises on my body such was the force of their restraint. I said “NO! Get off me!” and was painfully violated and verbally insulted in return. I was then sedated and sectioned without just cause and without consent verbal or otherwise from me inspite of having told the attending OB months prior that I was against having a cesarean except in the most dire of circumstances. My experience was rape.

      • August 6, 2010 at 9:47 am

        Asking a person to consent or decline something after informed discussion of the risks and benefits is not blaming them, it is respecting them. Taking the time to discuss these things prior to labor is helpful, but does not replace the consent process that must occur prior to the procedure.

    • July 29, 2010 at 8:56 am

      >> Getting patients in and out of the hospital in a “timely” manner is important to the hospital.

      This part is to some extent true. I don’t think that physicians really push things for this reason, but from a hospital administration point of view a long admission is an unprofitable admission. The hospital is paid a set fee for the entire labor and postpartum stay, so shorter stays are better. However, in this case the hospital’s interest line up with the patient’s interest. Long labor admissions come with inductions in women with unfavorable cervixes. Short labor admissions when women come to the hospital in active labor, have a baby without intervention, and go home the next day.

      One of the things that gets us is that some women show up only 1-2 cm dilated in latent labor and want an epidural. If theys stay, they are setting themselves up for a long labor stay in the hospital, and greater exposure to potential intervention. There is no doubt that with a lot of doctors there is a tendency to want to do something, when what really should be done is nothing. When a patient in a labor gets an epidural, her labor will often stop for a while (because of the effect of hydration on natural oxytocin production), which in many cases can lead to her getting on pitocin. A better route is to just wait for labor to resume, but admittedly not everybody (patient and doctor both) has the patience.

      • CountryMidwife
        July 29, 2010 at 12:57 pm

        I totally agree. I was on a task force at a Seattle hospital to reduce the c/section rate (which was a pretty good 23% with a 78% VBAC rate — awww miss the mid 90s). We implemented one single rule – no admission until 4 cm regardless of membrane status, and the c/section rate dropped 6% within months. We did give big doses of morphine, if requested, for therapeutic rest in or out of hospital per preference and situation.

  82. Jessica
    July 29, 2010 at 8:12 am

    I do believe that many c-sections are unnecessary, meaning, had different decisions been made on the part of the patient and the doctor it could have possibly been avoided. For my first delivery I was completely uneducated. I went into spontaneous labor at home and asked for the epidural once admitted into the hospital ( I was only 2 centimeters dilated). So immediately I’m laying down, helpless to do anything that may encourage my baby to move into proper position, and pitocin being administered to help speed back up the contractions. Eleven hours later, having pushed six times, my doctor tells me that the baby’s heartbeat was non-reassuring and I needed a c-section. A c-section it was. Of course I was happy that my baby was healthy and that I was relatively healthy but I was certainly not happy about the method of delivery. I really began to educate myself regarding birthing practices, statistics, etc…Knowing at this point that if “I” had made better decisions and would’ve been more proactive with my first birth the entire outcome could’ve been different. When I got pregnant with my second child I conferred with my OB regarding VBAC, he was very negative about it. He told me I could try but only if I were induced, which concerned me because of the compounded risk of uterine rupture. He told me that the shape of my pelvis was not “conducive” for a vaginal delivery and since my first baby had a non-reassuring fetal heartbeat and had failed to descend that my chances of having a successful VBAC were slim to none. He said that I could attempt VBAC but I’d probably fail. He was VERY QUICK to lecture me on the risks of VBAC but NOT ONCE did he ever inform me of the risks of a repeat c-section (or the risks of c-sections in general).
    I decided to get a second opinion. This OB, who I ended up switching to, said in her opinion the shape of my pelvis was fine. As far as VBAC she would not induce me, even if I went past due. She was an incredible doctor, very “hands off” and allowed my body to do what it was made to do. Her mentality was more indicative of a midwife. She’s one of the only OB/GYNs in my area who will vaginally deliver twins and breeched babies (which is so unfortunate that doctor’s like her are rare). Three days before my due date I went into natural labor, 45 minutes of pushing and my beautiful baby boy was born!
    All this being said, I believe that there are “unnecessary sections” but there are many women who contribute to their own outcome, as exampled by my story.
    Women should really take the time and interest to educate themselves and doctor’s should really be HONEST about all benefits vs. risks.
    I really enjoyed reading everyone’s opinions and thank you Dr.Fogelson for keeping an open dialogue and for being so respectful.

  83. Christy
    July 29, 2010 at 9:03 am

    Dr. Fogelson,
    I don’t have time to read all the replies, but since you seem to be reading the comments, I will leave one for you. I am very happy to see you mention:

    “I completely agree about looking at the factors that promote normal birth:
    here’s a few:
    1) avoiding unindicated inductions
    2) control of gestational diabetes
    3) delaying hospital admission until the onset of active labor”

    In my area in WV, virtually all OB attended hospital birthing women are induced, and are thus in the hospital the entire labor. We also have the 5th highest rate of c-sections in the nation, and are running about a 50% chance of induced women getting c-sections. The only women I know who escape this are the homebirth moms I know, and the VERY rare lady who refuses induction despite enormous pressure from her doctors. These are done for the convenience and scheduling of the doctors, and always occur PRIOR to the due date!

    I can not figure out why women in my area do not question the insanely high c-section rate. They happily go in for their scheduled inductions implicitly trusting that the doctor has their best interests at heart. How have humans managed to survive if so many women are incapable of birth?

    I am a natural birth advocate, having had one birth center birth, and two homebirths (one unassisted.) I realize emergency care is sometimes needed, and I am very thankful we have such care available. However, treating all births like emergencies, intervening from beginning to end, causes the very problems women think they are being protected from.

    If women are left alone to labor and birth as they choose, almost all will birth fine, and free from any complications. The best thing we could do to greatly minimize c-sections and other things like forceps or vacuum delivery and episiotomies, etc., for women who choose hospitals to birth, is to leave them alone! Give them peace, quiet, and privacy, and minimize interruptions. Let them labor as they choose, freely walking or moving as desired. Let them birth in whatever position desired. I’ve never known any women who actually chose to birth flat on their back, which hinders birthing efforts, as it narrows the pelvis and compresses blood and oxygen to the baby, often resulting in fetal distress. Keep the dreaded continuous electronic fetal machine away, shown to actually CAUSE unneeded c-sections. A doppler every 30 minutes or so should give plenty of reassurance that baby is well. Also, get rid of the timeline which says if a woman doesn’t produce a baby in a certain amount of time, she has “failure to progress” and winds up with a c-section or a forced vaginal birth (forceps, etc.) Do not use pitocin to either induce or hasten labor.

    The typical hospital scene however, treats women as cattle, herding them in and out as quickly as possible. Induction, pitocin, labor in bed, “failure to progress,” c-section. I hear this story of induction to c-section all the time from women I know.

    What’s needed is a midwifery model of care for most women. Let labor begin and proceed on it’s own. Let the woman do what her body innately knows it needs to do. Tragically, this scenario is the opposite of what most women encounter. Therefore, you will continue to have women who feel violated and cheated, and yes even medically raped.

    Birth is a very special, sacred experience in a woman’s life, which is not at all respected in our current obstetric model of childbirth care. Not only are most women cheated out of a positive birth experience, the aftercare of the newborn is deplorable. Separating the mother and baby after birth tremendously interferes with the natural bonding hormones and breastfeeding. So many women report feelings of detachment towards their infants, which they very often attribute to a labor and birth in which they were at the mercy of doctors and staff, who completely took over their labors and performed unneeded c-sections. Many of these women have found later healing in homebirth, which is infinitely more peaceful than a hospital birth.

    I hope you will continue to advocate lowering c-section rates among your colleagues, and also seek to advocate for a far less interfering approach to childbirth, which will result in far fewer c-sections. Thank you.

    • July 29, 2010 at 9:17 am

      Thanks for your comments. Lots of good advice.

    • Melissa
      July 30, 2010 at 10:26 am

      Amen, Christy! I agree with every single thing you said.

  84. coffeegirl2000
    July 29, 2010 at 10:42 am

    I apologize in advance for not reading any of the other comments posted, there are so many of them and I just do not have that much time right now. But I feel compelled to respond to this post.

    In my opinion, you being “damned tired” of women who lash out against the group you represent gives you no right to undermine these women in their fight against damage to their body and their mental health. Many of the women that are angry at the obstetric community actually are victims of a protocol that gives very little room for autonomy over one’s own body, which is a very difficult thing for anyone to experience.

    Many women do go through this scenario of one intervention after another that leads to cesarean. For the hospital staff it is another day at the job, whereas the woman will remember it vividly for the rest of her life and has a profound impact on her world view.

    I would propose that the majority of women who categorize their birth experience as “rape” are going through post traumatic stress disorder and could really use some gentleness from the group that she feels is responsible for the damage. The truth is, you are dealing with people who have been hurt really badly and your response is to hurt them even more (and over semantics even?).

    Who cares if you agree or not? How about a little empathy for some people who are in extreme emotional pain? I bet you have not had nightmares to the point where you are afraid to go to sleep. I bet you have not spent weeks, even months of your life crying on a daily basis without understanding why. I bet you have not had severe panic attacks when driving past the place where your children were born or a myriad of other reminders that can trigger an attack. The specific group of women you are targeting in your post have had these thing happen to them. It does not have to be traumatic for you to be traumatic for someone else, you know.

    If obstetricians were to try, just once, to understand what the whole woman needs, instead of focusing on anatomy only, there would be hope for your profession. Academic… and heartless.

    • Alayna
      July 29, 2010 at 1:18 pm

      Thanks.

    • July 29, 2010 at 1:56 pm

      Might help to read more of the thread.

      But here’s the thing. OBs in general care very much about their patients, want great relations and great outcomes. Perhaps a certain group of women wants a different path than most OB’s would recommend, but to then call that rape seems quite off to me. Rape is a expression of power and violence towards a woman, and I don’t really think that is what is going on. If you think that somebody is expressing some desire to control or hurt women through their practice of obstetrics, then I suppose rape would be some kind of metaphor for what is going on. If you think they are doing their best to get the best outcomes, in the system in which they believe will achieve that, then the word rape is a gross malignment of good people. It think its the latter, not the former.

      • Abbey
        July 29, 2010 at 2:13 pm

        So it’s okay to “control and hurt” as long as you think that you are doing your best to get the best outcome?

      • July 29, 2010 at 2:47 pm

        While I would not classify most unneccesary c-sections as ‘rape’ (and I don’t think it’s the majority of women describing thier experience in these terms) and I sypathize with what it must feel like to imagine that at your job, doing what you feel is best for your patients health, they might someday call you a ‘rapist’ I implore you to explore this topic further and LISTEN to the voices and experiences of women who feel they were medically raped. Most that I have heard feel it was an entire system that violated them, and not some monster doctor. Also, I must point out that many rapists (child molesters in particular) truely BELIEVE their victim is ‘enjoying’ it and that they are recieving some benefit. I AM NOT comparing you or your collegues to child molesters, but the point is, it doesn’t matter what the ‘perpetrator’ believes- Nothing excuses violating a woman, putting hands inside her, cutting her etc while she is SCREAMING “No!” As a fairly empowered woman myself, it is hard to accept that this happens. I shamefully admit to searching these women’s stories for something they did ‘wrong’ so that i can believe it couldn’t happen to me. I was told by a fellow mother/doula that she had been raped, and would choose to be raped again over the ‘birthrape.’ I ask everyone out there to sit with that- try to wrap your mind around it. Listen to these women, Dr Fogelson. There are too many to ignore if you’re willing to look. It’s not about the Drs. It’s about women being victimized Here is a great example of a huge failure of our system- there were no ‘monsters’ but there was still a victim, because legal force was used to assert what ‘they’ thought was best for HER. http://advocatesforpregnantwomen.org/issues/court_ordered_interventions/laura_pemberton_speaking_on_her_experience_of_a_courtordered_cesarian_surgery.php

        As this is the second time this month this debate has consumed great portions of my day, I may have to blog about it myself!! lol.
        Even though I think you are sorely mistaken on this point, I think you are listening and THANK YOU for that.

      • July 29, 2010 at 2:53 pm

        Lia – I understand that some women feel that way, and that is horrible. I’m sorry those things happen. What I don’t know is how to fix it on a large scale. One one hand you have a woman who wants to feel more involved or more in control, and in the other you have an OB who, rightly or wrongly, really thinks they need to act to prevent the injury of a baby. Its terrible that the clash of these issues has led to people feeling raped in some circumstances.

        Read my comment below as it might help.

  85. July 29, 2010 at 2:14 pm

    I think these comments clearly illustrate the clash of the organics vs the mechanics. I would highly recommend the book Birth Wars (http://www.penguin.com.au/products/9780702237225/birth-wars) which explores this clash and the implications for women (not written by a midwife or an obs)

    I also think it is very important that we do not tell women (or anyone) that their interpretation of their personal experience is not valid or is wrong. It is not for us to redefine or interpret but to LISTEN to them and try and understand what it meant for them.

  86. Abbey
    July 29, 2010 at 2:30 pm

    Abbey :So it’s okay to “control and hurt” as long as you think that you are doing your best to get the best outcome?

    I hate to add this, but isn’t this the arguement for all injustice?

    • July 29, 2010 at 2:47 pm

      No – my point was, which I think was pretty clearly stated, was that if OBs want to control or hurt women, that is a problem. Its not OK under any circumstances.

      • Abbey
        July 29, 2010 at 3:11 pm

        Nicholas Fogelson :want to control or hurt womenP>

        What if they don’t want to control or hurt them, but what if they feel that they have to control and hurt them to have good outcomes? Does this give them the right?

      • July 29, 2010 at 3:51 pm

        No.

  87. July 29, 2010 at 2:45 pm

    So here’s a fair question for all – if a woman doesn’t want to have any intervention in their labor, why come to the hospital at all? One can deliver at home and in many places they can deliver in birthing centers under the case of midwives. While I don’t love everything about standard OB care, I also don’t think OBs should become midwives, and that seems to be what a lot of folks commenting want OBs to be.

    OBs are not trained to stand back and wait until the last minute to intervene in a labor. OBs are trained to anticipate any and all problems potentially harmful to fetal well being, and intervene to prevent those problems before they happen. The one thing we want to prevent is injury to or death of a fetus or infant. That is paramount. While we know that most pregnancies and labors will go well, it is not our attitude that every labor is going to go fine. Every labor can potentially go bad, and it is our job to prevent that. We are not trained to let problems get serious before we intervene. We are trained to identify problems early and intervene before they are serious.

    While most OBs recognize that pregnancy and childbirth is often a wonderful time in a woman’s life, we do not consider the participation in that wonder to be the core of our job. It is the frosting on the cake. The cake is preventing bad outcomes.

    Obstetrician/Gynecologists are physicians and surgeons. Physicians are trained in the diagnosis and treatment of disease with medicine and surgery. This basic and fundamental nature does not lend itself to a non-interventional view of pregnancy.

    If any woman doesn’t think that is a good model, or thinks that the general model of obstetrics does not actually do what we think it does, then they should consider seeking the care of a midwife. If they do like the model of obstetrics, but also want someone who can be a major emotional supporter in labor and spend the entire labor with them, they should consider hiring a doula.

    While OBs will argue about how and when and whether we should intervene in things, most still adhere to this basic philosophy.

    • July 29, 2010 at 2:56 pm

      That is a very fair assessment IMO (and the reason I didn’t choose to involve ANY professionals in my birth (prenatal care only))

      I only wish that all women were told this by the professional they call for thier first prenatal appointment because they were on thier list of ‘insured providers.’ There are simply not enough options out there. We are too often just taking what we can get, or what we can afford.
      The second issue being that it doesn’t seem that transfers of care from HB midwives to hospitals is usually a smooth process (adding to the relatively low risk of homebirth)… but that is probably another can of worms ;)

      • July 29, 2010 at 3:10 pm

        OBs that don’t accept transfers of care from homebirths and birthing centers gracefully are taking things far too personally. Midwives who bring transfers with a chip on their shoulder are doing their clients a disservice.

    • Abbey
      July 29, 2010 at 3:06 pm

      Many women don’t have access to midwife or birth center care unless they are willing to travel a great distance at great expense.

      Why did I go to the hospital even though I wanted a natural childbirth? Because I couldn’t conceive of the way that I would be treated or the damage that would be done. The classes that I paid to take at the hospital told me that natutral childbirth was the best, how that is achieved and that even though things were generally done a certain way that I would still have control over my birth. The last part was an all out lie.

      You better believe that I won’t be going back to the hospital for seconds until every other option is exausted and the situation is dire.

      You want to know how to get women who want midwife care access to midwives? How about helping with legislation, training, insurance coverage, helping other OB’s realize that it is in the patients interest to work with midwives. The reason a lot of people go to the hospital is that they do not have access to midwives. The reason that there are not many midwives is that the midwives do not have the support that they need in a lot of areas. I know that you can’t accomplish all this, but the obstetrical community makes it very difficult to get midwife care in a lot of areas and that needs to change.

      • July 29, 2010 at 3:41 pm

        The midwife community deserves more support from the OB/GYN community in my opinion, but not in the opinion of most OBs. I am for providing the care that serves the needs of patients, and if what they need to feel good about their birth is midwife care, I’m for that. Whether or not its is better, worse, or whatever, is really irrelevant. The differences are in the decimal figures, so ultimately people should be able to get what they want.

      • July 29, 2010 at 3:46 pm

        I think this blog actually does some good. While the comments come mostly from the non-physician public, a lot of OB/GYNs do read this blog and listen to the podcast, and it does have some impact. It definitely had an impact in regards to delayed cord clamping, because I heard back from all kinds of folks that were turned on to it because of the blog.

    • PrecipMom
      July 29, 2010 at 3:09 pm

      I cannot speak for anyone but myself, but I don’t want obstetricians to become midwives. But I do want a more judicious use of technology in the birth process. I don’t want an OB (or any maternity care provider) asleep at the switch, BUT I also don’t want them jumping the gun. And I especially don’t want them providing care in *any* way that undermines a woman’s confidence in her own judgment. Birth is a medical reality *and* a human event in the life of a family. It’s a difficult dance to negotiate, but let’s just say that some people are better at avoiding their partners’ toes than others…

      And as for why many women have obstetricians when they really want midwives, many women have health insurance that would not cover midwifery services or choose hospital based obstetrical care to make their partners or families comfortable. That’s a difficult situation where there can easily be unrealistic expectations or projecting issues that aren’t really there.

      I wish there was a way to almost certify a doctor as one who will practice evidence based medicine and respect patient autonomy. It’s just very very hard to sort the good doctors from the bad ones, and sometimes you’re stuck with bad ones and no recourse to any other professionals.

      And I just wanted to say that I have been really disturbed by the vitriol I’ve seen thrown in your direction, and am sorry for it.

      • July 29, 2010 at 3:42 pm

        I (usually) don’t take it personally. It isn’t really thrown at me. It is thrown at the OB/GYN effigy that I represent.

    • Lucia
      July 29, 2010 at 4:28 pm

      I agree completely, however it comes down to a couple of things, fear, money/insurance coverage and legality. In many places midwives can’t practice or can’t practice except in a hospital or can’t practice unless they are technically under an OB. Most insurance companies don’t cover home birth likely due to the opinions of OB advisors who believe home birth is dangerous. Slander campaigns have gone on for over a century preventing midwives from practicing openly or at all sometimes midwives have gone to jail for practicing medicine without a license. As a result of smears as well as a culture that is hospital centered when it comes to birth many women are afraid of home birth or birth center birth a fear that is real but on a premise that often is not. Do things happen, absolutely and thank goodness we have hospitals and OBs but most of the time a healthy woman left to labor on her own with full access to movement and without medications in her spine or blood will produce a healthy baby without intervention. Many women because of our culture do not believe they can produce a healthy baby or are so afraid of something going wrong that they choose obstetric care and a hospital birth even though babies still die in the hospital and so do mothers. In the case of women who do not feel empowered Drs have to be sensitive to that and help women to give birth the way we evolved to, out the vagina. There will likely always be some women who will want to be induced or have scheduled c-sections but there will also always be women who will want to birth at home with a midwife’s care or even unassisted. I think most women fall in between, they want an OB’s care they want intervention, they want pain relief but they still want a vaginal birth. It’s up to the Drs who treat them with judicious use these interventions to help the mother reach her goal of her ideal birth (barring unforeseen circumstances of course). The women who want completely natural home births or birth center births need to have sufficient access to them and with good access (without threat or punishment) to hospital care should the need arise with her midwife and family supporting her through a seamless transfer.

    • VW
      July 29, 2010 at 8:33 pm

      So here’s my situation: I/my daughter experienced a serious shoulder dystocia during her birth. The worst my midwife had seen. She was big (9lbs 4oz) but I also had an epidural, forceps due to non-reassuring heart rate before I could figure out how to push while feeling nothing, and an asinine position for pushing.

      Because of the severity of the SD, she strongly recommended I give birth in the hospital next time because of the risk of recurrence. I can see the reasoning of that, but essentially what you’re saying is “you buy the hospital ticket, you get the hospital ride”. But I don’t want the hospital ride (I actually want a home birth) because I think many aspects of the hospital ride would actually predispose me to that recurrence. I do want neonatal resus available (because I don’t think that resolving a shoulder dystocia is very different in the hospital or at home, with midwives or with doctors).

      So why should I have to accept the standard hospital ride just to get an a la carte item? Why would I have to argue every step of the way to fight the routines, the set-in ways, etc.? Why does having one risk actor force me to get care that addresses all risk factors, which could actually create the very situation I want to avoid?

      • July 30, 2010 at 12:54 am

        I think this is such an excellent question.

      • July 30, 2010 at 3:47 am

        It is a fair question, and hospitals should be better with this. I think some are, it just depends on where you go. West coast hospitals, in my experience, are far more experienced/comfortable with providing a non-interventional labor environment.

      • Statler&Waldorf
        July 30, 2010 at 7:00 pm

        This is just my opinion, but if I have a shoulder dystocia history and risk for future pregnancy, I would not give birth at home. I’d protect myself with a doula or midwife who looks out for my interests during birth and risk the hospital ride, because it is far worse a risk to have a shoulder dystocia at home.

      • August 16, 2010 at 4:30 am

        VW: If you had not been numb and in an ‘asinine’ position, you might not have had shoulder dystocia. The worst position for a woman to birth is on her back…the pelvic bones need to be able to flare open to allow the baby to descend, which isn’t always possible when the woman is flat on her back.

    • Jennifer B.
      July 30, 2010 at 2:05 am

      When was the last time you told a client this? Have you ever told a client that they should seek midwifery care? You did say earlier that some of your clients are not well informed, did you inform them that there us a major difference between the care they should expect from you and the care they could reasonably expect from a midwife? Have you ever told a woman that they should consider hiring a Doula?

    • Abbey
      August 1, 2010 at 1:37 am

      Nicholas Fogelson :So here’s a fair question for all – if a woman doesn’t want to have any intervention in their labor, why come to the hospital at all?.

      Do you realize how you are blaming the victim here? I know that this is not your intention, but that is what this question does. This question has haunted me for days. Why did I go to the hospital if I wanted no interventions? Why did I go to the hospital if I didn’t want total control over myself to be taken away? For the same reason that the woman was in the parking lot late at night who was raped. I went there for the same reason that the man who was dressed too well was in the wrong part of town and had his head kicked in.

      Were the intentions of my caretakers noble? Were they well educated on childbirth? Were they doing it for the “greater good” by their definition? It doesn’t matter. It was wrong. I didn’t deserve what happened to me. I didn’t deserve it because I went to the hospital because I thought that they would help me labor and birth my child instead of taking all of it away from me.

      So again I must emphasize, why did I go to the hospital? Because I didn’t really know what they were going to do to me.

      Simply defending the actions of abusers is not going to help this problem or make it better. Earlier you said that women who feel victimized feel victimized by the whole system, yet you defend all doctors (that you know at least) as having noble intentions when caring for their patients. Telling abusers that it’s not their fault that the abuse is happening because their training is right and the brains of their victims is wrong is not going to help things. The abuse needs to stop. Women are being abused in alarmingly high numbers and the saddest part is that many of them don’t even know it. It took me almost 3 years of crying about what happened almost daily to finally recognize what happened and get help. I couldn’t get over it because people were a little mean to me. I couldn’t get over it just because people have it so much worse. Every detail of my sons birth is permanently etched into my brain down to the minute that every “intervention”, every word that was spoken, everytime that I tried to get up or do something and then felt that I had to lie back down because I had no choice.

    • Abbey
      August 1, 2010 at 1:56 am

      Nicholas Fogelson :So here’s a fair question for all – if a woman doesn’t want to have any intervention in their labor, why come to the hospital at all?.

      Do you realize how you are blaming the victim here? I know that this is not your intention, but that is what this question does. This question has haunted me for days. Why did I go to the hospital if I wanted no interventions? Why did I go to the hospital if I didn’t want total control over myself to be taken away? For the same reason that the woman was in the parking lot late at night who was raped. I went there for the same reason that the man who was dressed too well was in the wrong part of town and had his head kicked in.

      Were the intentions of my caretakers noble? Were they well educated on childbirth? Were they doing it for the “greater good” by their definition? It doesn’t matter. It was wrong. I didn’t deserve what happened to me. I didn’t deserve it just because I went to the hospital because I thought that they would help me labor and birth my child instead of taking all of it away from me.

      So again I must emphasize, why did I go to the hospital? Because I didn’t really know what they were going to do to me and there was no way for me to know.

      Simply defending the actions of abusers is not going to help this problem or make it better. Earlier you said that women who feel victimized feel victimized by the whole system, yet you defend all doctors (that you know at least) as having noble intentions when caring for their patients. Telling abusers that it’s not their fault that the abuse is happening because their training is right and the brains of their victims is wrong is not going to help things. The abuse needs to stop. Women are being abused in alarmingly high numbers and the saddest part is that many of them don’t even know it. It took me almost 3 years of crying about what happened almost daily to finally recognize what happened and get help. I couldn’t get over it because people were a little mean to me. I couldn’t get over it just because people have it so much worse. Every detail of my sons birth is permanently etched into my brain down to the minute that every “intervention”, every word that was spoken, everytime that I tried to get up or do something and then felt that I had to lie back down because I had no choice.

    • sara
      August 19, 2010 at 1:34 am

      In my case the decision was purely financial. I pay every week for health insurance, but my insurer will not cover a home birth, period. So I chose to go to the hospital even though I really wanted a home birth. I was one of the fortunate ones since I had a very fast, uncomplicated labor and the staff had no time to intervene to “help” me other than making me get in the bed (I was doing just fine at home pushing instinctively in a squat, but ‘thanks’).

      It would have been better for the insurance company and me for them to pay for a home birth. The hospital billed at least 5,000$ for my 15 minutes of delivery and 24 hours in the hospital, and another 2500$ for the ob/gyn practice for prenatal care, and I had to ride to the hospital in the pushing stage of labor. If they had covered a home birth they would have been billed only 3,000$ by the midwife group for the whole thing. Prenatal care and labor/birth.

      Insurance companies really need to give low-risk women the option of choosing a home birth. I wish I had just chosen the midwife group, and next time I will, despite the insurance issue, but I’m sure many women don’t do a home birth because of the up-front cost involved. It’s easy for someone to say, “it’s the birth of your child so why would you worry about the cost”, but those people apparently aren’t looking at my bank account…

  88. July 29, 2010 at 2:57 pm

    Nicholas Fogelson :
    So here’s a fair question for all – if a woman doesn’t want to have any intervention in their labor, why come to the hospital at all? One can deliver at home and in many places they can deliver in birthing centers under the case of midwives. While I don’t love everything about standard OB care, I also don’t think OBs should become midwives, and that seems to be what a lot of these folks want OBs to be.

    I totally agree. Women do need to take some responsibility and ask themselves what is important to them about birth then seek the appropriate practitioner. Why go to hospital and have an obs if you don’t want medical intervention unless absolutely needed (not just in case)? The problem with this argument (my own) is that often women only do the research in response to a birth experience that did not meet their needs. Women need access to unbiased information early in pregnancy about all models of care AND access to these models of care… from unassisted freebirth to planned elective c-section and everything in between. Unfortunately much of this information and choice is blocked.

    • Heather
      July 29, 2010 at 4:33 pm

      Yes, women need to take responsibility. If we could get everyone to read even ONE pregnancy book (NOT “What to Expect When You’re Expecting”! Dr. Sears’ pregnancy book, maybe?), it would be a good first step.
      The problem is, though, we are still living in a time where, for many women, if not most, the only REAL & legal choice they have is the hospital (or an unattended home birth). We still have states where such midwives as exist are working illegally–in Missouri, the practice of midwifery was a FELONY until 2 years ago. In such a case, there is no continuity of care if the patient has to transfer, because the midwife can’t stay around, and the hospital staff write on the mother’s chart that she has had NO prenatal care–even though she has had the gold standard. That’s the situation I found myself in with my first, as midwives were legalized by statute a few days after she was born, and then the law was tied up in court for another year. I couldn’t even give the name of my midwife to the hospital staff.
      Other states have midwives technically legal, but with such great impediments that they are still effectively banned. For example, unless the law has recently changed, Arkansas women are supposed to be approved for midwifery care by TWO different OB’s before they can legally use a midwife’s services. Yeah, THAT’s gonna happen! Needless to say, Arkansas’s “black market” midwives are much busier than their legal ones.
      And, even in states where there really are legal midwives readily available, insurance often doesn’t cover them, so, unless the new parents have an extra few grand to pay out of pocket, they are forced into the hospital system, whether they like it or not.
      It is, of course, painfully obvious that the situation needs to improve. Unfortunately, it is largely the obstetrical community that is standing in the way of progress. Unfortunately, Dr. Fogelson, you give tragically many of your professional colleagues way to much credit for, well, professionalism. I wish you could have been a fly on the wall during the Missouri House and Senate hearings on legalizing midwifery. Those representing MO’s obstetricians were so thoroughly and obviously unacquainted with honesty and integrity that the Senate committee, which was ON the OB’s side, told them they needed to provide some documentation for claims such as “this law will let midwives do abortions” and “babies will be dying in droves”.
      I am glad you wrote this article. I hope you are not feeling too piled-upon by the feedback, because I think a very healthy discourse is going on here. I most earnestly hope LOTS of OB’s are reading this. What so many of the posters are saying is that the customer service provided by the obstetrical community is in major need of a thorough revamping. They are telling you what they require–or the trend of women who can take their business elsewhere doing so will accelerate. I don’t actually have a lot of personal experience with OB’s. I think I’ve seen (professionally) 2 in my life–one for a female exam on a rare occasion when I had insurance, and the one who delivered my daughter, who I really never saw till I was ready to push, and who I had to yell and cuss at till the bed they insisted I be in was rendered as upright as possible, because flat on one’s back, while convenient for doctors, is a STUPID position in which to push a baby out.
      Actually, that’s the crux of the whole deal. When OB’s stop focusing how they practice on what’s convenient for them and how they want to do things, and start realizing that it’s the Mama who is doing all the work, and it’s the care provider’s job to facilitate, the situation will improve. If OB’s don’t want to facilitate, as it’s not what they are trained to do, then they need to quit standing in the way of having a proper midwifery care setup in this country.

    • SaanenMother
      July 29, 2010 at 4:35 pm

      C’mon- now these are two really ALMOST hilarious comments they are so absurd-

      why come to the hospital at all”

      yes doctor, and when the baby dies at home- the ob can tell the mother she assumed the risk, sorry honey here’s a dead baby and now I can point to how dangerous home birth is. Additionally, what is wrong with doctors that they refuse to cooperate with midwives who deliver babies at home? I have lost so much respect for the entire obstetrical community because of their refusal to put their money where there mouth is- do you really want a zero infant and neonatal mortality rate- or are we on the margins- what’s a dead baby here and there…This I have decided is not only severe hypocrisy but a supreme form of cowardice. If doctors do read this blog I say “dude, grow a pair.” and lady doctors harden your ovaries. You can offer your “medical opinion” and assistance and not be blamed later if there is a bad outcome.
      Doctors can and do – cooperate with midwives because they do know that it leads to safer birth. This is why we go to the hospital. When midwifery cannot address a situation during birth medicine is available- this too is a choice.

      and WRT this comment-“Why go to hospital and have an obs if you don’t want medical intervention unless absolutely needed..”
      Does this statement lend itself to the “outcomes are outcomes routine” that some midwives hold about birth at home where a midwife has a disaster then say well you assumed the risk by birthing at home. I informed you that I could only do so much…because I practice midwifery not medicine.

      either way we are screwed- it’s either the hospital model and all its well meant but not always comfortable or sensible trappings-or roll the dice at home. What a ridiculous system, so archaic and crazymaking.

  89. July 29, 2010 at 3:09 pm

    Nicholas Fogelson :Lia – I understand that some women feel that way, and that is horrible. I’m sorry those things happen. What I don’t know is how to fix it on a large scale. One one hand you have a woman who wants to feel more involved or more in control, and in the other you have an OB who, rightly or wrongly, really thinks they need to act to prevent the injury of a baby. Its terrible that the clash of these issues has led to people feeling raped in some circumstances.
    Read my comment below as it might help.

    On a large scale, women need the right to say “NO” and accept responsibility for the outcome and Doctors/Midwives need to feel safe (from lawsuits or loss of license) in respecting this right. A professional should not have to choose between his/her livelihood and compassionately caring for his/her patients. There needs to be more compassion and less pressure put on the OBs (and MWs) so they can take the pressure off laboring women.
    I think REAL education should be more of the prenatal care process. The book my OB gave me at my first prenatal should have said, on the first page, EXACTLY what you said below rather than simply ‘trust your Dr’ throughout.

  90. coffeegirl2000
    July 29, 2010 at 3:33 pm

    Nicholas Fogelson :
    Might help to read more of the thread.

    I did not read the comments (you know, by the other visitors of your blog), but I did read your entire post and even made that clear in my previous comment, but thanks for showing your condescending nature, at least now we all know what type of person we are dealing with here.

    But here’s the thing. OBs in general care very much about their patients, want great relations and great outcomes.

    This may be true, but it is irrelevant. I never said anything about the intent of the OBs or whether they care or not and I am quite sure that they want good outcomes. I never suggested that OBs are out to get women or are causing harm on purpose. As a matter of fact, your entire response is nothing but a straw man argument. http://en.wikipedia.org/wiki/Straw_man.

    You propose that I am arguing the case that unnecessary c-sections is akin to rape, which was not at all what I said. Let me reiterate for you the point that you would argue against if you had ‘read more of the post’ yourself:

    “the majority of women who categorize their birth experience as “rape” are going through post traumatic stress disorder and could really use some gentleness from the group that she feels is responsible for the damage.”

    You argument should be that they are not going through PTSD or that they don’t really feel that the obstetric community is responsible or that they do not need gentleness from your kind. So which is it?

    What you fail to understand is that berating new mothers for using terms that describe the depth of their pain will only widen the gap between you. You may not be hurting your patients, but when you defend doctors that do or try to deny that it even happens, you loose your credibility. You will never understand if you do not listen and I do not mean listen long enough to form your argument, but listen with empathy and without judgment. Listen to understand.

    Should they have to beg for your empathy? Would that even work? OBs say they care then they make hurtful posts aimed at the most vulnerable of women. Go figure.

    • July 29, 2010 at 4:06 pm

      No condescension intended, sorry you took it that way. The thread does have a lot in it, and I think it does develop in a way that helps to put the post in better context.

      I am sorry that some women are traumatized by their birth experience, and for whatever part an obstetrician played in that.

      So here’s a question – are the blogs that vilify obstetricians trying to effect change? Or are they just support groups? If they are the latter, any language they want to use is their business. If they are the former, those terms will not help the situation.

      • coffeegirl2000
        July 29, 2010 at 4:52 pm

        They are trying to effect change and serve as an outlet for some very serious hurt at the same time. It is perhaps this duel purpose that makes it so ineffectual. Obstetrics, all of science really, is very unemotional. Mothers, especially new moms who experienced trauma during the birth of their child, have a really hard time removing the emotion from it. All the emotion causes people to dismiss them, but there are very valid arguments behind their intensity that ends up not being heard.

        They need an outlet and they also want to make the system see how it offers little to no choice for women and their bodies and how a lot of people are getting hurt. It is hard to reach out to those that you feel have hurt you. It is not like a career, you plan for that for years. This hits a woman out of the blue, most people are just like you before it happens and they see no way that they could be so damaged by birth. It comes as a total shock and so there is no action plan to go on. By the time a woman is healed enough to deal with the obstetric institution without all the emotion that gets her dismissed, she is usually tired of the fight and moving on with her life so you are now dealing with a whole new group of women with fresh raw pain. This is why it is so important to try to get past the arrows that are being tossed at you long enough to see the message that is attached. The harsh words from women are a cry for help and a reflection of the pain that they are feeling.

        I don’t know what the answer is, I would love to find a way to help OBs understand what these women are experiencing, because I truly believe that if this happened we could prevent a lot of PTSD in young mothers. I am glad you are making an attempt to understand, thank you, we need more of that in the medical field.

  91. Washi
    July 29, 2010 at 4:33 pm

    If a woman doesn’t want to have any intervention in their labor, why come to the hospital at all?
    In case the baby is born needing special care.

    • July 29, 2010 at 4:39 pm

      Hospital based birthing centers address those needs fairly well. There should be more of them.

  92. July 29, 2010 at 5:03 pm

    Abbey :

    Nicholas Fogelson :want to control or hurt womenP>

    What if they don’t want to control or hurt them, but what if they feel that they have to control and hurt them to have good outcomes? Does this give them the right?

    Abby, I think you hit the nail on the head.

  93. Washi
    July 29, 2010 at 5:15 pm

    According to the American Association of Birthing Centers my state has none. My state also has the highest cesarean rate in the nation.

  94. July 29, 2010 at 6:37 pm

    OB doc :
    People: If this is really your experience, I urge you to go to a different hospital. Or a birthing center attached to a hospital…. Research your options for delivery–and that doesn’t just mean your doctor, but also your hospital. If your hospital doesn’t look kindly on your ideal plan (assuming all things are equal and you are a low risk patient), consider a different hospital. There are OBs out there (and certainly midwives too, but I’m just responding to the OB-bashing) who will explain things to you and answer your questions, and treat you with respect. Leave the rest of them to wonder why their patient numbers are dropping like flies

    Yeah this! But first there must be transparency in maternity care. And we birthing women must remember that we are consumers. We must walk with our feet and our health care dollars. Have full disclosure on induction rates, cesarean rates, episiotomy rates, vbac rates, etc. Make this info freely and easily available. Allow women to support those who practice evidenced based care. When this is in place, then those who who abuse their position will indeed wonder why they suddenly have no patients/clients.

    • July 29, 2010 at 6:40 pm

      Oops , I messed up the quote and reply. First paragraph is a subset of ob doc comment. Second paragraph is my reply. Stupid iPad typing.

      • VBAC Mama
        July 31, 2010 at 5:50 am

        I fully agree with your reply. Sadly, many women have no clue until all is said and done that they should have chosen a different doctor/midwife and birth location. I agree that maternity care needs to be transparent and all info needs to be laid out on the table. Of course any woman desiring a vaginal birth would choose not to birth at a hospital with a high cesarean rate. It is really hard to find the cesarean rate of hospitals and even harder to get them for individual doctors.

      • July 31, 2010 at 11:42 am

        Hmmm.. Did my early appearance with an iPad at REACHE get you to buy one?

  95. July 29, 2010 at 7:38 pm

    @OB doc – I can’t find your post on here so I’ll cut and paste from my email subs:

    “Statements like this only add to the “us versus them” mentality, regarding MW and doctors and providers and patients. If I said “all midwives are inherently inferior to all OBs because they have less formal training,” what would you say? I don’t happen to agree with that statement at all, having known and worked with many fabulous midwives, but it’s similar in tone and intent. I think most reasonable people would agree that the truth lies somewhere in the middle (oh, that people could see this in other walks of life…politics comes to mind as well.)”

    Read my earlier post re. us and them (birth wars). Perhaps I am finding it a little difficult to relate to this debate. I am from the UK where midwives and obs work in collaboration with respect for each others area of expertise. MW = supporting ‘normal’ and are the lead practitioners for most women. Ob = mw refer women to them if medical expertise is needed. This is the norm and funded by the government. There is not a them and us – we both need each other. Then again our system is very differently set up and the obs are happy to focus on complicated and leave the ‘normal’ to us mws. I worked with and learned lots from some amazing obs. Equally I have been asked to teach junior obs about normal birth and waterbirth. This is true collaboration and the safest way to provide maternity care.

  96. Laurel Brant
    July 29, 2010 at 10:27 pm

    Well said coffeegirl20, I thank you too.
    Drs. Tuteur and Fogelson, you believe the medical propaganda that has pathologized the normal physiological process of birth. It is the propaganda that originally took birth out of the hands of midwives and into the hospitals. It is what you have been immersed in before, during and after your studies. It is what allows Dr. Tuteur to use the breast biopsy analogy and the ‘preventative medicine’ argument. You believe it and we listen to you defend it.

    Some of us look at the situation quite differently. Birth is a process as digestion is a process. Some people choke while eating and they die. Some people develop bowel obstructions or Crohn’s disease and require intervention. Does every person get tested for all aspects of the digestive process such as HCl concentrations, peristalic action, gut bacteria levels, sphincter muscle strength, or whatever can possibly be tested as a preventative measure? How many lives might be saved? We assume the digestive process works fine until a problem develops. We assume the birth process works fine until a problem develops.

    Do you accept the premise that your attitudes toward birth are based on propaganda (i.e., the fear-based misconceptions used to convince women to move into hospitals)? Probably not. If you did, you would be faced with uncomfortable knowledge – just think of how many of your colleagues have made their reputations by cutting up women and putting their names to this study or that – Dr. DeLee comes immediately to mind. Do you recall what he did to black women while they were in their birth process? I don’t expect you to change your position as it would be a very dangerous thing for you to do. I do expect you to know that most of us recognize the difference between a cesarean section and a breast biopsy. Some of us have had both. You can call it ‘preventative medicine’ – I call it another thinly veiled attempt to rationalize your inhumane practices. I feel using such an analogy trivializes the inherent dangers of cesarean surgery to both the mother and her baby.

    Actually, I am tired of listening to the medical profession talking with authority about childbirth. I have experienced your forceps, your x-ray pelvimetry, your elective (preventative) cesarean section, your unsupported VBAC at home, twice. I am tired of listening to the same old clever manipulations of half-truths and of your need to be told what a good job you are doing. You’re not. You may have good intentions but you are not doing a good job and the statistics show it. There are many things you could do to make a huge difference and you are smart enough to figure it out. I need to be smart enough to know that I am wasting my time arguing with you. I just want other women to know that I support them, especially the Unnecessarean. I am tired both literally and figuratively. You make your money and my blood is all over it and you are hurt that I don’t say thank you. Women populated the earth rather well before the obstetrician made an appearance and that is something you might want to try and accept.

    • July 30, 2010 at 3:19 am

      ” Birth is a process as digestion is a process. Some people choke while eating and they die.”

      Some?

      What proportion of people choke to death each year? What proportion of women die in childbirth? What proportion of babies die in childbirth or shortly thereafter? Let me guess, you don’t know.

      The problem here is not propaganda, it is ignorance of the facts all the way down to the most basic facts. NCB advocates literally don’t know what they are talking about. Most of what they “know” is factually false.

      Look over this long list of negative comments. It is not a coincidence that there are no doctors.lawyers or physicists complaining here. Women who understand science and statistics can read the data for themselves. Women who cannot, and most NCB advocates lack basic knowledge of the scientific method, statistical analysis and even childbirth itself, make up all sorts of baloney and pass it around among themselves as “knowledge.”

      Reading the NCB literature and thinking you are “educated” about childbirth is like reading the creationism literature and thinking you are educated about evolution. Both are nothing more than made up mumbo-jumbo.

      If NCB advocates expect ANYONE to take them seriously, they need to learn the facts. And that means reading books and papers that have not been vetted, pre-digested and spoon fed back to them by other NCB advocates.

    • SaanenMother
      July 30, 2010 at 5:01 am

      “Actually, I am tired of listening to the medical profession talking with authority about childbirth. I have experienced your forceps, your x-ray pelvimetry, your elective (preventative) cesarean section, your unsupported VBAC at home, twice. I am tired of listening to the same old clever manipulations of half-truths and of your need to be told what a good job you are doing. You’re not. You may have good intentions but you are not doing a good job and the statistics show it.”

      amen.

    • Heather
      July 30, 2010 at 6:03 am

      Laurel, I don’t think it’s fair to lump Dr. Fogelson, who seems to be honestly trying to effect change for the better, in with “Dr.” Amy (who is not actually licensed to practice anywhere), and does her level dirtiest to keep maternity care in the shameful state it currently occupies. You’ll notice that, when people start asking her to substantiate her claims, she disappears.

      • July 30, 2010 at 8:16 am

        “You’ll notice that, when people start asking her to substantiate her claims, she disappears.”

        Stop making things up. I have offered to PUBLICLY debate Henci Goer, Jennifer Block, and Ken Johnson and have been turned down by all three. Celebrity NCB advocates don’t dare appear anywhere they can be questioned by a medical professional. The are well aware that their claims would be eviscerated in short order.

      • Melissa
        July 30, 2010 at 10:56 am

        I thought I recognized Amy from other boards…very heated and full of venom against NCB advocates. I wonder why no one will debate her…maybe because she likes to compare birth to breast cancer biopsies? LOL Or maybe because they recognize that it is more important for her to be right then that women have choices.

        You can prove your ideas with all kinds of statistics….there will always be studies to prove one side or the other…but what you fail to address, is why NCB is not a viable option in a hospital? Why is it nearly impossible to achieve…when you can answer that, you will be able to end this debate.

        While I don’t agree with OB’s on a lot…I still respect them for what they do. I just excercise my right to not use them, unless medically needed. And since that can only be guaranteed in a HB setting, that is where I choose to deliver my babies.

      • Heather
        July 30, 2010 at 6:15 pm

        I’m not making things up. Twice in this thread, you have been asked to provide links to back up your claims. So where are the links? The same has happened in the past couple of threads I’ve followed on other sites in which you have crept out from under your rock.

        Why will no one debate you?

        1. You’re NOT a birth professional. OR a medical professional. Once upon a time I was an insurance agent. I was licensed, and had the training and testing required by my state. I no longer sell insurance and my license has lapsed. This being the case, I do NOT try to pass myself off as an insurance professional, even though I still could sit down and pass the licensing exam. To do so would be dishonest. It is just as dishonest for you to list yourself as M.D. and allow people to assume you are a practicing, licensed, physician.

        2. The “birth celebrities” you list have probably decided that your irrationalities are not worthy of their attention. I know for a fact that there are lots of people who have decided that it is better to leave you to rant on alone, allowing everyone to draw their own conclusions. I agree with them. Which is why I usually limit myself to pointing out that you are NOT the licensed, practicing, physician you like to allow people to assume you are.

        3. Like as not, these luminaries have more important matters to attend to. Like making sure the physiological maternity care movement continues to progress.

        4. Advocates for physiological, evidence-based maternity care debate medical professionals all the time. They just do most of it where it really matters & not on online blogs. There’s plenty of such debate going on in state capitols all over the country. And those advocating for physiological, evidence-based, maternity care are mostly winning, despite most of our opponents wearing the title “doctor”, which often gets far more respect than it often deserves, AND despite the fact that the money is not on our side of the debate.

        5. I’m busy nursing my homeborn toddler to sleep. I have time to leave comments on blogs. These folks probably don’t.

  97. July 30, 2010 at 12:36 am

    OB doc :
    See above: when you sign a consent form for a surgery, you cannot allege “birth rape.” Sorry.

    Unfortunately, that is simply untrue. Even in cases of actual rape, if the woman in question felt pressured and felt she had no other options, it doesn’t matter if she signed her life away. Still rape. And it’s this type of callous attitude that leads to the castigation of OBs, who vehemently deny the subsequent trauma. Tell that to the women who, after lying strapped down on a table while their children were cut from them, experienced nightmares, tremors, anxiety, depression, and sexual side-effects for months (and sometimes years) afterward.

    What your knee-jerk reaction is failing to take into account is that “birth rape” is, at least in my case, not perpetrated by one individual. It’s rape by the process and the system. It’s the fetal monitoring, the drugs, the interventions, the drugs to counteract the drugs, the negative commentary on progress, more drugs, a cold and heartless OR, more drug side-effects, well meaning nurses who insist you should sleep and take your baby away, well meaning family who insist it was “for the best,” etc. It’s the sum of these experiences, filtered through the mind of the mother, that constitute birth rape. Do I believe my OB “raped” me? No. Am I glad she’s no longer at the practice I went to (a midwife-OB collab)? Yes. But she was just a small piece in the puzzle, one more negative voice in a sea of them. It doesn’t matter who held the knife – I couldn’t see it anyway.

    • July 30, 2010 at 3:56 am

      Obviously anybody can allege anything they want. That’s the nature of an allegation. Oops, semantics again :)

      The issue is one of perspective. As you describe it, the women feels like the entire birth experience was taken out of her hands, and out of her control. Things are done, that while technically consented for, felt against her will internally. Overall the experience feels like violation.

      In a methaphorical sense, I can understand that language.

      From the other point of view, a physician feels like they are being called a rapist for doing what they perceived as their job, and with the best intentions. That doesn’t feel so good, and creates anger.

      • CountryMidwife
        July 30, 2010 at 9:22 am

        Rape is such a strong, strong word and I wonder if the use of it as applied to OBs is really the root of this whole discussion rather than “unecessarean” which is a catchy pun.

        While I’m sensitive to, for example, Lisa’s example, an entire system failure cannot really be called a rape.

        But Doctor F., I have seen countless cases (hundreds, literally) of a woman saying “no no no not yet!” to a vaginal exam and thoughtless OBs, even midwives or nurses, for whatever reason, doing it anyway. Or a woman pushing and concentrating and someone thrusting their hand in to check for a lip without warning – and seen these women scream and cry in pain and fear.

        Penetration without consent, for any reason, really is rape. And the desensitization to woman’s bodies that OBs learn in residency (in part because most women they attend are anesthetized) needs to be urgently addressed.

        (And don’t get me started on the practice of multiple med students “learning” pelvic exams on unconscious surgical patients with ZERO consent – which happened to me when I was semi-conscious at age 15 just before an appy. Fodder for another post?)

  98. July 30, 2010 at 1:23 am

    I guess I’m in the minority here. I had one c-section that was emergent and even in retrospect required, a repeat that appeared required but in retrospect (would that we could live that way!) was not, and a VBA2C, all with medical-model OB-GYNs. The OB was supportive of attempting a VBAC again, given our intention to have several more children, and the possible risk of six or so c-sections in a row.

    I found the “unnecessarean” rhetoric pretty upsetting, even though I was the demographic it was aimed at. Caring for a new baby is hard enough without being exposed to inflammatory rhetoric about his entrance into the world.

    • July 30, 2010 at 3:57 am

      I think you’re in the far less vocal majority. Activism comes from dissatisfaction, not from contentment.

  99. Dana
    July 30, 2010 at 7:06 am

    Dr. Fogelson, I am honestly interested in your opinion here, and am glad you wrote this article. My question is a little off topic, but I would like to know what steps you think a woman can take to reduce her risk of C-section. Does being in a healthy BMI range pre-pregnancy, for example, have an effect? If she would like to have a TOLAC, should she avoid all types of induction? Where can I find some good studies to review in preparing for a TOLAC?

    • July 30, 2010 at 10:09 am

      It is a big question, but in short

      High BMI is associated with higher cesarean rates, Having a BMI < 25 is associated with fewer cesareans, and all kinds of other health benefits as well

      TOLAC that are induced have a somewhat higher rate of uterine rupture, but as long as only pitocin is used it is still around 1% if there is one prior low transverse scar. Still, awaiting spontaneous labor is going to decrease cesarean rates in all labors, TOLAC or not.

      As for studies – I'm not sure that scientific literature is going to 'prepare one for TOLAC'. It might help you decide if you want to do one or not. There are lots of papers out there, the recent Cochrane review is good. You might want to read my previous post http://academicobgyn.com/2009/12/17/ten-thoughts-on-vbac/ and the ensuing comment thread if you haven't already.

  100. CountryMidwife
    July 30, 2010 at 9:03 am

    A very thoughtful post from Lookup Doc at http://lockupdoc.com/2010/07/in-the-practice-of-medicine-less-is-sometimes-more/ which is so relevant to obstetrics…

    As the saying goes, when you’ve got a hammer, everything looks like a nail. Send a patient to a surgeon, and he very well might get surgery. Send a patient to a psychiatrist, and he very well may end up on psychotropic medication.

    As physicians, we need to take responsibility for our own actions. We should not prescribe or perform procedures unnecessarily. However, even if we are responsible for our own actions, not looking at our culture as part of the problem here would be a mistake.

  101. Candice
    July 30, 2010 at 10:11 am

    Amy Tuteur, MD :
    “You’ll notice that, when people start asking her to substantiate her claims, she disappears.”
    Stop making things up. I have offered to PUBLICLY debate Henci Goer, Jennifer Block, and Ken Johnson and have been turned down by all three. Celebrity NCB advocates don’t dare appear anywhere they can be questioned by a medical professional. The are well aware that their claims would be eviscerated in short order.

    No one will publicly debate with you Amy because you are rude. You don’t know how to make nice with others, and you are mean-spirited to anyone who has an opinion different then your own. You haven’t practiced Obstetrics in the last 2 decades…you stopped at a time when routine shaving was on the way out, and episiotomies were starting to become routine. Things have changed since then; reading peer reviewed papers, and studies does not put you in the know of what is happening on the L&D floors across the nation, or around the world. You spout statistics…sure, great, but you’ve got nothing anecdotal, no heart, nothing personal to add. And it makes you out to just be a cold-hearted B!^ch.

    • July 30, 2010 at 10:21 am

      “No one will publicly debate with you Amy because you are rude.”

      It’s not just me. No celebrity NCB advocate will publicly debate any medical professional or appear in any venue where they might be questioned by a medical professional. They know as well as I do that their claims are factually false, and that would be exposed for all to see.

      They are afraid, Candice, very afraid, as well they should be.

      • July 30, 2010 at 10:39 am

        And with that said, if anyone wants to debate Dr Tuteur, let me know. I would love to make a podcast of a debate between Dr T and any NCB advocate. I will moderate and be on the side, and demand that both parties be reasonably respectful. She’s game, how about one of you? Any takers?

      • Krista
        July 30, 2010 at 9:25 pm

        For what it’s worth- I did see Abby Epstein and Ricki Lake on the television show “The Doctors” where they did debate with the OB on there.

  102. daniel h. chappell, M.D.
    July 30, 2010 at 10:16 am

    Good to hear a success story.

    The rhetoric is mostly just that but some people have taken a bad story and multiplied to represent all of us (OB’s) and everything we try to do. Then they preach it to others as if it were gospel.

    • Melissa
      July 31, 2010 at 4:48 am

      You may choose to ignore it, because you don’t feel you are part of the problem…but that doesn’t mean that it doesn’t exist in your field and isn’t being perpetuated by your colleagues.

      These women are not being told how to feel…they already have these feelings and are just being given a place to tell their story, take another look at their experience and move on from there.

      No one is denying that OB’s save lives and some c-sections are necessary…we are only debating whether they are all necessary…which I think we can all agree is not always the case.

  103. July 30, 2010 at 10:46 am

    PrecipMom :

    Quick question: is a history of shoulder dystocia a known contraindication to vaginal breech birth? My comfort level is such that I would choose elective c-section with my history of shoulder dystocia if I had a persistent breech, but I don’t know if there has been any official evidence or recommendation regarding that risk factor.

    I realize that I misread your comment. I didn’t see the part about breech.

    I don’t think we have any data to look at whether a prior shoulder dystocia affects safety of subsequent breech delivery. Its a rare combination of events so its very hard to look at. Shoulder dystocia is multifactorial – a small pelvis is almost certainly part of the risk, but fetal size and position are also part of it.

  104. Washi
    July 30, 2010 at 10:50 am

    Why would anyone want to debate with a liar and sociopath? No thank you.

    • August 6, 2010 at 9:52 am

      I completely disagree, and find it a shame that the NCB movement people cannot tolerate a passionate and occasionally abrasive person that disagrees with them, yet tolerate many members who hurl vicious insults at OB/GYNs, even to the point of mock death threats. Amy Tuteur is extremely well read, and has an excellent command of the evidence. She does use debate tactics to push her points and ideas, which is a good idea when one is trying to further their message. I have heard her speak on several occasions, and find nothing remotely sociopathic about her, or ever noticed her tell a lie. A lot of folks make the ridiculous accusation that because someone else says something they think is wrong that they are lying. To call someone a liar because they disagree with you is playground argument tactics.

      • Aly
        August 6, 2010 at 4:10 pm

        Why don’t you debate Dr. F? I ask that sincerely because it seems it would be much more educational (perhaps you have and I missed it). It seems like pretty much all of the obs (maybe 4?) who have commented on here are somewhat sympathetic to the fact that there are women truly hurting out there because of their treatment in the medical system. Even if they don’t agree, they want to find a way to make childbirth a better hospital experience for women in this country, natural or not. That doesn’t have anything to do with interventions, but how a woman was treated by her medical team. That seems like you. Then we have someone like Amy who harasses mothers who have lost their babies in hb, on their own blogs, even after being BEGGED to stop by mourning mothers. Not to mention posting those stories publicly on her blog without permission (legal, yes, ethical, no). Most of her blog is a continual bashing of dirty, ignorant, “swindler” midwives. Midwives, of all people. Why would anybody take that up in a podcast, particularly with a moderator who has made it clear that he supports her “debate” tactics? I certainly understand being against homebirth, or even arguing sectioning every woman at 39 weeks as a precautionary measure. What I abhor is her tactics, particularly (at least lately) low on facts and high on hyperbole, repetition, and namecalling. Really, really suprised you don’t get that.

        The “NCB movement people” are not a homogenous group and if you don’t want to be lumped in with the very few obs who sexually molest their patients, some distinguishing on your side would be nice too. I understand it’s difficult after the names you’ve been called here. This midwife vs. ob war (that’s been going on for 100 years, maybe more) has GOT TO STOP. Dr. Amy (and a few other obs) and militant ncba do nothing to help the cause and women and babies suffer for it.

        And I’ve seen posts on Jill’s and other blogs condemning some of the crazies in the ncb movement, btw. There are many vocal ncba against unassisted birth. As for me, I’m not sure I’d be considered a natural childbirth advocate at all, as my position is one of pro-choice, whether that be homebirth, natural hospital birth, epidural, or elective cesarean. I think it’s sad that women are forced into a possibly less safe homebirth because some obs refuse to support the choice of natural childbirth in hospital.

        WRT mock death threats, I have read several obstetrician comments (on kevinmd i think) that any woman who is stupid enough to choose waterbirth or unassisted birth DESERVES to have her baby die. Yuck. It’s not right on either side, ya know? And no, these statements weren’t challenged by a fellow ob.

        Thanks for listening.

      • Washi
        August 6, 2010 at 6:19 pm

        “I have heard her speak on several occasions, and find nothing remotely sociopathic about her, or ever noticed her tell a lie. A lot of folks make the ridiculous accusation that because someone else says something they think is wrong that they are lying. To call someone a liar because they disagree with you is playground argument tactics.”

        I don’t throw the term liar around lightly. I’ve researched her questionable statements before. However I couldn’t be bothered writing up a lengthy rebutal to anything she says because I believe that’s how she gets her jollies; spreading false information, derailing conversations, upsetting people and wasting their time. It wouldn’t be productive. Due to the inflammatory nature of this blog I never took you seriously to begin with and you lost all credibility for me (and several others I noticed) when you offered her a soap box to stand on. So forgive me if I don’t care to “debate” with you either.

  105. Melissa
    July 30, 2010 at 11:29 am

    It concerns me that c-section should be considered “preventative” care by anyone…preventative implies you are preventing something…when in fact you prevented nothing…you are in fact treating a symptom of a condition, that in some cases could have been prevented but wasn’t. Preventative care would be addressing health issues and rectifying them in early pregnancy…i.e. changing the mother’s diet to prevent GD or pre-e, which are both diet related and often result in c-section deliveries.

    It doesn’t have to be a NCB vs. hospital protocols debate…we could give women a choice in how they labor…hospitals could offer NCB as an real option and actually let it occur, with OB’s there to step in when necessary. This is standard in a lot of other developed countries and they have much better statistics than the U.S. So it’s not about NCB advocates vs. OB’s…it’s about how the women are essentially taken out of the equation…when they are the most important part of it. You asked why someone wanting NCB would go to a hospital…there are many reasons…the most important being, why shouldn’t women be able to labor naturally in a hospital and have the piece of mind that if something were to occur that they would have immediate medical care? You are essentially saying that if they want medical backup that they need to be resigned to laboring in whatever fashion is deemed fit by the OB.

    Birth is not just a physical act…it is also emotional and spiritual in nature…and when you try to force it into a purely physical event and tell the woman she should be happy because her baby is alive & healthy…you are telling her to deny her feelings about herself, her birth and her well-being. Until OB’s recognize that there is more involved than just extracting a child from the womb, then there will continue to be a disconnect between the NCB community and the medical OB community.

  106. Candice
    July 30, 2010 at 11:31 am

    Nicholas Fogelson :
    And with that said, if anyone wants to debate Dr Tuteur, let me know. I would love to make a podcast of a debate between Dr T and any NCB advocate. I will moderate and be on the side, and demand that both parties be reasonably respectful. She’s game, how about one of you? Any takers?

    Nicholas Fogelson :
    And with that said, if anyone wants to debate Dr Tuteur, let me know. I would love to make a podcast of a debate between Dr T and any NCB advocate. I will moderate and be on the side, and demand that both parties be reasonably respectful. She’s game, how about one of you? Any takers?

    No offense Dr. Fogelson, but you won’t find anybody. Not because they are afraid, or unprepared, or unknowledgeable (though Amy would vehemently disagree) but because truly Amy is not worth it. It would not be a debate but a heated and angry argument. She is in it for a fight, not to help educate and learn. Ob’s and Midwifes/NCB advocates get into debates all the time…often times they both come away with further enlightenment and understanding of the other side. For example the breech birth conference held in Ottawa, Canada last October. It was attended by OB’s and miwives from around the world, everyone came around with new knowledge and understanding.

    Amy isn’t interested in any side but the one she sits on. It is literally like talking to a piece of drift wood, except the drift wood doesn’t name call and belittle.

  107. doctorjen
    July 30, 2010 at 12:39 pm

    Dr. Fogelson, I just wanted to thank you for your tone throughout your comment section. Despite some really nasty things being hurled your way, you’ve remained quite polite and civil and rational!
    I wanted to comment much earlier in the week, but I’m having one of those crazy weeks where I’ve had no time for anything but work and sleep and try to say hello to my family once and a while. I usually average a little over 1 birth a week in my own practice, but this week have had 4, involving 3 overnights, so am probably too fried still to be rational.
    I’m a practicing family doc and include maternity care in my practice. I have a fascination with birth and American birth culture as well, and read around a lot of the “birth blogs” that are out there. I do somewhat understand your point about the term “unnecessarean.” It’s especially unfortunate that it seems that some birth activists paint all doctors, and all interventions with such a broad brush. I really cringed reading some of these comments directed at you (especially a couple I saw before you managed to get them deleted.)
    It seems to me that the discussions around unnecessary cesarean sections fall into many categories, and just as it’s unfair to call all OBs evil, brainwashed rapists, all those who speak againt the high cesarean section rates aren’t the same either. There are a fair number of folks who have had terrible experiences out there, whose animosity towards physicians seems pretty justified. On the other hand, I’ve read some birth stories ending with very angry women that are mystifying to me, because the care described sounds very compassionate and thoughtful, but is assumed to have been evil because an intervention ended up being necessary.
    I really respect your willingness to let people talk about their stories here, and your stated opinion that it’s not about you and that you don’t have to be personally offended/hurt by people railing about OBs. I think it would be a great step for healing for many women if they could find someone in real life to do the same. I feel the same way – doctors have to have broad shoulders. If you are going to get personally offended every time someone doesn’t do things the way you want, or blames you for something that’s not your fault, or won’t adhere to what you feel is the optimal treatment plan, you’re going to end up one angry and unhappy physician! If folks want to rant about doctors, it doesn’t bother me much, and in fact, I find listening to those rants often helps me be a better physician because I get ideas about how to better explain things, and what to ask to make sure a patient really understands what I’m saying and recommending.
    I think I want to practice where you are – this place where women are given good informed consent all the time and never hurried or bullied. I saw some pretty awful things when I was in training – in one place the residents loved when a certain fellow was the in-house doc on call, because he’d allow forceps on every vaginal birth so the residents could get practice. Saw an awful midline episiotomy extend to a 4th degree with the forceps on a 16 yr old patient who’d only pushed 10 minutes (the informed consent consisted of the resident saying “I’m going to help you get the baby out”) Saw women badgered and bullied into things they didn’t think they wanted – epidurals especially (“this will be the worst pain you’ve ever had in your life, and the anesthesiologist is only available in the next 5 min, so if you don’t get an epidural right now, you may not get one.” Which was not true, since there was a dedicated OB anesthesia in house fellow – the nurses just wanted their patients quiet and in bed and soon as possible) I still see some crazy things – a town not far away has an OB practice that practices pretty obvious daylight obstetrics. All patients come at 38 1/2 weeks for induction – they start pit at midnight, doc arrives for AROM at 8 am, and everyone is delivered one way or the other by 5pm. Of course they have the cesarean rate that goes with this style of practice. My friend went to that practice and wanted to refuse a routine induction and was hasseled about it at every visit. At 38 weeks she had an ultrasound and was told her AFI was dangerously low (she later got the report – it was 10 cms) and she had to be induced urgently. She agreed to be admitted that night, but they called her in the afternoon and told her the hospital was full and she’d have to come in 3 days later instead. When she expressed concern that something might happen to her baby in the next 3 days since the doctor had said it was urgent to get the baby out, they told her it wasn’t that much of an emergency.
    Anyway, I also see many wonderful caring docs taking excellent care of their patients, of course. My point is just that when it comes to maternity care, I know when I run into a hostile person who thinks modern obstetrics is awful, some of them are coming from situations like the anecdotes above, and I can understand why they feel the way they do!
    I think more transparency in our decision making processes and better communication helps everyone be happier with decisions and ultimately outcomes. I think listening to our actual evidence is also great – those elective inductions in primips for example – I don’t find many women still wanting one once presented with the evidence for doubling the cesarean rate (conversely, I just had a client tell me yesterday “that’s the risk? Just double the cesarean risk? Big deal. What day can I come?) I think your list of things to do to reduce the cesarean rate is excellent, and sure seems to work in my own practice. I think we could do a lot to reduce the cesarean rate by just limiting inductions, not admitting before active labor, and not performing AROM with no indication (since it seems to increase the rate of non-reassuring tracings without providing a lot of other benefit.) Add in not calling failure to progress too quickly as long as the tracing is reassuring, and allowing women to make their own choice about VBAC and we’d really be heading somewhere!

    (side note on the cutting muscles thing: I have seen quite a few physicians describe cesareans to patients as cutting through the abdominal muscles, when they are actually referring to the fascia, since muscle is a term more folks understand. Also, I have on rare occasion seen my OB back up transect part of the rectus on one side if he just can’t get enough room to get the baby out.)

    • July 30, 2010 at 2:11 pm

      >> I have on rare occasion seen my OB back up transect part of the rectus on one side if he just can’t get enough room to get the baby out

      Happens sometimes – usually because there wasn’t enough room superiorly in the rectus dissection prior to hysterotomy

      >> I think I want to practice where you are – this place where women are given good informed consent all the time and never hurried or bullied

      If only we could reach that ideal…. I’m at a academic community hospital that practices fairly interventional obstetrics. Most of what goes on is inductions with epidurals and pit and everything most of the commenters don’t like. I’ve got great partners who do their best to get the best experiences for patients we can. We have a relatively high risk population with lots of sick women, so one definitely has to balance various priorities. I think we can accomodate someone who wants a non-interventional labor, though.

  108. VW
    July 30, 2010 at 1:19 pm

    Nicholas Fogelson :
    Not all all, but we do have statistics that show what the recurrence rate is. Women with a shoulder dystocia with no risk factors (like a baby > 4000 grams or maternal diabetes), have about a 10% recurrence rate. Given that only 10% of shoulder dystocias lead to fetal injury, and only about 10% of those are permanent, that’s still a pretty low risk of a long term problem. As such, you have to do a lot of cesareans to prevent those injuries, though you need fewer to prevent a non-injurious shoulder dystocia.

    I’ve heard those numbers before, could you provide a link to the source? Would like to review it with my statistician husband and put it in my files. Thank you!

    • July 30, 2010 at 2:09 pm

      Basket TF, Allen AC, Perinatal implications of shoulder dystocia. Obstet Gynecol 195:86:14-7

      Bahar AM. Risk factors and fetal outcome in cases of shoulder dystocia compared with normal deliveries of a similar birthweight. Br J Obstet Gynaecol 1996;103:868-72

      Smith RB, Lane C, Pearson JF. Shoulder dystocia:what happens at the next delivery? Br J Obstet Gynaecol 1994; 101:713-5

      Ginsberg NA, Moisidis C. How to predict recurrent shoulder dystocia. Am J Obstet Gynecol 2001; 184:1427-9

      Lewis DF, Raymond RC, Perkin MB, Brooks CG, Heyman AR. Recurrence rate of shoulder dystocia. Am J Obstet Gynecol 1995; 172:1369-71

      Pub med will get you abstracts, you’ll need some access to a medical library for the entire articles.

  109. VBAC Mama
    July 30, 2010 at 2:23 pm

    Dr. F,

    I appreciate this article while I might not completely agree with your take on it. As many others have said, the wording may be just an issue of semantics. It is true, and you and your colleagues would agree that the cesarean rate is too high and many cesareans could be prevented by “managing” differently.

    One commenter above mentioned that if she had been treated with empathy regarding her cesarean maybe she wouldn’t have harbored so much anger about it. I completely agree. The doctors and nurses who preformed/attended my cesarean birth acted as if it was no big deal. Yeah, it was no big deal *TO THEM*. But I was the one who had to take a newborn home who depended soley on me while I was recovering from major abdominal surgery. I missed out on the first few moments of my daughter’s life while I was being stitched up. When I got out of surgery, I didn’t even know what my baby looked like, and when I finally got to see her she had already been bathed and dressed. I was shaking so badly that I couldn’t hold her on my own without help. By the way, my cesarean was for breech presentation during labor. Cesarean was listed as the only option, and I had planned an unmedicated birth. I was disappointed and heart broken not just to lose the birth I desired, but because I missed out on those first precious moments with my daughter whose APGAR scores were a strong 9 and perfect coloring! Why the hell did they whisk her away from me so quickly….I’ll never know.

    Also, for many women there is emotional healing to take place after a cesarean as well. I can only speak for my own experience, but I felt that I was blindsided by the emotional impact of a cesarean that nobody (at least in the “medical community”) talks about. I think it would have made a great difference if my doctor or any of the nurses who cared for me during my hospital stay would have sat down with me and my husband and told me/us something validating like “I know this isn’t what you had planned. There is a range of emotions you might experience in the next months or years as time passes and whatever you feel is ok (there is no right or wrong way to *feel* about your cesarean).” followed by something empowering like “Just because this birth was a cesarean doesn’t mean your next birth(s) have to be. You can try for a VBAC next time.” Instead, there was nothing of the sort. I was left wondering if there was something wrong with me for the way that I felt emotionally about my cesarean. A little empathy/sympathy from the hospital staff would have gone a long way. I’m in no way saying that they were heartless and uncaring, but maybe when you see cesarean after cesarean day after day you become numb to it….if i can put it that way.

    You asked why women come to the hospital at all instead of staying home or birthing in a birthing center attended by midwives. I did just that with my VBAC last October! But ACOG frowns upon home birth, don’t you know!! :) And honestly, I was kinda suprised an OB would say that. With my first birth, I had an OB even though I planned on having a natural birth….why??? Well because that’s just what you do when you get pregnant- find an obstetrician and plan a hospital birth. Back then (3 years ago), I really didn’t even know midwives still existed, much less home birth! So there lies one problem: knowledge of and access to midwifery care. And then there’s another problem with the midwife/homebirth idea….ACOG doesn’t support it at all and many OB’s (Dr. Amy and those like her) tell women that midwives are inferior and babies born at home are likely to die. Who should we trust? What should we believe? I wish women didn’t have to dig so deep to find that if they are serious about having an unmedicated birth, their best chance at that is with a midwife who has specifically been trained in dealing with unmedicated births rather than an OB who has been trained to deal with high risk or “chosen” medical births. As for me, I am thankful that we have obstetricians who can safely deliver babies via cesarean if that is what will save a mom/baby from a deadly situation, but I choose to stay home with my midwife unless such a situation arises.

    And about a Dr. Amy debate….oh boy! I’m not sure if you read her blog or the blogs of NCB advocates, but many have tried to debate Amy. It’s useless, not because she’s a medical “professional” with the big bad “M.D” at the end of her name, but because she refuses to be respectful and resorts to personally attacking her opponent- she just plays dirty. Personally, I’d like to see YOU debate Amy on your stance that midwives and homebirth are a good option for women.

  110. Susan Peterson
    July 30, 2010 at 2:26 pm

    From what I can tell here, we shouldn’t put Dr. Fogelson and Dr. Tutelar in the same box. The former has some interest in listening and perhaps even in changing to some degree; I don’t believe that the latter does. She just wants to “get” the natural birth community. She doesn’t want to know the meaning of the Farm statistics, for instance, or she would have no trouble removing an aencephalic baby from the mortality statistics. And trying to equate a biopsy for possible breast cancer with a C section is either a deliberately specious comparison or a dead give away that she considers birth itself pathologic. I also have a word for the doctor who said that all vaginal birth causes some damage to the vagina. The analogy for that is that walking, running, frequent squatting and lifting, etc causes damage to the knees and other joints, which is why most people past 60 have some osteoarthritis. But that is what knees are for! One doesn’t call the normal process of becoming a mother, and turning from a primip into a multipara, “damage.” It is life, maturity. Suggesting C section for that reason is like suggesting that people live in zero gravity, were that possible, or that they never walk except on a padded floor, or suspended from the ceiling.

    I don’t think the more angry and vituperative comments here are useful, although I do understand the anger. I remember a feeling similar to the loss of power involved in rape, although I am sure much less in degree, because of something which happened in the course of a “spontaneously completed vaginal delivery.” I had had one C section and one mid forceps rotation delivery. Having a natural delivery had become the one desire of my life. I had birth fantasies instead of sexual fantasies. I wished for blizzards, natural disasters, anything that would give me an excuse not to go to the hospital. I felt no fear in those fantasies, as at some deep down level I was sure that I could give birth, but my rational mind had reasonable doubt, and to the hospital I went. My doctor had said that IF I could push out my baby myself I could deliver in the labor bed. He was a good doctor, the hero of the local home birth community, as he did home births and backed up midwives but he didn’t travel as far away as I lived, and the midwives who did, didn’t do home VBACS, saying, “If he thinks its safe, let him do it.” So there I was; my waters had grossly ruptured and I had had fast and intense labor in a pickup truck on the way to the hospital and arrived at 7 cms. I sent away the doctor who came in to offer me an epidural, puzzled why he was there at all, hadn’t my doctor told him I didn’t want that? A female resident came in unwrapping something and started to feed it up my vagina and I said sharply, “What are you doing?” “Putting in the internal monitor,” she said. “My doctor said I don’t have to have that!” I insisted. She went away. I had to pay for the monitor wire, though.(I was uninsured, so I got to see the bill.) So then I was pushing, at my own pace, and feeling wonderful and strong. At one point the doctor told me “We only give you two hours,you know.” I understood that he was under certain pressures also in the hospital setting, so this didn’t make me as angry as perhaps it should have. I asked him how long I had been pushing. “How long do you think?” he asked. About 20 minutes? I said. It had been an hour and a half. So I got up into a complete squat, and pushed like hell. I told him “I feel a little of that burning, stinging sensation.”I was feeling so powerful, so in tune with my body, so confident. He looked. And suddenly he was calling to have me taken to the delivery room. “But you said if I could push the baby out myself, I could deliver here!” I wailed. “Then it’s a good thing I lied to you.” he said. I was stunned. And I was furious. There was no saying “No” to going to the delivery room. Someone, I guess a nurse, pushed me down on the bed, out of my squat, while another one started dragging the bed/stretcher thing I was on down the hall. I was beside myself with anger. I was pushing with the strength of all that anger. The nurses were telling me to stop pushing, and I was saying “F-you” I am not like that, you know. It is hard for me to believe I talked like that. We got to the delivery room, just like an OR, table in the middle, and there I was trussed up with my legs in stirrups and covered with blue drapes, everything I didn’t want for my birth. I was scared my baby would come out on the floor as the doctor stood there by the door, tugging on his gloves. “Get the f-over here and catch this baby before it falls on the floor!” I yelled at him. He did, and in another moment he was apologetically holding up my son. “Next time you can stay home,” he said sort of sub voce when the nurses weren’t close by. “And YOU won’t be anywhere near me!” I thought. He asked how big I thought the baby was, and I said, “Oh 9 1/2 lbs like the other two.” He shook his head. They came back from weighing the baby; he was 11lbs. Later, in his office he told me that such a big baby was a panic issue for him, because when he was in training he had a baby die, the woman was a diabetic, she had been knocked out and couldn’t help, the shoulders got stuck, he hadn’t yet been taught what to do, there was no one else around, and the baby died. He also told me that once he was delivering a baby at home, which turned out to be over 11 pounds, the shoulders were stuck and the mother’s butt sank in a soft bed, and he couldn’t get in there to unstick them. ‘We propped her on some pillows and it turned out all right. But all the time I was having flashbacks to that baby that died.” So he said when he realized how large my baby was, he felt he had to get me where he would have room to maneuver. He admitted that no such maneuvers had turned out to be necessary, but he hadn’t known that. Now, had he told me why he wanted to go to the delivery room, I certainly would have cooperated, and I wouldn’t have given birth while in a state of complete fury at what felt like a betrayal. But as it was, I did feel as if I had been in control and pushing powerfully and going to give birth actively, and that I was shoved down and had no further part in the process, my baby was taken out of me. (I think I must have been given an episiotomy and the baby just came out.) Because of the explanation, which was very human and humble, I forgave him, but I still was depressed over it for quite a while. I guess his inexplicable comment “Then it’s a good thing I lied to you” must have come because he was very anxious at that moment, and he felt hurt that I didn’t assume he had a good reason for what he wanted to do. I can imagine a calm query as to why might have elicited a different response from him, but that’s a lot to expect of a woman who is about to give birth!
    I did take his comment to heart, by the way, and stayed home the next time, and the time after that and…..I had six home births, including one baby who was 12+lbs. (And yes, I probably did have GD in the two pregnancies with the hugest babies, but I had passed the GTT in two other pregnancies after the 11 pounder, so it wasn’t done in that one that produced the 12+ lb baby, not so much testing done back then.)
    For women like myself, and many who have commented here, control is very much an issue. I don’t think we should doubt the doctor’s comments that many women he takes care of do want to leave everything up to him, do want to be induced, do want above all to avoid pain. I guess for those women it is perhaps even more important not to abuse their absolute trust.

    It also should not be necessary for people to choose between such an intensely interventional medical model as prevails now, and going it alone. What we were always looking for was a cooperative relationship in which there were trained home birth midwives in collaboration with doctors available for advice and to take over in those cases in which the natural process was not working-which definitely exist, although they are not nearly so numerous as I think you OB’s believe they are.

    Again, I do appreciate that Dr. Fogelson is willing to engage in this dialogue.

    Susan F. Peterson

    • VBAC Mama
      July 30, 2010 at 6:08 pm

      In my comment that Dr. Fogelson should debate Dr. Amy, I didn’t mean to “throw them into the same box” if that’s how it came accross :)

      Though I do think it would be interesting to hear 2 different OB’s with obviously different outlooks on birth matters debate. A Dr. Amy vs. NCB advocate debate is useless and unproductive as she pretty much sees it as herself the “mighty MD” vs. the inferior incompetent midwife/doula/mom. Seeing 2 people with the same kind of education in the same profession debate would be better in my opinion.

      We all know that Dr. Amy always has her boxing gloves on ready to get in the ring with a NCB advocate….but is she willing to debate with another OBGYN who happens to see things differently than she does?

      I also think it is great that Dr. Fogelson has taken the time to respond to comments on here!

  111. July 30, 2010 at 2:40 pm

    “She doesn’t want to know the meaning of the Farm statistics, for instance, or she would have no trouble removing an aencephalic baby from the mortality statistics.”

    If you remove babies with congenital anomalies from The Farm statistics, then you MUST remove them from the hospital statistics, too. When you do that, The Farm still has triple the neonatal mortality rate of comparable risk hospital births.

  112. July 30, 2010 at 3:41 pm

    Nicholas Fogelson :And with that said, if anyone wants to debate Dr Tuteur, let me know. I would love to make a podcast of a debate between Dr T and any NCB advocate. I will moderate and be on the side, and demand that both parties be reasonably respectful. She’s game, how about one of you? Any takers?

    What would the topic of debate be? My innitial impression, as someone who sees many shades of grey in every sitaution, is that it would be irrelevant to debate someone who seems to see only black and white (and the bitterness is a huge turn off, too) I’m sure I would fall into the catagory (possibly the outer fringes even) of NCB advocates, but I consider myself a Woman’s advocate first and formost…. So if the debate were “which kind of birth is best” how could one side possibly win? No formula for birth is best for everyone (I’d debate that if someone disagrees) and if the debate is “what do the statistics prove?” it’s not a real debate- ask a statastician to answer that. But if the debate is “Should women have the right to birth however they choose?” or “Does our maternity system need improvements?” I am seriously considering it. I suspect that, if in fact, Amy’s offer to debate has been turned down, it’s because her presentation is hard to take seriously (and reading your comments here it seems a contradiction that you do) I’m only interested in being productive…

  113. RuralObGyn
    July 30, 2010 at 4:39 pm

    Thanks to Dr. Fogelson for honestly trying to bridge the very large gaps between women who want a different kind of birth than the “hospital ticket” provides, and ob/gyns who work hard to practice safe and respectful obstetrics. 312 comments take a long time to read and there is a world of pain out there. Though few OB’s have posted here, some of the commenters would be surprised at how much hurt there is among us too. I am under no illusions that most of you would feel compassion for OB’s. Yet to move forward we all need to understand where we come from, how decisions are made, and the environments we face. I am glad to see some dialogue here, not just ranting. Maybe someday we can really talk to each other. Thanks again, Dr. F!

    • VBAC Mama
      July 30, 2010 at 6:12 pm

      I’d be interested to hear about some of the hurt that is among the OB crowd….while still respecting privacy of patients of course. But it might change the way some of the hurt and angry women feel about doctors if they would show their hearts too.

      • July 30, 2010 at 6:14 pm

        Hurts to pour your blood sweat and tears into years of education, 100+ hour weeks of residency, and 70 work weeks therafter, truly believing that you are doing the best you can for your patients, and then get called a rapist.

      • Melissa
        July 31, 2010 at 3:30 am

        The women who use that term, hopefully are using it to speak directly of their own personal experience and their own OB and not at the OB community as a whole. Rape is a very strong word, so just think of the kind of hurt & pain that is behind it.

  114. Statler&Waldorf
    July 30, 2010 at 6:48 pm

    Amy Tuteur MD said, “If NCB advocates expect ANYONE to take them seriously, they need to learn the facts. And that means reading books and papers that have not been vetted, pre-digested and spoon fed back to them by other NCB advocates.”

    As opposed to the women who are not NCB activists who read general pregnancy and birth books written by medical professionals who have vetted, pre-digested and spoon-fed info back to the reader, or simply listen to pieces of information spoon fed to them by their MD during their pregnancies and births? I don’t suppose that information is ever limited or biased?

    The vast majority of men and women out there are not doctors, academics or statisticians so they often rely on info being analyzed and presented to them in a way they can understand. It is the responsibility of those analyzing and presenting the info to be fair, balanced and truthful about the information. Unfortunately, the propaganda is working both ways. Both medical professionals/academics and NCB advocates should be able to be honest when presenting research results and giving recommendations for ob-gyn practice. I’m not letting anyone off the hook for creating bad research, obfuscation, dishonesty or conflict of interest.

    Nicholas Fogelson and other MDs commenting here are openly communicating about issues with ob-gyn care, commenting on flaws in the system, being empathetic to patient stories, and appear to want to work towards better outcomes and satisfaction amongst their patient groups. It seems most are practicing ob-gyns or MDs with motives based on improving the care they give their patients.

    Amy Tuteur’s motives are to de-bunk and subsequently eliminate the natural childbirth movement, midwifery, and homebirth. Her attitude on her blog is “Look at the NCB morons making false claims again (citing her analysis of a research study). Let’s pity those idiotic women who drink the kool-aid. Let’s all have a laugh at them with my witty satire posts.” Hmm, not very professional. But she doesn’t have to be professional because she isn’t accountable to any medical board, medical institution or any professional affiliations. She hasn’t published academic articles or books related to ob-gyn research or analysis. And she wonders why no one has been interested in debating her?

    Let’s get a credible, professional, well-intentioned ob-gyn or MD to debate NCB activists if it is commonly felt that NCB activists are spreading misinformation to families. I bet there would be interest, and if not, then maybe those NCB activists need to reconsider whether their assertions really are backed by enough scientific evidence if they feel they cannot debate. The debate topic(s) should be narrow enough to pin down appropriate studies and data, and include discussion of the shades of grey that are also significant when discussing pregnancy and birth issues. I would love to hear a podcast debate!

    Thanks for your post Dr. Fogelson, even if I don’t agree with all of it. I really appreciate your efforts to bring dialogue between patients and doctors about their ob-gyn care. (And I still wouldn’t mind more informative and detailed discussion on cervical lip incidence, effect on second stage, complications, treatment etc.)

    • July 31, 2010 at 2:06 am

      “As opposed to the women who are not NCB activists who read general pregnancy and birth books written by medical professionals who have vetted, pre-digested and spoon-fed info back to the reader”

      When was the last time you heard one of them boast that she is “educated” about obstetrics because she read “What to Expect”? Never, of course. That’s because those women understand that they have read books written for lay people and that does not qualify them to judge what is and is not appropriate obstetric care. If only NCB advocates recognized that reading NCB literature does not make them “educated” about obstetrics and certainly does not qualify them to judge the appropriateness of specific obstetric practices.

      • Melissa
        July 31, 2010 at 5:07 am

        I am highly educated, but don’t consider myself an expert in obstetrics…just informed enough about childbirth to make my own decisions based on the facts as I see them. I would think that any practicing OB would like for his patients to feel confident in the decisions they are making and not just blindly following what they are told. An OB is there to serve his patients…not dictate care. Just because they are highly educated doesn’t qualify them to make my health decisions for me…just to advise on what they feel are the best options. The decision ultimately belongs to the individual. Just as you don’t let your doctor dictate to you…you listen to what they have to say, look at the circumstances & possible consequences and decide for yourself. NCB advocates are only asking for that same right.

  115. VBAC Mama
    July 30, 2010 at 7:10 pm

    Dr. F,
    Hopefully none of your “real life” patients have ever called you a rapist or felt that they were a victim of “birth rape” while they were in your care. Especially if you are a doctor who makes a conscious effort to make sure your patients are well informed and consent to procedures before they are performed.

    I don’t believe the word “rape” is one that should casually be thrown around. But I also don’t think that sticking your hand in a vagina is as casual as a tap on the shoulder. I think docs need to keep it in mind that the body parts they are dealing with are “private parts” that the women only let their partners see/touch. It’s important to be respectful and sensitive about it. I know many doctors probably strive for this, but some sadly likely don’t.

    I was going to quote what someone said above, but couldn’t find quick enough looking through over 300+ comments. Someone had said something about the cervix checks for dilation where the woman says “no” or “wait” and the doctor shoves his/her fingers up there anyway with the woman screaming in pain and fear. Would you not call that “birth rape” or at least “assault”? What should women do if/when their doctors or midwives do such a thing to them when they specifically said not to or to wait for the contraction to be over?

  116. Krista
    July 30, 2010 at 8:09 pm

    Nicholas Fogelson :
    But is that lying? Its a physician explaining the risks and benefits as they see it, given their experience and training.
    If folks want OBs to look at pregnancy as a completely low risk event that will always go well, maybe they’re being a little unrealistic. Most OBs see risk in pregnancy because they spent four years of residency working with very complicated pregnancies and seeing a lot of bad outcomes. In a lot of ways this biases their view (an mine in some cases.) I agree with Sharon (commented down lower) that a system where midwives work with low risk patients and have OB backup can work very well, and with many patients is preferable to primary OB care.

    Yes, there are risks to everything in life. However, lying by omission is still lying in my book. That is NOT *informed* consent. In my opinion, surgery should always be given as the treatment of last resort where risks of surgery are clearly outlined and discussed. That often does not seem to be the case in obstetrics. I rarely hear of truly informed consent.

    I completely agree with what you’re saying re: OB training. OBs are trained for surgery and high risk. They should stick with what they’re good at and send all 90%+ of their low risk patients to midwives trained in the normal physiological process.

  117. Statler&Waldorf
    July 31, 2010 at 3:29 am

    Amy Tuteur, MD :
    “As opposed to the women who are not NCB activists who read general pregnancy and birth books written by medical professionals who have vetted, pre-digested and spoon-fed info back to the reader”
    When was the last time you heard one of them boast that she is “educated” about obstetrics because she read “What to Expect”? Never, of course. That’s because those women understand that they have read books written for lay people and that does not qualify them to judge what is and is not appropriate obstetric care. If only NCB advocates recognized that reading NCB literature does not make them “educated” about obstetrics and certainly does not qualify them to judge the appropriateness of specific obstetric practices.

    Once again, the language you use is so patronizing to lay people and NCBers. Not all NCBers are saying they are educated like an medical professional. What they are educated enough to do is ask those medical professionals more questions about their care and help decide what kinds of risks they want to accept instead of just going with the risks the doctors or hospitals will accept in their medico-legal context. That’s what many in the birth world mean by educated, not that they are as educated and skilled as an ob-gyn. Once again your true colours are coming through – “Patients don’t have a clue. They should just shut up and accept what their expert doctor has decided will be done.”

    • July 31, 2010 at 3:48 am

      Excuse me, but you are the one who made a derogatory comment about lay people who read books like “What to Expect.” By reading the NCB literature, you are no more “educated” than they are; the problem is that you don’t realize it. Reading the NCB literature to become “educated” about childbirth is like reading the creationism literature to become “educated” about evolution. In both cases, the literature is biased, incomplete and often factually false.

      • Melissa
        July 31, 2010 at 5:21 am

        This made me giggle! “What to Expect” could be more accurately called ‘An Idiots Guide to Having a Baby”…it is just enough information for a person to not be ignorant of the process, so they don’t ask too many stupid questions of their OB, but scared enough of all the <1% risks that can occur in pregnancy and childbirth that they won't question anything they are told to do. I wouldn't call anyone "educated" after reading it.

        You say that NCB advocates are not educated or knowledgeable…have you ever attended a NCB, Amy? Have you ever been present and experienced the birth of an infant in that environment…then you are also speaking out of ignorance and should not debate it until you have.

        Also, love the comparison of creationism vs. evolution…are you still waiting for that half ape/half human exihibit at the zoo? I am…not all theories are correct…the world is also not flat…the sun does not revolve around the earth…and I hate to break it to you, but the possibility of there being intelligent life out there is highly unlikely. But keep looking up, Amy!

      • July 31, 2010 at 5:28 am

        “have you ever attended a NCB, Amy?”

        Not only have I attended hundreds, but I’ve had some myself.

      • Statler&Waldorf
        July 31, 2010 at 6:04 am

        Re-read, because I said nothing derogatory, unlike what you wrote about NCBers “not recognizing” (aka too stupid to understand) that what they read doesn’t make them as educated as a doctor. And this is a doozie too;

        Amy Tuteur MD said “Look over this long list of negative comments. It is not a coincidence that there are no doctors.lawyers or physicists complaining here. Women who understand science and statistics can read the data for themselves. Women who cannot, and most NCB advocates lack basic knowledge of the scientific method, statistical analysis and even childbirth itself, make up all sorts of baloney and pass it around among themselves as “knowledge.””

        Exactly how do you know what professions the women “complaining” here belong to? Perhaps you have your own biases as to the education level and types of professions found in the NCB community. Call me weird, but I can imagine that scientific women could find themselves on the receiving end of a traumatic birth experience with substandard care and/or a c-section they didn’t need. I don’t know how their knowledge of science is supposed to make them ok with what happened.

        Amy, you don’t hold all pregnant women to the same standards of reading primary research for themselves. Would you consider someone reading more sources and reading sources covering a variety of perspectives on a topic, as being AS educated on that topic as someone who has read one or two general sources on the topic? Oh well, there is no point arguing about this anyway, because you stated here and on your blog that essentially the only people educated enough to make decisions about care during a woman’s pregnancy and birth are the medical professionals.

  118. daniel h. chappell, M.D.
    July 31, 2010 at 5:35 am

    Amy, be careful, you just insulted two groups of people at the same time. I am a creationist and a scientist.
    But to counter S & W, I have to admit, though I am thoroughly educated in the anatomy of the heart, the physiology of circulation, the chemistry of coagulation and cell death, I did just “shut up and accept” what the expert cardiologist decided what would be done when I had a heart attack. I had to trust that he/she had my best interest at heart and was not doing the procedure just to make money. What is missing here is trust. If you can’t trust your doctor, you are in the wrong place.
    Heart attacks are a natural process, over half survive, most of those heal enough to function. I did not just trust in the process, I trusted in my doctor and his choices, as a result I have survived and done well. I want all my patients to survive and do well. (whether I get paid or not)

    • July 31, 2010 at 6:37 am

      This is an interesting point.

      Someone asked about how OBs feel about all of this, where they find emotional difficulty in these things.

      How about this – Think about how difficult it is to think about all of the medical issues involved in anything – the patient’s history, physical findings, labs, indexing that all with your knowledge and experience, trying to figure out where that knowledge and experience are lacking and you need to go read more, finally trying to help the patient make a decision on the way to go. That in an of itself is hard. Its really hard.

      NOW – add on the fact that the patient doesn’t trust you.

      At this point, only a subset of physicians can continue to operate at their best in this situation. The basics of medicine are hard enough. Trying to take care of a hostile patient pushes it over the edge sometimes. Add on the feeling (right or wrong) that a patient’s hostility and distrust implies that they will blame you for a bad outcome, and suddenly medicine feels like a big ball of hurt.

      That is what doctors face when people come to them with a huge chip on their shoulder about what medicine is.

      The media has pushed the world to “question your doctor”. They should have said “ask questions, be a part of the process”. Perhaps this is semantics, but it feels different from the other side.

      • Statler&Waldorf
        July 31, 2010 at 7:20 am

        It must be very hard to deal with hostile and mistrusting patients. I hope that when you meet this kind you have some successful techniques for diffusing their hostility and winning them over to trust in you and your quality of care.

      • Abbey
        August 1, 2010 at 2:29 am

        Nicholas Fogelson, MD :NOW – add on the fact that the patient doesn’t trust you.

        Why don’t patients trust their doctors though? Trusting your doctor is very important. Should patients go in with a blind trust or should there be a basis of trust?

        I had met with the doctor at my birth previously in the office. When I told her that I desired to walk around. Her response was, “I know what the research says but the jury wants to see the EFM tape.” So I had the doctor that was there the day that I went into labor tell me that she knew that research shows that what I wanted yielded better outcomes but she was against it because it provided better legal protection for her if by a small chance something went wrong.

        Would you have trusted this woman? No, you would have been crazy to.

        Doctors need to realize that trust is very important and foster and earn it with their patients over the course of their pregnancy, not expect some sort of blind devotion. They need to be taught this. They need to be taught about human beings and how to relate to them. Knowing how to slice open an abdominal cavity and pop a baby out of it and then sew the woman back up without the expectation of death is all well and good, but it’s not everything.

        *Once again, this was the only OB practice at the hospital that I was near at the time. It was a large practice, the next hospital was a long ways away. I took my chances and paid the price. I still didn’t deserve what happened to me.

    • CountryMidwife
      July 31, 2010 at 12:50 pm

      daniel h. chappell, M.D. :
      If you can’t trust your doctor, you are in the wrong place.

      Yep, bullseye. Too many doctors practice in a manner that does not warrant trust. I have been in maternal-child health in ALL settings, in America and in a developing nation, for 17 years. I am now a rural nurse-midwife doing 50% freestanding birth center, 35% home, and 15% hospital births. I have obstetricians who are very close personal friends. But by and large, I find Obs to be untrustworthy too often (even my friends) – especially, again, when true maternal-fetal well being conflicts with personal convenience or comfort even when the evidence is against them. They freely admit it to me! I just want Obs to take a long hard look at themselves – and ACOG seems to be anything but nurturing to real self-examination, progress or change.

      • CountryMidwife
        July 31, 2010 at 12:55 pm

        Nicholas Fogelson, MD :
        How about this – Think about how difficult it is to think about all of the medical issues involved in anything – the patient’s history, physical findings, labs, indexing that all with your knowledge and experience, trying to figure out where that knowledge and experience are lacking and you need to go read more, finally trying to help the patient make a decision on the way to go. That in an of itself is hard. Its really hard.

        I don’t know, Dr. F, that reeks of a little insincerity to me. When so often of the time, we’re talking about waiting a few extra hours when FHR tracings are reassuring. Or of taking an extra 30 minutes (over an entire pregnancy) to establish relationship, communication and true informed consent.

      • July 31, 2010 at 1:05 pm

        I’m not sure what about what I wrote sounds insincere, but it wasn’t.

  119. daniel h. chappell, M.D.
    July 31, 2010 at 5:36 am

    Dr Tuteur, be careful, you just insulted two groups of people at the same time. I am a creationist and a scientist.
    But to counter S & W, I have to admit, though I am thoroughly educated in the anatomy of the heart, the physiology of circulation, the chemistry of coagulation and cell death, I did just “shut up and accept” what the expert cardiologist decided what would be done when I had a heart attack. I had to trust that he/she had my best interest at heart and was not doing the procedure just to make money. What is missing here is trust. If you can’t trust your doctor, you are in the wrong place.
    Heart attacks are a natural process, over half survive, most of those heal enough to function. I did not just trust in the process, I trusted in my doctor and his choices, as a result I have survived and done well. I want all my patients to survive and do well. (whether I get paid or not)

  120. daniel h. chappell, M.D.
    July 31, 2010 at 5:41 am

    I apologize for the first name reference in the first rendition of my post, it was not intended to be patronizing or imply familiarity. I tried to stop it being posted but failed. Please forgive me.

  121. Statler&Waldorf
    July 31, 2010 at 6:06 am

    Amy Tuteur, MD :
    “have you ever attended a NCB, Amy?”
    Not only have I attended hundreds, but I’ve had some myself.

    What is your definition of natural childbirth?

    • July 31, 2010 at 6:12 am

      “What’s my definition of natural childbirth.”

      The same as yours.

      • Statler&Waldorf
        July 31, 2010 at 6:50 am

        Well, my definition wouldn’t be as narrow as this, but this is what a homebirth can look like. Natural spontaneous onset of labour with no pitocin augmentation, no IV, no continous electronic fetal monitoring (intermittent hand held doppler instead) full movement during labour, no pain meds, baby birthed in any position mother feels most comfortable, no episiotomy, no pitocin to speed removal of placenta, delayed cord clamping until umbilical done pulsing. Baby immediately stays skin to skin with mother (as long as healthy) and encouraged to suckle.

        Some feel natural childbirth is birth with no pain meds, but I’d call that an unmedicated birth. Also some call a vaginal birth a natural birth, but I’d call that a vaginal birth. Hospitals see many unmedicated vaginal births, but I think the only natural births they see are the ones where the woman turns up and births almost immediately before anything can be done to her.

    • Melissa
      July 31, 2010 at 7:11 pm

      I was going to ask the same question. I find it very hard to believe that you have attended 100’s of NCB or had one yourself and yet are so anti-NCB. What I mean by NCB is mother directed labor…meaning the woman labors in an environment and in a manner of her own choosing, without medical intervention and pain medication. Is this similar to your definition or are you trying to imply that an unmedicated/vaginal delivery in a hospital is NCB?

  122. Statler&Waldorf
    July 31, 2010 at 6:28 am

    daniel h. chappell, M.D. :
    But to counter S & W, I have to admit, though I am thoroughly educated in the anatomy of the heart, the physiology of circulation, the chemistry of coagulation and cell death, I did just “shut up and accept” what the expert cardiologist decided what would be done when I had a heart attack. I had to trust that he/she had my best interest at heart and was not doing the procedure just to make money. What is missing here is trust. If you can’t trust your doctor, you are in the wrong place.
    Heart attacks are a natural process, over half survive, most of those heal enough to function. I did not just trust in the process, I trusted in my doctor and his choices, as a result I have survived and done well. I want all my patients to survive and do well. (whether I get paid or not)

    It would be great to trust the doctor, but malpractice happens. Patients can be ignored, mistreated, neglected, injured, and killed in hospitals where people always have the best intentions.

    I don’t see how heart attacks being a natural process can be compared to birth. A heart attack is always dysfunctional and has life-threatening results. Birth is not always dysfunctional and does not always produce life-threatening results. For both of my labours and births I can’t think of one medical procedure (besides some perineal stitching) or intervention that would have improved the birth or made us healthier. Of course, all births are not this way, sometimes a little help is needed and sometimes a lot. The point is that there is no need to treat all births like a high risk medical event without indication that it is so. You cannot say the same for a heart attack.

  123. Laurel Brant
    July 31, 2010 at 6:38 am

    Dr. Fogelson, I’d like to think that you are sincerely wanting to bring about change – change to the existing maternity system and, perhaps, to your own practice. For the system to be more responsive to the needs of birthing women, women’s voices must be heard.

    A career in obstetrics is chosen for any one of a number of reasons or a combination of reasons (a desire to help women and/or babies, following a family tradition, some wish for domination/control/power, to punish women, to be thanked repeatedly for saving lives, a subconscious quest to resolve personal birth trauma/imprinting, to experience the adrenalin rush of saving lives, to witness the indescribable miracle of birth, and probably for many other reasons – or maybe it’s for the money!) Speaking about money, it is my understanding that obstetricians generally make decent incomes. You have entered a profession built on the shoulders of others and having a reputation created by those Drs. of the past and also, of your own colleagues. Good or bad; like it or not, it is their legacy that you have ‘inherited’. All the hours of studies that you have mentioned (and the educational costs that you didn’t mention) may not have prepared you for this ‘legacy’. What has happened to women at the hands of your predecessors and of your colleagues has, in some instances, been very negative – pathological even. Faced with that reality (if you believe it), what do you do? How do you feel?

    Why do you feel defensive? This is an important question for you to ask yourself and to find the answer to. This is what will make the difference to how you respond to the hurt and anger women are expressing. You were motivated to start this blog thread and the responses have given you an opportunity to explore your own feelings/reactions – what a gift! And, I would like to say, it is a gift to me to have this dialogue with you as we are all noticing, few of your peers have identified themselves. By the way, do you get paid for doing this? I think you should be but I also think we should know if you are. There already exists such a disparity between the ‘paid’ professionals and the ‘unpaid’ clients/patients/volunteers who work so hard to make the system more responsive to the needs of birthing women. The ‘unpaid’ so often get tired, frustrated and burn out.

    I could say something about the importance of the ‘evidence’ and its place in actual medical practice but not now, as it is long and involves my personal experience. Suffice to say that after 30 years of studying trends, research and the ‘evidence’, I have come to the conclusion that birth is an affair of the heart. Physicians are not Gods, and, with rare exceptions, Mothers are not irresponsible – we care more about our babies than anyone. When the mental and physical issues are confusing and decisions are difficult, I remember the words of Blaise Pascal, “The heart has reason for which reason knows nothing of.”

  124. July 31, 2010 at 6:42 am

    >> By the way, do you get paid for doing this?

    Paid to be an OB/GYN, yes

    Paid to blog, very little. The podcast is sponsored by another company, but I own that company. If you see any other industry sponsorship on the site or on the podcast, you can assume they are paying for it. If I mention a particular surgical instrument on a surgical video, I’m not getting paid to do that (not right now anyway.) I have gotten some industry sponsorship for some dinners put on for the blog and podcast. If you click on links to books on the site and buy through those links, the blog gets a percentage of those sales. All in all the expenses are greater than the income.

  125. Washi
    July 31, 2010 at 7:43 am

    Melissa :
    The women who use that term, hopefully are using it to speak directly of their own personal experience and their own OB and not at the OB community as a whole. Rape is a very strong word, so just think of the kind of hurt & pain that is behind it.

    I use that word to speak directly of my own experience and not of the whole community. It is the right word to describe what happened to me.

    • Melissa
      July 31, 2010 at 7:18 pm

      I was actually directing that comment at Dr. F…as he seemed to be taking the term personally. I agree with the use, because I know women who have been treated in this way, so I know it happens.

  126. daniel h. chappell, M.D.
    July 31, 2010 at 8:35 am

    S & W, I am sorry that you can’t trust your doctor.
    To add “malpractice” to the discussion leads to a whole different direction. It seem the discussion has been mainly about what is accepted care as opposed to “malpractice” that is not accepted care.
    Much of the debate has not focused on when doctors go wrong and do things that below accepted care but rather it is focused on when doctors do more than what is desired.
    “Malpractice happens.” But malpractice by definition is not just errors happening but requires a standard that is expected AND evidence that the care provided falls below that standard AND evidence that this falling-short caused an injury.
    Much of this debate has been on the other end of the spectrum. Most of these people think that there is too much medical and surgical care, not too little.
    There is, indeed, much room BELOW the accepted “standard of care” where some doctors can practice and still not cause injuries. But also, there is much room at or ABOVE the standard of care where most doctors practice and can still cause injury without being considered “malpractice”.
    So, I ask, please don’t add the word “malpractice” to the discussion. It is fear of this word that drives many doctors to do some of these things that natural childbirth advocates abhor.

    • Statler&Waldorf
      July 31, 2010 at 4:12 pm

      Sorry about using the word malpractice – I did take it away at first, but then decided to put it back. I just wanted to point out that bad things happen in hospitals even when the people working there don’t intend it. You are correct that the main issue is in fact medical personnel doing too much instead of too little.

      In general I do trust my docs, but it doesn’t mean that I back off from participating in my care.

      I mostly trust my GP and try to read up on ailments and treatments so that I can ask questions and make decisions after discussing with him. We’ve been with him for a while. If my young ones are sick for more than a few days I take them to the pediatrician. It was disappointing that our friend who sees the same GP did not get diagnosed with blood clots after he went several times over the course of a month complaining of fatigue and shortness of breath. It wasn’t until he collapsed at work and went to hospital and they checked his blood oxygen that they discovered the clots. He could have dropped dead at any time in that previous month! The GP had ordered blood tests but didn’t do any tests related to the complaint of shortness of breath, and the family history of blood clots was unknown to the doc.

      We’ve been through a few pediatricians until we found one we liked and who provided the care we are looking for. For example, should I have continued with a pediatrician who told me to stop breastfeeding my 10 month old who was suffering from gastroenteritis for a few days? I did listen to him at first and after 24 hrs my child’s condition worsened and he was dehydrated even though we tried giving oral fluids. I gave in and let him nurse when he wanted and his condition improved and he was wetting diapers again. I looked for more info and it turns out that the medical advice usually given is that formula and diary should be discontinued for a few days, but breastfeeding is actually encouraged! The pediatrician we have now is quite skilled, always listens and answers questions, checks the child thoroughly and is more conservative about prescribing medicine, which we like.

      I thought I had a great relationship with my first OB but in the end she broke trust and showed that she actually had a negative attitude towards me because of my natural birth leanings. Here’s an example; my friends who birthed with her with epidural were given Ibuprofen suppositories after to help with pain for a few days. I had an unmedicated birth, so I wasn’t given anything for the pain for the few days after the birth. More importantly, she did an episiotomy to “save my baby’s life” after heart decels with contractions after 15 min of pushing, but he came out with apgar of 9. Sounds fishy don’t you think? Of course I stated in my birth preferences – no episiotomy unless ventouse or forceps needed. There are other things that happened and didn’t happen in the hospital setting that bothered my husband and I, and in fact, could have resulted in the injury or death of our baby. After my experience with hospital birth the first time around, I decided to go for a home birth the second time around. I was just being honest about my care – I wanted OB skills for my prenatal care and as back-up if my birth became complicated, but I felt that a midwife was better for dealing with my birth in the absence of any problems. It was a smooth and uneventful birth. Truthfully, if this kind of birth was allowed in a hospital setting I would have done it there and not at home. (I’m not American and have not birthed in the US.)

      • Alex
        August 3, 2010 at 9:22 am

        I also work in the UK. I think that your comment about the episiotomy is unfair – yes your baby was born with an Apagar of 9 but the Dr clearly believed that he was in trouble. We know that the majority of babies born with abnormal CTG’s are fine, but don’t know which ones are struggling without testing their blood. Babies can also cope with some comprimise. You do not say what your son’s cord gases were – it could be that your Dr got him out at the right time, when he was beginning to struggle but before he was compromised.
        Wrt the brufen – I am sure that it was not done deliberately, surely you could have just asked for more analgesia? If it was truly done to punish you (impossible to prove?)then that is appalling.

  127. coffeegirl2000
    July 31, 2010 at 9:23 am

    I just want to address this seeming confusion about the term rape when used to describe birth. I think what obstetricians are missing here is that when a woman says this, she is not talking about you, or even her own doctor. She is talking about her, and her own experience. I have seen one doctor here describe rape (very accurately) to show that the term does not fit and his assessment was quite fair. The problem is that he described it from the rapists point of view and intent, which is not how these women are looking at it. They are looking at from the point of view of what it feels like to be a rape victim.

    When a woman is raped she has no control over her own person…someone else does. She is often scared for her life, or just terrified overall about what has/will happen to her. She is is physical pain. She is in emotional pain. She feels desperate to regain control, but cannot, even after the event is over. She feel ashamed and embarrassed. She feels forever changed, and not in a good way. She fears that no one could ever understand what she feels. She feels that there is no where she can escape to safety. She feels guilty, and goes over and over the scenario find where she went wrong or what she could have done to avoid the rape.

    Long term affects often include going to extremes avoiding reminders of the rape or rapist. She may have flashbacks or nightmares reliving the trauma. She may cry hysterically or become very withdrawn from the world around her and rather lethargic without understanding why or even that it is connected to the rape. She may have difficulty sleeping or may sleep all the time. She may even have a myriad of physical symptoms like headache, nausea, loss of appetite and insomnia.

    When we look at it from a victims point of view, rape it is not about power and violence. It is about fear, loss of autonomy, and pain. When you truly understand what a rape victim feels like AND you truly understand what some women with traumatic births feel like, you can see there is a striking resemblance.

    I also want to point out that rarely are these women referring to their c-section as rape. Rather they are referring to the whole process which starts when they check in to the hospital.

    If you are a doctor reading this and you have ever had a patient call you a rapist, I beg of you, please reevaluate the way you practice. You may very well be traumatizing a whole lot of women (and their families) without even knowing it and that is a horrible tragedy for all involved.

  128. CountryMidwife
    July 31, 2010 at 12:29 pm

    Nicholas Fogelson :
    Hurts to pour your blood sweat and tears into years of education, 100+ hour weeks of residency, and 70 work weeks therafter,

    I think you hit the nail on the head why the average OB isn’t, by the end of it, even recognizable as the same caring “I want to help mothers and babies” person he or she may have been once upon a time. Frankly, why so many docs can be callous and cruel when they indeed know better. I acknowledge the stresses and strains physicians face – especially obstetricians given the malpractice epidemic. But our American maternity system is so flawed, and very, very few doctors recognize that, or care to affect one iota of change within it. That is where my profound disappointment with ‘the culture of obstetrics’ and indeed individual physicians lies.

  129. July 31, 2010 at 1:14 pm

    I just came across this: http://vimeo.com/5648654
    The letter the mother wrote to her obs is featured at the end and she certainly feels that her c-sections were unnecessary.
    I’m not too sure what all the bulb suctioning is about at the homebirth but I guess it’s less invasive than the hospital approach to ‘managing’ the newborn. I think routine suctioning must be a US thing as I have never seen or done it. Anyhow I thought it might be nice to add the voice/experience of a mother to the debate to remind us all that this is who it is about.

    • July 31, 2010 at 1:35 pm

      Its a great video of a great experience. I hope she understood that there was about a 1/100 risk of uterine rupture in that birth, and if that rupture occurred at home her chance and the baby’s chance of dying were far greater than if that occurred in the hospital.

      Everything is great when it works out. Fortunately, uterine ruptures are very rare. Had it occurred, it wouldn’t have been a happy video.

      Everybody gets to make choices though, and if they feel good about making that choice understanding those risks, then that’s great for them.

      • July 31, 2010 at 2:01 pm

        I am sure she was more than aware as any woman having a VBAC will be told how dangerous it is, often and by many. It’s about individual assessment of risk – for her a 99% chance that her uterus would be OK was good odds to have the birth experience she wanted for herself and her baby.
        I recently attended the VBAC homebirth of a previous client (now friend). I attended her ‘necessary’ c-section with her first baby – which she did not consider a traumatic experience. For her VBAC she booked into the hospital as back-up and listened to the stats (1:200) from the obs. The day that she birthed her second baby at home a woman in the hospital had a uterine rupture (VBAC). The women in the hospital had a syntocinon infusion running and an epidural. Unfortunately her rupture will go into the stats as the stats don’t distinguish between ‘natural’ ruptures and ruptures created by intervention.

      • July 31, 2010 at 2:13 pm

        I think you are showing some bias in the suggestion that somehow these ruptures should be considered different. Ruptures are rare, even with pitocin infusion going. Pitocin augmentation of a labor in progress probably doesn’t increase rupture risk (studies are mixed), but even at the worst it is still around 1%.

        >> for her a 99% chance that her uterus would be OK was good odds to have the birth experience she wanted for herself and her baby.

        I agree with this. I always wonder how mothers will look back on this thought if they are the 1%. I would think that if a mother had a fetal death with a uterine rupture in a homebirth, they would feel very guilty over their decision to birth at home, perhaps for a lifetime. If the mother dies in a uterine rupture, I think the whole family would feel guilty, and the remaining children very angry. Everyone has a right to their own decisions though.

        It would be preferable that the person doing a VBAC could get the environment they desired in a setting where a uterine rupture could be appropriately managed.

      • Melissa
        July 31, 2010 at 7:33 pm

        I’m sure that a lot more women who would prefer to VBAC in a hospital setting, but unfortunately most are forced to turn to a midwife if they truly want it to happen. A lot of OB’s WILL NOT do them even though the statistics support that they can be done safely. And even those who say they support VBAC, put so many restrictions on the conditions of labor that it is almost impossible to achieve in a hospital setting.

        I mentioned in an earlier post that my SIL is trying to VBAC with her OB. Although he has told her that he is willing to give her a “trial of labor”, he has colleagues who will not do them, so her right to a hospital VBAC depends on which OB happens to be present for her delivery. So she may or may not get a c-section depending on who attends her birth…not because she actually needs one.

  130. CountryMidwife
    July 31, 2010 at 1:34 pm

    Nicholas Fogelson :
    I’m not sure what about what I wrote sounds insincere, but it wasn’t.

    I’m sorry, I honestly didn’t mean to offend. I think you’re one of the good guys and I do appreciate all the discussions and openness.

    In explanation – it just felt like — history, labs, that’s routine, everyday OB no matter how complex they are — it doesn’t excuse the 32% c/section rate, the over intervention in the face of evidence against induction, continuous monitoring, coercion, etc. It felt like your comment was pulling out the but I’m an expert card in referencing things not well understood by the average consumer/blog reader. My flip reply undervalued the “personal experience” part of your reply (especially the gestalt impact of the experience of a single bad outcomes on OBs practice, for example).

  131. July 31, 2010 at 2:34 pm

    >>>>I agree with this. I always wonder how mothers will look back on this thought if they are the 1%. I would think that if a mother had a fetal death with a uterine rupture in a homebirth, they would feel very guilty over their decision to birth at home, perhaps for a lifetime. If the mother dies in a uterine rupture, I think the whole family would feel guilty, and the remaining children very angry. Everyone has a right to their own decisions though.
    It would be preferable that the person doing a VBAC could get the environment they desired in a setting where a uterine rupture could be appropriately managed.<<<<

    Everything we do in life involves risk. If we approach everything in life with the 'worst case scenario' perspective we would experience very little. I understand that OBs particularly in the US are battling against a legal system that will not accept the notion that sometimes shit happens.

    Attending homebirths after years of working in hospitals opened my eyes as why women do take the small risks involved in homebirth. Yes, it would be great if there was access to 'home like' environments to birth – but this is not going to happen if we (obs and mws) are focussed on protecting ourselves from the worst case scenario all the time.

  132. C the K
    July 31, 2010 at 3:13 pm

    A lie of omission is still a lie. When an OB says to a patient, “You need a c-section,”, that’s not informed consent. What you really mean is, “In my professional opinion, based on years of schooling and experience, in this situation I recommend a c-section.” But the two are vastly different. The first conveys that the OB is the one making the decisions. The second conveys that the OB is going to give the reasons why s/he thinks a c-section is warranted, the other options, and that the decision is up to the mother. When you leave out one of the options — for example, not taking any action at all — and we later find out that it was a viable option — we feel lied to. Using the term “unnecessarean” conveys that we feel hurt and betrayed by a doctor or system we trusted. Ultimately the patient is always in charge of making the decisions — even if you don’t agree with them. I hear a lot of talk lately about the need for patients to be more involved in their own health care. It is difficult to do that if the doctor is always trying to be in control.

  133. July 31, 2010 at 5:53 pm

    VBAC Mama :
    I fully agree with your reply. Sadly, many women have no clue until all is said and done that they should have chosen a different doctor/midwife and birth location. I agree that maternity care needs to be transparent and all info needs to be laid out on the table. Of course any woman desiring a vaginal birth would choose not to birth at a hospital with a high cesarean rate. It is really hard to find the cesarean rate of hospitals and even harder to get them for individual doctors.

    Well, more than the cesarean rate! Tertiary care hospitals like university of wa med center here in Seattle have a high c/s rate by their very nature. But, they handle very high risk moms from a five state area with often complicated and chronic health issues or very compromised fetuses. I would expect them to have a high rate. But another local hospital with a low rate of complicated deliveries, has the highest c/s rate in the state. Shame on them! That scares me more!!! Somehow the model must be changed so that maternity consumers can receive information about the important details that will help them choose a provider wisely. But, one doctor’s stats in a practice that shares call really should not carry much weight. And also the “bait and switch” must go away. The philosophy and care plan at one end of pregnancy often look much different than at the other end of pregnancy, with nothing changing but the words out of the doc’s mouth. “of course we are supportive of VBAC” changes to ” we need to schedule surgery on your due date”. That is hardly fair. And often too late to switch, or at least very difficult.

  134. Washi
    July 31, 2010 at 6:03 pm

    “Ultimately the patient is always in charge of making the decisions — even if you don’t agree with them.”

    Sickeningly in my case this isn’t true. Because I am petite one OB I saw said “you have to have a cesarean” without even examining me. I told him I did not believe him and I did not want a cesarean. I went for a second and a third opinion and was told both times that the first OB was wrong and not to worry and I reiterated that I was against being cut. Unfortunately it was the first OB who was working when I was in labor, I was in the hospital less than 15 minutes and had already been picked up and forcibly held down on a table by 4 people because I refused lay on my back as per their orders whilst being agonizingly vaginally violated. I didn’t even know that first OB was there because he slipped in unbeknownst to me and was standing behind me when he told the people I was struggling to get away from that I “had” to have a cesarean. I was treated as less than human. My words fell on deaf ears. I just closed my eyes and prepared myself to die. I didn’t sign the consent form and I’d told him “no” many months in advance. I decided against all that was done to me that day, but ultimately I wasn’t in control.

  135. Statler&Waldorf
    July 31, 2010 at 9:28 pm

    Nicholas Fogelson :

    It would be preferable that the person doing a VBAC could get the environment they desired in a setting where a uterine rupture could be appropriately managed.

    Amen!

  136. Abbey
    August 1, 2010 at 2:50 am


    I agree with this. I always wonder how mothers will look back on this thought if they are the 1%. I would think that if a mother had a fetal death with a uterine rupture in a homebirth, they would feel very guilty over their decision to birth at home, perhaps for a lifetime. If the mother dies in a uterine rupture, I think the whole family would feel guilty, and the remaining children very angry. Everyone has a right to their own decisions though.

    Do you not think that a woman who has a traumatic childbirth has a family that is resentful of her? Because I can tell you that they do.

    When experience has taught a woman that a hospital is not safe and that the other option now carries greater risk, what is the right decision? Of course the “hypothetical hospital”, the one where people are caring and interested in a woman and the process. The one where a laboring mother is repected and cared for and not bullied and abused. The one where “life saving” techniques are only used to save lives (Yes, I realize that this is an unrealistic expectation of what doctors can know, but this is hypothetical). The “hypothetical hospital” is just that. Women making these decisions only have knowledge and EXPERIENCE with the actual hospital, they don’t have the option of “hypothetical hospital”.

    I myself have often cried because everything was fine last time and I couldn’t find anyone to help me. Now I’m at a greater risk because of what happened last time, so how can I expect anyone to help?

    Women who choose to birth at home with or without assistance know the risks, but the past experience makes those risks acceptable to them. It’s not fair to give women 2 less than desirable options and then judging them when they choose.

  137. August 1, 2010 at 3:49 am

    Thanks to all for the continued passion and commenting. I have been a little too busy to keep responding to each one, but I’m reading them all and keep learning.

    I think the medical model of birth has a lot going for it, but there needs to be a better way to accommodate different desires in birthing. I can hear the passion you all have here, and clearly the hospital model did not serve you all well. A lot of folks are happy with their hospital births, though.

    I appreciate the comments in regard to my question about whether people who want a noninterventional birth should choose to not deliver in the hospital, and I do see that point of view, but I have further comments of my own.

    I think that if women want to have a completely non-interventional birth, that should be more readily available to them. That being said, a fair bit of the safety provided at the hospital is because of some of those interventions. We have to do fetal heart rate monitoring at least intermittently, and if there is a problem we need to do it continuously. That’s one of the things natural birthing complains about, but that’s not going to go away. Removing continuous monitoring in low risk labors is fine. Having it go away completely is not. That also means that in some case, internal monitoring is required if one wants to benefit from monitoring.

    Hospital workers assume that patients are comfortable with what is going on, because most are, but that’s probably a dangerous assumption. I think it would be worthwhile to discuss patient’s feelings about what they want in their labor when the patient gets to the hospital. Its really not that hard to accommodate what different women want, but if they don’t know what that is may be impossible. I think the NCB community assumes that what they want is the best way to go, but that is just an opinion, and it is not shared by many hospital workers (MD, RN, and others.) These workers are not necessarily against providing what a woman wants in her labor, but they wouldn’t do it that way if they didn’t know what was wanted.

    That’s a little bit of what I am saying when I say people might want to stay out of the hospital if they don’t want a medical birth. It doesn’t mean a non-interventional birth is impossible in the hospital. It just means that there is likely to be some resistance, if only because it is not what the hospital staff is used to. Just the same as if a person who wanted a very medical birth with an epidural and continuous monitoring showed up at a homebirth midwife’s house. My experience has been that it is very helpful to have a L and D nurse who also has some natural labor tendencies, as that nurse can be a very good advocate for the patient. Having a nurse who is generally against NCB is more difficult.

    The unfairness of it is that the hospital has resources that cannot be had outside, and those resources improve outcomes. The rapid availability of skilled neonatal resuscitation staff is probably the biggest one. Though out of hospital workers may take a neonatal resuc. class, this is nothing compared to the years of skill and experience that professional neonatal resuc. staff have.

    Birthing centers that are near or, preferably, attached to the hospital, are a very good compromise that can meet the needs of those who want a non-medical birth, while still providing access to high level care when needed. There is still some tradeoff for experience vs. availability of advanced care, but this is a very good compromise that should be more supported.

    Irrespective of all of this, hospital based OB should be more patient with birth and be much slower to recommend cesarean for protracted labor. We should also do fewer inductions. That alone would reduce the cesarean rate, and decrease the amount of intervention that would be required in labor.

  138. CountryMidwife
    August 1, 2010 at 5:17 am

    There is still some trade off for experience vs. availability of advanced care

    Most accredited birth centers are staffed by very experienced CNMs who have typically been in hospital before (and left knowing things should be better for moms and babies). But a “birth center” within a hospital is often just a trick, a marketing ploy, in my opinion. For example: per accrediting rules, birth centers CANNOT under any circumstance use EFHM in labor. Hospital “birth centers” routinely “get a strip” and then “one 20 min strip per hour” and you know how that all goes sometimes. Hospital “birth centers” also offer epidurals!!! Please also know that home birth CNMs have every single tool we have at the birth center, literally. And in my rural area, homes are typically closer to the hospital than our center.

    But in discussing the value and safety of in vs. out of hospital birth, I remind you Dr. Fogelson that many (most?) hospitals serving American families do not have in house OB, anesthesia, OR, neonatology or even peds. So unless you’re having your baby Monday to Friday between 730 and 5, what is REALLY the value of the hospital? Highly over rated.

    • August 1, 2010 at 5:51 am

      Well I guess we can agree to disagree here. Getting an occasional strip is a reasonable thing to do, as are epidurals if a patient desires.

      If a birth center has no more connection to a hospital than a home does, then I would expect the same risks to be there as there are with homebirth.

      Plenty of folks on this thread have stated that they would like to have a noninterventional birth but still have the facilities of a hospital available to them or their infant if it were needed. That is what a hospital based birth center can provide. The idea that you are bothered that a hospital based birth center might offer something seems more about your ideology than about offering choices to women. What is to be gained by denying someone a choice?

      • Kathleen, CNM
        August 1, 2010 at 9:39 am

        If a woman is in a birth center, her risk status should be such that continuous EFM, or intermittent EFM, is not indicated. A low-risk, apparently normal labor is appropriate to monitor via intermittent ausculation, but not “occasionally”; at the regular intervals specified by professional association guidelines, such as ACOG or NICE.

        If a woman wants an epidural, she SHOULD be monitored continuously. Powerful medications are being administered, and she SHOULD be in a fully equipped L&D unit. Yes, an epidural is a completely reasonable thing to request, but it’s not a thing you want to just throw in while in the back of a cab or something.

        Blurring the lines between birth centers and hospital L&D units in this way seems deceptive. It seems hospitals want the birth center “market” and are applying the label inappropriately.

  139. CountryMidwife
    August 1, 2010 at 6:06 am

    You miss my point – it’s not a birth center if it offers monitoring and epidurals. What you’re talking about is a low intervention (evidence-based) L&D unit – which of course I’m all for.

    • Statler&Waldorf
      August 1, 2010 at 3:38 pm

      CountryMidwife, I think a birth centre should offer those things so that a woman doesn’t have to transfer if she needs them. If the whole point is that women can labour and birth how they want, but still have access to necessary interventions after seeing how the labour and birth progress, then why limit what is available? I’m all for a natural birth, but if I have a posterior baby with horrendous labour pain and am at risk of not being able to have a vaginal birth with the way the labour is going, I would change my mind and opt for the epidural. It could turn the labour around and accomplish the goal of a low-intervention vaginal birth as opposed to a cascade of interventions and c-section which is what can happen if I were in too much pain and too tired to birth. As for the monitoring, there should always be at least intermittent hand held monitoring, but what is the harm of having the option of continuous electronic fetal monitoring to help confirm if there is a problem and transfer to the regular L&D ward is needed? CEFM and epidurals would be rarely used by the population choosing to birth in a birth centre, but the option should be there. (Though this now has me thinking, what happens if pitocin is needed… the lines do get blurred between birth centre and standard L&D… Maybe all L&D units should just be much better at offering no to low-intervention births!)

      • August 1, 2010 at 3:44 pm

        I think these are good points. Intermittent auscultation may be as good as continuous monitoring for low risk births, but the ability to look at a continuous strip can be far more helpful, and may even allow one to avoid a transfer and achieve the desired birth.

        For example – a fetal decelleration is noted during intermittent auscultation, and this is recurrent. At this point, one needs to look further. A strip might show that there are variable decels, but variability is adequate to continue to labor as it is. One might not be able to make that determination without the fetal monitor.

        Having the monitor available doesn’t mean one needs to continuously use it.

      • Kathleen, CNM
        August 2, 2010 at 7:44 am

        Transfer is not the end of the world, and shouldn’t be the end of a possible vaginal birth.

        Here’s the thing that confuses me. I LIKE that we have access to modern day obstetrics. I don’t think everybody is capable of a no-or-low intervention birth with all parties involved healthy and/or alive at the end. Let’s face this. If we are auscultating an infant with repetetive decels, I would like to have this mother on continuous monitoring, with the ability to move very very quickly to the OR or the NICU. I don’t want to stay in the birth center!

        A woman with an epidural does not, according to the research, have a higher risk of c/s, but she is more likely to slow her labor down, leading to augmentation, and also to need vacuum or forceps delivery. Which is more likely to result in hemorrhage and a list of other complications that, again, I don’t want to deal with in the birth center!

    • VBAC Mama
      August 1, 2010 at 4:41 pm

      It’s not a “free-standing” birth center if it includes those things. I think freestanding birthing centers are great and I would likely have chosen one over a homebirth if I had one that was closer than 2 hours away. I think it just may have been easier for my husband to wrap his mind around than our home birth since he was worried about the brand new carpet lol.

      I found it a little ridiculous that the hospital based birthing center near where i live has a ban on VBACs. :(

  140. August 1, 2010 at 9:50 am

    >> it’s not a thing you want to just throw in while in the back of a cab or something.

    Are you equating a birth center with the back of the cab? :)

    I appreciate your points here, but I think you have a narrow idea of what a birth center could be. It is entirely possible to have a place, either in the hospital or out, that presents itself as non-inteventional and has the appearance of a birth center, but that still has the ability to escalate care when it is needed. This is not unlike what is practice in many other countries, where birth is managed primarily by midwives in these sorts of locations. Whether or not this place is in the hospital or just near the hospital doesn’t matter to me – there is no reason why the building you are in should change how you manage labor and treat women.

    It is entirely possible to offer unmonitored labor in a nice environment with everything a birth center has, but to able to monitor labor and put in epidurals if a patient wants.

    • Kathleen, CNM
      August 1, 2010 at 2:03 pm

      >>It is entirely possible to offer unmonitored labor in a nice environment with everything a birth center has

      Are you equating intermittent auscultation with unmonitored? ;) No of course birth centers aren’t the same as the back of a cab, but obviously if you’re giving someone epidural anesthesia, you want a certain level of monitoring and access to intervention. Those 20 minutes-post-epidural decels sure are exciting.

      What you’re proposing, like CountryMidwife is pointing out, is a low-intervention L&D unit. I wish more existed and I hope more L&D units decide to make some big changes to their protocols. But I’m job-hunting all over the country right now, and more and more hospitals are advertising their “in-house birth centers”. Look into them and they’re a standard hospital birth environment, complete with NPO policies, automatic cEFM, bed restriction, tight clocks, and cesarean rates to match.

      You’re right, there IS no reason why the building you are in should change how you manage labor and treat women! Yet that’s the way it is.

      By the way, if your hospital is hiring, I’m applying. Sounds nice!

  141. CountryMidwife
    August 1, 2010 at 11:06 am

    There is a national, professional organization for birth centers, which sets certain standards and requirements. There are also typically state regulations specific to birth centers. Monitoring and epidurals, for instance, are absolutely prohibited. Likewise, a birth center cannot be on an elevated floor, for example. Calling it a “birth center” does not a birth center make.

    I wonder how you feel about Naturapathic or Chiropractic Doctors being called Doctors? Do you kinda get what I mean?

    • August 1, 2010 at 11:17 am

      Not really. Naturopaths and Chiropractors have doctorate level degrees so they get called doctor, just like biologists and physicists.

      • VBAC Mama
        August 1, 2010 at 4:33 pm

        …and Naturopaths and Chiropractors also know a lot about how the body works and what it needs. Just from my own experience, I’ve never had an MD of any kind (OB, pediatrician, general…etc) discuss the importance of diet and exercise for myself or my kids, but my chiropractor always does. They really deserve much more respect than they seem to get from the medical doctors.

        Naturopaths and Chiropractors seem to have the same strained relationship with MDs as OBs have with midwives and it isn’t helping patients. No, chiropractors cannot prescribe a pharmaceutical drug like an MD, but they do “prescribe” many natural practical things to their patients….and no, I’m not talking about herbs or supplements here. Just like midwives can’t perform a cesarean. It doesn’t mean they are worthless whatsoever.

  142. CountryMidwife
    August 1, 2010 at 11:36 am

    Ok, interesting, point taken. Your colleagues don’t share that viewpoint, largely. But please, please, don’t disrespect the ‘blood sweat and tears’ that the birth center movement is based upon by saying a “lowish” intervention L&D unit is a birth center. Again, there are standards.

  143. Leelee
    August 2, 2010 at 7:59 am

    Dear Dr. Fogelson – I’m a layperson (mother) delurking because I have a question, if you can bear to read any more of this interminable thread! My background, as short as I can make it: I had a primary cesarean for arrest of labor/suspected infection after term ROM at home (weak labor), admission at 1.5 cm, 9 hrs weak/inconsistent unaugmented labor (Pitocin was encouraged and I initially refused), followed by another 15 hours of labor with Pitocin, 10 of that with epidural. Temperature spiked and baby’s heart rate went up, and that was it. I was hoping for a natural birth and have been slowly processing all this for a couple of years. I’m not angry about the cesarean anymore – mostly just angry about the first two of the three OB’s I saw (none of whom were “my” doctors) and that *the hospital promised things it didn’t deliver.* Namely that it was a friendly environment for unmedicated labor and turned out to be quite the opposite (for instance, in the hospital-sponsored childbirth classes they mentioned that we would “walk around” and that some rooms had wireless monitoring – which the admissions desk vehemently denied when we arrived). But my treatment also had to do with *a then-new ACOG guideline I knew nothing about* – that management of term ROM had switched from “wait 24 hours” to “induce immediately.” I had no idea why I was being treated like a high-risk patient – not allowed to walk around, fussed at any time I moved enough to disrupt the strip (despite my first labor nurse’s attempts to assist me, and she was quickly replaced with a nurse who joined the chorus that I should just get Pit and an epi). This was not covered in the hospital childbirth class – the only coverage of term PROM was that it “only happens in 10% of cases,” it was “not likely to happen” to anyone in the room, and if it did we should just “call our care provider.” My birth experience was horrible enough that I’m very nervous about another pregnancy, but I don’t really need to rehash the rest of it here. My question is: in your opinion, given what has been bandied about recently regarding induction in primips, particularly in an unfavorable cervix, I am wondering if this means that term PROM is likely to equal cesarean under the current guidelines. What do you think? How do you prefer to manage term PROM, and what do you tell your patients? I still feel like it was the one “blind spot” in our preparation, and of course that is what happened to us!

    • August 3, 2010 at 10:20 am

      >> I am wondering if this means that term PROM is likely to equal cesarean under the current guidelines.

      I don’t think so at all. There is no guideline that says that you must immediately induce or augment when there is PROM. PROM will be followed by the onset of labor within 24 hours in the vast majority of cases, and most within 6-12 hours. Some are more quick to augment when the mother is GBS+. Some also augment immediately. As PROM is something that usually happens as part of cervical ripening, it is usually a sign that there will be cervical change to uterine contractions. As such, augmentation is usually successful, but still not always.

  144. sv
    August 2, 2010 at 10:33 am

    Well, i couldn’t possibly read all of these, but I did read quite a bit. I have attended a C-Section that I consider a perfect birth, and I have attended home water births… and many in between… my sadness around this issue is the lack of disclosure. If you ask 1000 women what an epidural actually is? they don’t know. But they sign up. That’s just one example. Prostaglandin Gel is made to sound like Aloe Vera, Epidurals are practically over the counter, and Induction sounds like a great idea to a woman who is 39 1/2 weeks and so tired of being pregnant. I just wish more women knew what they were really saying YES to. That’s all. I don’t think getting an epidural is a moral issue, or even an elective C-Section really… although, I’m not sure doctors would say Yes to an elective appendectomy, and there’s only one life on the line there. I’m a very open person… I just believe that people assume that what Doctors suggest, especially in a time of emotional distress, is the only way to go, or the safest way to go. I’m just talking about an imbalance of power due to social paradigm. Like Banks convincing people they could afford the loans (why would they give it to me if it wasn’t a good idea… they are financial experts!) Because a DOCTOR says surgery is a good idea, it must be. And I think we are going to find our birth system bankrupt if we are not careful. Intervention of any kind can lead to an increased chance of C-section… and every intervention or drug has risks of it’s own, that women take while their bodies are in the middle of a pretty miraculous, intricate process…. it’s not really logical…. but they are surrounded by people in white coats who do it all day long, and know how to fix it if it goes wrong… sort of… I just think they would choose other wise if they really knew what was up. That’s my humble opinion.
    If we had a 5% C-Section rate 30+ years ago… and a 30% rate now… and they were really helping… then we should have the lowest infant mortality and maternal death rates in the world… we don’t.

  145. Ann S
    August 2, 2010 at 12:17 pm

    I accept your not indicated premise. But based on your list of necessary cesareans, there are still a LOT of unnecessary ones. And they happened to women who understood the risks of VBAC and were willing to take those risks, believing they were less than the risk of having a Cesarean, but could not find a physician willing to even allow a TOL. And many physicians are unwilling because of the guidelines set up by ACOG. Therefore, many unnecesareans by any definition. I’m hoping, but not very hopeful, that ACOGs new guidelines will lead to more TOLs with legitimate chances at VBAC (differing from docs who give lip service to TOL and bail at the first sign of any variance from perfectly normal). Unfortunately, I’ve been around long enough to be cynical.

    • August 2, 2010 at 1:48 pm

      I think the changed ACOG guideline will help some, but it will still take time. The pendulum is swinging back, but it has great momentum to overcome.

  146. Laurel Brant
    August 2, 2010 at 12:56 pm

    Nicholas Fogelson :
    “You are right that OBs and midwives have a different approach to labor. As for improving on mother nature – unfortunately mother nature does lead to fetal and maternal deaths, and we have done a good job at preventing these things. Go back a few hundred years and the number one and two reasons for maternal death were hemmorhage and infection. With modern antibiotics and blood banks its nearly unheard of.. . . . . ”
    I would like to refer your readers to Williams Obstetrics, 15th edition, pp757-758. If we go back a few hundred years, to the 1800’s, women died of Puerperal Fever, commonly called childbed fever. Readers may also want to refer to Wikipedia for information and it is the history that is particularly interesting, especially in light of this discussion. Even when their own peers noticed fewer women died at home of this disease and recommended physicians wash their hands before examining women (especially after they had been working with cadavers), it was years before practises changed – who takes the credit with ‘saving’ womens lives?

    This is what I’m trying to speak of when I say doctors believe their own propaganda. Granted, this is only one example but I know there are more. Do we really need to remind/teach obstetricians about their own history of refusing to change practices? If obstetricians don’t know this history, they should. If they do know it, a little humble pie and less arrogance, please.

    • August 2, 2010 at 1:47 pm

      Laurel – the folks that didn’t wash their hands died over a hundred years ago. I don’t think its right to ask modern obstetricians to somehow be responsible for the actions of our ‘ancestors’. The practice of modern obstetrics has almost eliminated maternal and fetal death, something that was not uncommon back when these folks were alive. A great deal of progress has been made since then.

  147. Washi
    August 2, 2010 at 3:00 pm

    “I don’t think its right to ask modern obstetricians to somehow be responsible for the actions of our ‘ancestors’.”

    She didn’t ask them to be responsible, she asked for less arrogance. Not the same thing. Obstetricians make and often deny a whole new set of mistakes today. Was not the OB I spoke of earlier extremely arrogant? A little less arrogance can make all the difference in the world to a patient.

  148. Laurel Brant
    August 2, 2010 at 6:21 pm

    What confuses me is that I’m using to your own words, Dr. Fogelson, although perhaps it wasn’t obvious that it was your quote. You said to go back a few hundred years when women died of hemorrhage and infection and I did. The attitudes and behaviors of obstetricians were highly questionable in the face of evidence that proved their practices killed thousands of women. Obstetricians could not believe it then, and it appears that they cannot believe it now, that they sometimes they DO harm women.

    I don’t expect you to be humble. I don’t expect you to really hear what so many women are telling you. You have not been trained to do so and if the facade were to slip, well, I think your ‘air of authority’ would be difficult to maintain. I was very fortunate to work closely with an obstetrician in the 80’s who supported VBAC (OK, somewhat reluctantly at times!). He was the one to explain the hierarchy that exists in medicine generally and in obstetrics specifically. He commented on my status as an ‘unwashed’ and he told me that what I had to say simply didn’t carry any weight. I adored him for his support of women and for his honesty, if only privately and not publicly.

    As women we can request/demand representation on the various panels that make recommendations regarding what is happening at the most intimate and personal level to our bodies, but if you followed the recent NIH conference on VBAC, you would have noticed we were not represented. The consumer rep was a woman who worked with teen pregnancy. I was told it would be too difficult to choose a woman who has had experiences with the issue – the issue that millions of women have tried to deal with, with varying degrees of success. Oh, I know, we were ‘allowed’ to ask questions and make statements but to sit shoulder to shoulder with the SIX obstetricians and others on the panel and to participate as if we were important in this issue – no. It is outrageous! Especially since some of us are able to read and understand ‘scientific’ studies and research, i.e., the evidence. Not one of those well educated women from ICAN were suitable to represent us – fascinating. Oh well, another opportunity missed because, in my opinion, we, as women and as consumers of obstetrical services, don’t count. Please convince me otherwise.

  149. August 3, 2010 at 12:49 am

    Laurel –

    Your implication (seems to me) is that the rate of death and injury seen in childbirth throughout history is somehow the fault of obstetricians, and that if we had just washed our hands childbirth would be the extremely safe thing it is now.

    Yes, there was a time that humans did not understand germ theory. Midwives didn’t understand it either. Nobody did. Long before any of this, lots of women and infants died in childbirth, and it was a leading cause of death. This is now almost unheard of.

    As underrepresented as non-physicians were at the NIH conference, it did seem to do some good. ACOG’s revision to their VBAC statement was significant, and will help move things back towards greater VBAC availability.

    >> Please convince me otherwise.

    I don’t think I could. I appreciate your passion and your comments.

    • Laurel Brant
      August 3, 2010 at 9:30 am

      Nicholas –

      My implications are:

      -obstetricians, then and now, believe IF their intentions are to help women and babies, then that is what they do. I don’t believe doctors comprehend that they can and do, hurt/maim/kill women because that is not their intent. In the historical case of puerperal fever, the evidence was produced by their peers and still ignored and ridiculed. Today we might look at other issues such as episiotomy, twilight sleep, lithotomy position, second stage, nutrition during labour, x-ray pelvimetry, unnecessary cesarean sections. I just checked puerperal fever in Wikipedia (not necessarily an accurate source of information, granted, but easier than hauling out Williams), and would like to use their quote from a well known 1840’s obstetrician, Dr. Meigs, who when faced with the evidence said, “Doctors are gentlemen, and gentlemen’s hands are clean.” Good intentions or not, women died when THOSE ATTENDING CHILDBIRTH did not wash their hands. (the death rate from puerperal fever was less for women delivering at home.)

      – from the above example, my next implication is that obstetricians had certain attitudes and beliefs that prevented them from seeing the evidence and thus, changing their practices – and this still exists today.

      – obstetricians in general, and you in particular, are defensive. The way you interpreted my first paragraph illustrates this. You cannot change the fact that your profession stands on the backs of the good, the bad and the ugly. It’s hard sometimes to take off the rose-tinted glasses and that goes for both groups, obstetricians and home-birth advocates as well, but here, for the moment, I am speaking of your responses, not mine.

      I also have noticed, and not without admiration, how cleverly both you and Dr.Tuteur manipulate the ‘debate’ or the information. You both do a splendid job of twisting what people say in such a manner as to have it look or sound believable. You will take one word, idea, event and loosely connect it with your beliefs in an ‘air of authority’ and it’s challenging for others to decipher exactly what you are saying. We stop and say, wait a minute, that’s not quite right because there are always half truths involved or ‘truths’ based on unsubstantiated practices. Oh, I know you or Dr.Tuteur will get defensive and claim that NCBer’s do the same – yes, true, but can you look at yourself instead of turning the finger around? Case in point, your comments on the NIH conference – ‘underrepresented’ versus, NOT represented is not the same and it’s not a case of semantics. We, as women who have been cut open, were NOT given a place at the table as a panelist who helps write recommendations. Being in the audience and given a chance to speak/present to the panel seemed to do some good, as you put it, BUT, let’s be clear here, we were not acknowledged as a valuable component of the VBAC issue. I was told, this is a medical conference – for and by medical practitioners. Why then, did they include a ‘consumer’ designated panelist? Perhaps it looks better or are they just trying to have it both ways (something Dr. Tuteur speaks of, I believe)? And, as you referred to the benefits of the resulting ACOG’s revised guidelines, you slipped past the issue. It’s the same thing as saying, ‘Well, you have a healthy baby and it doesn’t really matter how it got here’ to women who are trying to figure out what just happened and why they weren’t adequately consulted. You cleverly minimized my point by changing words and then you introduced the positive results although the result has nothing to do with my point. Clever but seriously disorganizing.

      When we speak of the improvements to the maternal and fetal mortality rates, I’m afraid the medical profession can’t take all the credit. For example, “An
      Evaluation of Caesarean Section in the United States”, (Marieskin,1979), found the increase in cesarean sections was not the reason for improved fetal outcomes but that improved fetal outcomes were related to improved maternal nutrition, education, hygiene, reproductive control (contraception and abortion) and the availability of neonatal intensive care units.

      And, lastly, why can’t you convince me that women, as consumers of obstetrical services, DO count? Because you don’t have the evidence and, therefore, you won’t try, or because I’m such an unreasonable passionate person, you don’t think it’s possible? If it’s the former, I understand. If it’s the latter, PLEASE TRY, as I like to think I’m able to learn new ideas and facts and I’m quite sure that the readers and contributors of your blog will let me know if I’m just not getting your reasonable arguments. When you try to convince me (and I hope you will), could you please indicate where the impetus for changes originated. If you are going to use examples from hospital policies, OB practices, medical associations’ recommendations, etc., – did women friendly practices come from doctors or patients/consumers? Thanks.

      I’m looking forward to discovering which aspects of my posting you will respond to.

      • August 3, 2010 at 10:15 am

        I have a personal rule against responding to comments that take up 3 screens. It never seems very productive. Thanks for your comments and your passion. We have more in common than you think.

        But as for the NIH, you probably should take it up with them. I had nothing to do with the conference or how the panel was made up. I’m just one low level academic doc with a blog.

      • Laurel Brant
        August 3, 2010 at 11:40 am

        This a response to the following comment by Nicholas:
        A personal rule? of course, whatever suits your personal beliefs works well for you and does nothing for the dialogue and further, proves my point – you have clever tactics.

        I have already spoken to NIH and that is where I got my information.

        I”m sorry if I have misunderstood the purpose of this blog – is it discussion, sharing? Did I or anyone else say you had anything to do with NIH? Please, might we really dialogue – could you just acknowledge – yes, we were excluded from the panel and either you agree or you disagree.

        What, exactly, do we have in common??

      • August 3, 2010 at 12:39 pm

        Laurel – It doesn’t seem to me that you really want dialogue. It seems to me that you want an OB/GYN punching bag. So am I interested in playing along? Not really. I am a bit busy seeing patients at the moment. Thanks for your comments. There are certainly things that practitioners of every field could improve upon.

      • Laurel Brant
        August 5, 2010 at 1:54 pm

        Nicholas,

        I’m sorry if you feel like an OB/GYN punching bag, that is NOT my intention but thank you for sharing. You have given me more insights and that is valuable.

        Believe it or not, I do want dialogue but it would seem that we have a different idea of what that means. Websters definition of dialogue – 1. a talking together; conversation 2. open and frank discussion of ideas, as in seeking mutual understanding. I expect to be able to disagree with you and you with me and that each one of us will accept responsibility for our own reactions and feelings. When I succumb to the urge to rant, I like that you pick me up on it, or at least, give me your reactions.

        Is it accurate to say that your blog is more about readers asking questions and you answering the ones you are comfortable with? If it is, I just want it to be clear in order to avoid misunderstandings. Some readers may think, as I have done, that you wanted the opposing position/argument made. I sense that you cannot be completely honest here as this is a public forum and you have your colleagues to think of.
        I shall endeavor to listen more carefully and with more compassion, just I would like others to do.

        I do miss the many private conversations and heated debates my OB friend and I had 20 years ago . . . sigh.

      • August 5, 2010 at 2:08 pm

        Laurel – thanks for your comments. While I am in general support of a less interventionalist version of obstetrics, I completely disagree with many of your points, and think that they come from faulty knowledge. I don’t really want to invest the time in arguing those points with you, because I only have so much time and it doesn’t seem worth it to me to spend it that way. Your opening with very aggressive language about my field, claiming that I am trying to be tricky, and claiming that we are ruled by propaganda discourages me from wanting to debate you any further at this time. It strikes me that you do not come from a position that would be effected by any argument I would make. I am at a big disadvantage in these arguments as unlike the NCB community, I do not have a personality for attacking the opposition and pointing out their errors. I could write pages and pages and pages of completely screwed up things that have happened at the hands of various non-ob practitioners, but as I respect them as a group I don’t feel that this would be productive. As many of the more aggressive commenters do not respect OB/GYNs as a group, they have no issue with this.

        The blog started as a way to communicate with physicians, but over time it has become much more than that, and ultimately that is because of the many interested non-physicians that read it. I am happy to have anyone that wants to read it. Other than my primary posts, I have little control over what it “is”.

      • Heather
        August 5, 2010 at 4:06 pm

        Laurel, I’m certain such is not your intent, but you are starting to sound less than reasonable. The way I see it, Dr. Fogelson has, in this blog entry and others, actually been trying to have a real dialogue with the natural birth community and is trying to delineate the problems & come up with solutions–a wise idea, before the specialty of obstetrics loses any more respect. MUCH better than the “Dr.” Amy treatment, which is unfortunately far from being restricted to her. Maybe it’s time to regroup? Lay off the guy, at least he’s honestly trying. That’s SOO much better than we usually get.

  150. CountryMidwife
    August 3, 2010 at 7:27 am

    Do you really think the ACOG revision will make much of a dent? I am doubtful. Sure for the rare VBAC woman with twins or an unknown scar, perhaps… but not removing the words “immediately available” is very disappointing.

    • August 3, 2010 at 10:16 am

      I thought they changed it to ‘readily available’, which seems not quite as quick, but still very grey.

  151. Allison
    August 3, 2010 at 10:36 am

    I hope many doctors do read this, there are some great comments.

    @ Amy Tuteur – I agree there are some baseless claims from NCB advocates on here, but also MANY scientifically sound ones. And as Dr. Fogelson has pointed out, there are studies which support some aspects of NCB. For example, there is a lot of evidence for NOT inducing labor unless it is medically indicated – yet early induction has become a standard practice in MANY places, including the three different communities in which I have lived (in CA, SD and CO).

    Quoting Amy “It is not a coincidence that there are no doctors.lawyers or physicists complaining here. Women who understand science and statistics can read the data for themselves. Women who cannot, and most NCB advocates lack basic knowledge of the scientific method, statistical analysis and even childbirth itself, make up all sorts of baloney and pass it around among themselves as “knowledge.” ”

    I disagree VERY much that the scientific literature does not support NCB methods. Unless I am misunderstanding your statement? I AM a PhD Physical Chemist – and after reading MANY very sound research articles which showed the safety and lower intervention rates of assisted homebirth, I chose a midwife assisted home-birth. I am very happy to see that Dr. Fogelson supports this model of care in some cases, as well, though as he stated most OBs do not.

    Also in the minority, I write mostly from a place of contentment. However, where I did interact with the hospital model of care is where I became deeply disappointed. My story is this – Despite a couple things that would be cause for concern by an OB (going past my due date by about 2 weeks, and my water breaking about 24 hours before active labor started), my baby and I were in excellent health all the way through labor and the birth progressed smoothly without a “hitch”. My boy was a super healthy (Apgar 10) 9 lbs. 7 oz.

    Unfortunately, I had a severe post-partum hemmorhage. Despite a VERY sweet and obliging midwife, and a swift ambulance ride, my hospital transfer was a DISASTER once we reached the ER. As many including Dr. Fogelson have commented on, this is one key point of breakdown in our US medical system that I was unaware of when I chose a homebirth. After over 3000 births, my midwife had had MANY successful hospital transfers, but I just happened to have several very retaliatory ER nurses who were very against home birth and seemed to block my access to an OB at every turn. I am SOOOO grateful to the wonderful OB from whom I eventually received care – but by then I had a Class IV hemmorhage and nearly lost conciousness. Since we called L&D before leaving home, this OB had actually been waiting for me, but did not know where we were and was NOT receiving accurate information from the ER nurses! The records show that my hemoglobin levels were still quite high when I reached the ER – it was the nearly 2 hour wait for OB care that was so dangerous. For the record, the OB commended my midwife on doing everything right – including post-partum measures (including drugs) to stop the hemmorhage. I got to go home after 4 days and several blood transfusions – only to have a repeat hemmhorage 2 weeks later. Even after a D&C the only cause they could find a concrete for the hemmhorhage was lower uterine atony. Perhaps caused by my big and post-dates baby? The OBs said possibly but not necessarily.

    And I did receive care from several really terrible OBs during the course of my hospital stays. In all, I think I was cared for by about 10 different OBs during my post-partum, and I would say only 2 of them provided care on par with my midwife. So while I am nervous about having another terrible hospital transfer with my next child, I am even more terrified of being cared for by these OBs at the hospital. As an extremeley well-educated scientist with all the relevant data in my hands, I am still left in the bind that so many women are finding. It seems to me that the currently US medical system, overall, is NOT applying current knowledge and technology in the optimal way to meet the needs of women and children for the safest birth possible. After 3 years I am still researching my options for the best possible solution…and I wonder how an UNeducated woman can EVER get the safe AND psychologically healthy birth experience she and her baby deserve???

    • Laurel Brant
      August 4, 2010 at 10:51 am

      I’m very curious to know what happened to the response I posted last night. I are wanting me to stop posting or did it disappear into the mysterious land of blog?

      • Laurel Brant
        August 4, 2010 at 10:54 am

        Darn my inability to proof-read – apologies for the errors.

  152. CountryMidwife
    August 4, 2010 at 2:18 am

    Allison, the culture of hospital is so anti-home birth its awful and demoralizing. Born of the same spirit that gets a planned hospital birth with a birth plan a major eye roll. We work to change that by being professional in our transports, giving good report, copies of relevant records, etc, NOT returning the hostility, and hope we can change it person by person. But what you describe is both unsafe and unprofessional care. I hope you have written a letter to the powers that be at the hospital.

    Also, as an out of hospital midwife I have to admit I would not accept you for a home birth next pregnancy :( If you can have one in hospital without hemorrhage – I’d be ok for the third, though. Good luck.

  153. August 4, 2010 at 2:29 am

    >> We work to change that by being professional in our transports, giving good report, copies of relevant records, etc, NOT returning the hostility, and hope we can change it person by person.

    I applaud that attitude. I wish every out of hospital provider felt the same way. The only way to change attitudes is one person at a time. It only take a few positive interactions to change a hostile person to a open minded person, and just a few more to make them entirely supportive.

  154. Allison
    August 4, 2010 at 6:35 am

    Country Midwife – Unfortunately, I was a bit too tramautized by the care to ever write my letter – and busy finishing grad school with a baby in tow. But as I understand it my OB did speak up on my behalf in some sort of “investigation” (sorry I don’t the actual hospital logistics…). Sadly I developed PTSD regarding the ER experience – especially the hostility and roughness of those examining me – but after 3 years it is waning enough for me to discuss it.

    I am a very calm, peaceful person – as was my midwife – so the hostility towards us was very surprising and unwarranted. In any case, now that I am educated on the ins-and-outs of home and hospital birth, I do feel more confident that I can choose the right providers for a safe and healthy hospital birth next time, just in case I experience another hemmorhage.

    The experience (and those of my friends) has made me a “part-time” “natural birth” advocate, to be sure. It is difficult to find moms-to-be who are interested in having the discussion, but I still try my best to encourage “first time” moms to educate and prepare themselves without seeming too pushy. But I also try to discuss these things with my friends and acquaintances doing their residency in OB! The most receptive group I have found so far – L&D nurses! There are a couple in my family, but I also spoke to several in the hospital. Most I talk to seem to understand these issues very clearly, since they see the whole chain of events. However, they feel prohibited from having much influence over the course of any woman’s labor when the OB in charge is advocating in the opposite direction (early induction, early epidural, staying flat on back in bed, etc.)

  155. Allison
    August 4, 2010 at 8:07 am

    Oh, and THANK YOU to Dr. Fogelson and Country Midwife for your comments, positive attitude, and passion :)

  156. August 5, 2010 at 6:51 am

    Sweet, sexy Jesus, this is a lot of comments. Who has time?

  157. Washi
    August 5, 2010 at 9:02 am

    Melissa :
    I was actually directing that comment at Dr. F…as he seemed to be taking the term personally. I agree with the use, because I know women who have been treated in this way, so I know it happens.

    Strange I didn’t see your reply until today. I knew you were talking to Dr. Fogelson, I was just backing you up. :)

  158. August 6, 2010 at 4:23 am

    To what extent does the medical liability situation influence Ob-Gyns who are contemplating a C-section?

    • August 6, 2010 at 4:53 am

      I think it is dependent on the doc, and on the indication for cesarean.

      I don’t think it has a big impact on cesareans for labor dystocia, but I think it does have an impact on cesareans for non-reasurring fetal status and on repeat cesareans (vs VBAC.)

      The sad truth is that it is very hard to defend failure to do a cesarean when there is an injured baby and some period where a cesarean could have been done. When one is considering a cesarean for abnormal fetal heart rate tracings one has to choose where on the receiver operator curve one wants to be. You can be very very sensitive at finding babies that will be injured, at the cost of doing cesareans that weren’t ultimately necessary. You can also be very specific, only doing cesareans for the absolutely worst strips, at the cost of potentially failing to do a cesarean when one was needed to prevent injury.

      The legal hitch is that the retrospective standard is ultimate sensitivity – you are expected to do every cesarean that could have potentially have harmed a child, if indeed a child was harmed. While this seems reasonable to the patient (and lawyer) in retrospect, they will not consider that such a strategy would lead to a huge number of cesareans for bad strips that weren’t necessary. A common argument is that “no one has been sued for doing a cesarean, only for not doing one.” While this is somewhat cliche, it is also accurate for the most part.

      The same goes for VBAC, where no matter what level of informed consent has been reached and what level of monitoring has been provided for the patient, a uterine rupture with a fetal or maternal injury or death is going to be very difficult to defend. One might think that a clear informed consent document would be defense enough, but case law has shown us different, siding with patients who claimed that they did not really understand the risks (despite them being all over the paper they signed and the medical documentation.)

      So in short, it has a lot to do with it.

      • CountryMidwife
        August 9, 2010 at 2:45 pm

        Nicholas Fogelson : You can also be very specific, only doing cesareans for the absolutely worst strips, at the cost of potentially failing to do a cesarean when one was needed to prevent injury

        But, but but!! This said even though we KNOW that continuous monitoring has not changed apgar scores, NICU admissions, or the rate of CP… only increased the c/section rate. While I am highly sympathetic to the enormous problem of malpractice for the contemporary OB/GYN, I still urge each individual OB/GYN to read the evidence and let it guide decision-making better. Thus we can lower the c/section rate.

      • August 9, 2010 at 3:10 pm

        OBs are well aware of the (limited) data regarding continuous EFM, but its hard to believe when every OB has individual experiences of doing cesareans for bad strips and delivering extremely depressed infants with low apgar scores and bad cord gases.

        Some people want to believe that these situations don’t exist, but that’s because they don’t understand the way that statistics work, and they have never practiced obstetrics.

        Large studies have failed to show a benefit in cerebral palsy with EFM, but these studies do not define every case. Large studies by their very definition remove outliers. There are clearly cases where monitoring prevents bad outcomes. There are also clearly cases where monitoring leads us to do cesareans under the false belief that the fetus is in distress. As these cases are relatively rare, they get eliminated in the mathematics of large volume statistics.

        In my opinion, the best way to look at the data is to take heed that abnormal fetal heart rate tracings need to be taken with a grain of salt, particularly in pregnancies that are not at high risk. That being said, to then go on to say that there is no benefit to the technology is to ignore the many experiences every OB has had where it clearly did help. The question is not whether there is any benefit, because that question is clearly answered yes. The right question is whether the benefit of the technology outweighs the downsides of its implementation, and that questionissue is far more questionable.

        Sometimes people like to claim that all those positive experiences with EFM that OBs claim to have are some kind of mass hallucination, a willful ignorance of the mass of evidence in publication. This is a little off to me.

        The amount of data we base these conclusions off of is not so great, and for every 100 people that “quote” this data, 1 have actually read it. It has grown into some kind of urban myth, like many others in obstetrics.

        “EFM doesn’t improve outcomes!”

        “Tocolytics don’t delay preterm delivery!”

        “There is no role for thrombophilia testing in severe pre-eclampsia and IUGR”

        These little soundbytes are nice to carry in the back pocket, but these issues are far too complicated for such simple conclusions.

  159. August 6, 2010 at 10:25 am

    Nick, I expected your response, of course, and regret its truth. I suspect that litigation fear permeates OB-GYNs’ thinking more than most specialist. If a baby is born damaged, the presumption is that someone screwed up.

  160. Kip Kozlowski
    August 8, 2010 at 3:47 am

    Reasonable. However, perhaps the bigger issue is–who gets to decide? If the situation was presented as–“In our experience, when a woman does not progress faster than X cms per X, (or baby is breech, or whatever) a cesarean can be indicated, though of course, we can’t know that in your case. At this point, you and your baby are fine. How would you like to proceed? We will support your decision fully.” I would have no problem with it. This is not what happens tho–and you know it. It is ENTIRELY the mother’s decision, but she cannot make a responsible one without good information–especially in the stress of labor.

  161. CountryMidwife
    August 11, 2010 at 12:30 pm

    Nicholas Fogelson :
    These little soundbytes are nice to carry in the back pocket, but these issues are far too complicated for such simple conclusions.

    You really think the evidence supports continuous EFHM for low-risk women? I hear you about the harrowing memories, but anecdote does not evidence make. And those women were probably not low risk anyhow. Well, in final summary of this verbose thread, ultimately I think changing the induction rate will not lower the c/s rate significantly enough to be on track with recommended rates. Though that is a noble goal, for sure. But I think “the problem” of continuous EFHM needs to be equally addressed in creating unnecessary cesareans. Most of us CNMs working out of hospital, we’re here because we became so tired of “emergent” c/sections for apgars of 9 and 9, again and again and again…

  162. August 12, 2010 at 7:45 am

    I know several women who had “necessary” c-sections, but the necessity arose from the unnecessary interventions and drugs that caused their labor to go South. Completely healthy women were convinced that their babies were getting HUGE, and that if they didn’t induce immediately, their babies would be too large to birth vaginally. Others were convinced that going past their due date meant that their baby could die at any moment, so they needed to be induced ASAP. The inductions failed, the labor became too painful to endure w/out an epidural, and the combination of drugs put the baby into distress, creating the “need” for an emergency c-section. These c-sections probably could have been avoided if there was an ounce of trust for the natural process.

    Why aren’t OB’s looking at Ina May Gaskin’s statistics and saying “Wow, how is she doing this, and how can we learn from her?” Instead, they view her as some crazy hippy who’s just been lucky. We need our medical professionals to learn more about natural processes. Sure, there are times when modern medicine is necessary, and in those times it’s a true blessing, but there needs to be more trust in our natural abilities.

    Also, I once read a post about OB’s ordering “Pit to distress,” where they crank the Pitocin to purposely put the baby into distress, making an emergency c-section necessary. I thought “no way…there’s no way in hell that a doctor would ever do anything so deplorable.” Then I asked some L&D nurses and MW’s, and they said that yes, that is a practice of some OB’s. APPALLING!!!!

    • August 12, 2010 at 2:16 pm

      >> Also, I once read a post about OB’s ordering “Pit to distress”

      I have seen this and similar comments a lot and want to clear this up, as this is a misunderstanding of what this term means.

      First of all, its a stupid term that shouldn’t be used because it makes people think of what you are thinking, which sounds bad.

      What is really is –

      Sometimes there is a labor where every time there seems to be contractions the baby has significant heart rate deccelerations. This is typically when the baby is compromised in some way. One might have pit on for some reason and notice that the decels are happening, so it gets turned off. The labor goes on for some time and there is no cervical change over a long period of time, and the contractions are not strong (typically one needs about 180 monte video units of contractions to effect cervical change as measured by an internal pressure catheter). Now we are in a situation where the natural contractions are not strong enough to change the cervix, but stronger contractions seem to cause the baby stress. One might then decide to find out if one can reach a level of contractions that will change the cervix without compromising the baby, thus “Pit to distress”. One starts pitocin slowly and tries to get to an adequate level of contractions. If one cannot get there without noting severe fetal decelerations, one knows that the baby will not tolerate labor level contractions and it is now reasonable to deliver by cesarean.

      So now one might ask “so if the natural contractions are not strong enough to change the cervix, why not just wait for them to get stronger?” That is certainly an option, but the issue is not where the contractions are coming from but how strong they are. Oxytocin (pitocin) is the exact same molecule that is naturally produced in the posterior pituitary gland. If one adds exogenous pitocin slowly, presumably one would reach the point of adequate contractions that would eventually be reached naturally. If that is too much for the baby to handle, then a cesarean will be needed.

      This is not typically an issue with a term full grown fetus. It is much more of an issue with a poorly grown fetus or a pregnancy with a bad placenta (pre-eclampsia, pre-existing maternal diabetes) or otherwise compromised fetus.

      Nobody is using pit to intentionally stress the baby so one can do a cesarean.

      • August 16, 2010 at 6:19 am

        Thank you for that explanation. That was not how it was described to me.

        I disagree that natural oxytocin and Pitocin are exactly the same. Our body reacts differently to natural hormones than it does to synthetic ones. The natural oxytocin is released in bursts, rather than a continuous drip, and that can make a difference on how the uterine surges affect the baby, and how well the baby tolerates them.

      • August 16, 2010 at 7:23 am

        There’s not really anything to agree or disagree with. Pitocin, which is the brand name for synthetic oxytocin, is atom for atom the same molecule as the oxytocin produced in the posterior pituitary. They are exactly the same at an atomic level.

        One can discuss whether the difference between the pulsatile delivery of oxytocin from the posterior pituitary vs continuous delivery through an IV makes a difference, but there’s no data to support your claims about it. I think you are extrapolating some ideas of nature being superior into some unsupported statements of fact.

      • August 16, 2010 at 7:49 am

        Okay, I’ll have to search for some documentation to support my claim, if there is any available.

        Anyone who has experienced both the natural and synthetic versions can attest to the differences. Natural oxytocin is the ‘love’ hormone, and the synthetic equivalent does not create the same feelings of well-being and love that the natural version produces. The synthetic version also creates longer and stronger uterine surges, that are much more painful and difficult to manage without drugs. Anyone who has been through a natural birth and an induced birth knows these differences.

        They may be the same, atom for atom, but they are very different.

      • August 16, 2010 at 8:24 am

        Well we can agree to disagree here, but there is no science whatsoever behind what you are saying. Synthetic X is the same as natural X as long as they are identical. To believe differently is to create a new theory of chemistry than what is scientifically accepted in the world.

        It is possible that the speed or pulsatility of delivery between synthetic and natural pitocin has some effect on what labor feels like, but it is not because the molecule is different.

        Now if you believe in substances being different at some subatomic level, a la the theories of homeopathy, then we are really outside of science.

      • Susan
        August 16, 2010 at 8:12 pm

        Dr Fogelson,

        I’ve heard that, even though oxytocin and pitocin are chemically the same, the brain interprets them differently, releasing endorphins more with natural oxytocin than with pitocin. Do you know of any documentation for this one way or the other? Thanks in advance. :-)

      • Jaynie
        August 17, 2010 at 1:19 am

        IMO, what we know about science is only the tip of the iceberg. New discoveries are made every day, so it behooves us to remain open-minded. We may think that we know everything there is to know about the human body, but I guarantee that we don’t. There comes a time when we have to look at what works best and what doesn’t, rather than depending on what science tells us.

        Perhaps the difference between the natural and synthetic versions is that the natural is released from the pituitary, rather than injected directly into the bloodstream. As a comparison, think of all the money that is spent on research and development of vitamins and minerals. But, the absolute best way for the body to assimilate nutrients is through consuming whole foods. The natural way is always the best way, when it comes to normal, healthy people.

      • August 17, 2010 at 3:09 am

        >> IMO, what we know about science is only the tip of the iceberg. New discoveries are made every day, so it behooves us to remain open-minded. We may think that we know everything there is to know about the human body, but I guarantee that we don’t.

        You are so right. That being said, I don’t know of a single scientist that thinks we know everything about how the body works. People who aren’t scientists claim that scientists think that. People who have spent a life studying what we do know realize that we know very little.

        >>
        Perhaps the difference between the natural and synthetic versions is that the natural is released from the pituitary, rather than injected directly into the bloodstream.

        And what exactly do you think that the pituitary does? It injects oxytocin into the bloodstream.

        Most of this is coming from some kind of confusion of what the blood brain barrier is. Its not like there is some wall that the pituitary is behind and because oxytocin is being made there the brain gets exposed to it, where it wouldn’t be exposed if it were injected IV. The BBB is a huge network of cells that surrounds neurons throughout the brain, filtering out various things based on lipid solubility, charge, and size.

        The pituitary is dumping its products into the hypophyseal veins, which go directly back into system venous circulation. If that oxytocin were going to get back to the brain and do something, it would have be to be able to cross the BBB, which it can’t.

        There is a break in the BBB between the pituitary and the hypothalamus, which allows the hypothalamus to sample what the pituitary is producing. Does this somehow allow the brain to see some internal effect from the oxytocin? I don’t know, but as the hypothalamus does not control these feelings of love and joy that people are attributing to ‘natural’ oxytocin, I doubt it. Ask a neurophysiologist, which neither of us are (I think :))

      • August 17, 2010 at 3:13 am

        >> But, the absolute best way for the body to assimilate nutrients is through consuming whole foods. The natural way is always the best way, when it comes to normal, healthy people.

        You believe this not because of some data, but because it is your fundamental philosophy. From a scientific point of view I don’t know if this is true or not. I don’t fundamentally believe that just because it sounds good.

  163. Susan
    August 15, 2010 at 11:45 pm

    Alex :
    This is really an attempt to answer the why section at shift change comment above.
    I work 12 hr shifts on Labour ward. I may have been looking after somebody all night, been in the room on multiple ocassions to check the trace / examine / see how things are going with the syntocinon / see how mum is coping. I
    f there is lack of progress, despite everything I have done to try and improve things, I like to deliver the baby myself – after all I have built a relationship with the couple. This is only the case with failure to progress, fetal distress is a whole different kettle of fish.
    I have usually given a few warning comments earlier on “things aren’t progressing as fast as I would like” and then have a conversation about how I think that a vaginal delivery is unlikely to occur soon (note, not impossible) and offer the option to continue or proceed to LSCS.
    I am present on LW anyway, performing a LSCS is not going to get me away any faster and I am offering an opinion of what I think the best option is, and letting the patient decide.

    Forgive me if I’m just not understanding you, but how does it help the woman & child to go ahead and offer it then? I know you said you give warnings, but is that helpful for her? I’ve not been in that particular situation (I have fast labours), but I know I’d feel stressed and disheartened at hearing such comments instead of being allowed to labour as my body dictated. The other question would be how you define failure to progress. I’m one of those women who doesn’t dilate at all until the very end. With my son I went from 3-10 cm in 1 hour; with my daughter I went from 0-10 cm in a little over an hour, maybe as much as 2 hours. Perhaps it isn’t that the woman isn’t progressing, but that her body just doesn’t follow the curve. Of course, I know I’m nowhere near to being an expert, so I’d truly like to understand more. But honestly, the thought of being on the clock with labour frightens me.

  164. August 16, 2010 at 6:26 am

    I would like to see the US adopt the midwifery model of care like the UK has. Only 10-15% of pregnant women in the UK ever seen an OB – low-risk women are under the care of MW’s, and they often have the option for homebirths. Their rates of infant and materanal mortality and morbidity are much lower than the US, so it seems like a no-brainer to me. The big difference – they have national healthcare, so their maternity system is not profit-driven. I don’t mean to insult, I’m just sayin’…

    • Susan
      August 16, 2010 at 6:30 am

      I would like that, too, Jaynie. I’m an American, but currently live in the UK, and both of my children have been born in England. The first was at a birth centre attached to the hospital, and the second a home birth.

      • August 16, 2010 at 6:46 am

        I have fellow HypnoBirthing practitioners in the UK, and they’re just astounded with what women in the US have to go through to have a baby.

        One doesn’t need to be an rocket scientist in order to read and comprehend the statistics. There is absolutely no doubt that many countries do a far superior job than the US when it comes to birth.

      • August 16, 2010 at 6:52 am

        I know that someone will come back with the argument that the UK has the NHS, so all low-income women have access to healtcare, and that is why their stats are better than ours. I’ve never known a pregnant woman in the US to be denied maternity care, so I won’t buy that argument.

    • Susan
      August 16, 2010 at 6:50 am

      I was speaking with a midwife here, talking about the way antenatal care and labour & delivery are handled in the US vs in England, and she was quite taken aback, too.

  165. VW
    August 16, 2010 at 10:58 am

    Jaynie :
    VW: If you had not been numb and in an ‘asinine’ position, you might not have had shoulder dystocia. The worst position for a woman to birth is on her back…the pelvic bones need to be able to flare open to allow the baby to descend, which isn’t always possible when the woman is flat on her back.

    I know. The problem is that this means there’s no way to tell if the SD was iatrogenic or something about my pelvis. If it were the former, I’d be happy to birth at home. If it’s the latter, I would have to strongly consider the hospital.

    • August 16, 2010 at 3:47 pm

      VW – I wouldn’t lose too much sleep over it. There is no evidence to suggest that position has anything to do with shoulder dystocia evidence, or that the pelvis is wider in any particular position. Deep flexion of the hips does open the pelvis a bit, but this can be accomplished in many positions. Deep squats, all fours pushing back (Gaskin) or supine with hips flexed (McRoberts) all do the same thing anatomically.

      >> which isn’t always possible when the woman is flat on her back.

      Where does this attack on the lithotomy position come from? Its not like OBs invented it. There are images going back thousands of years of women delivering children in this position, and honestly I haven’t seen more than a few historical images of other positions in birth. Its not like it was invented by OBs. Sure lithotomy is easier for the OB to deal with, but that doesn’t justify all this anti-lithotomy stuff. There just isn’t any evidence to support it. Epidural -> lithotomy is going to be the only way. No epidural -> deliver however you like.

      • August 16, 2010 at 5:43 pm

        Nicholas Fogelson :

        Where does this attack on the lithotomy position come from? Its not like OBs invented it. There are images going back thousands of years of women delivering children in this position, and honestly I haven’t seen more than a few historical images of other positions in birth. Its not like it was invented by OBs.

        Dr. Fogelson,

        I would like to suggest you watch an “oldie but goodie” film that has been used in birth classes, doula trainings and the like forever (or the last 15-20 years for sure!) It is a film called “The Timeless Way” and has a bunch of images taken from anthropological resources showing women birthing through time. While I agree with you, OBs have not invented the lithotomy position, they have encouraged it. None of the images taken from native cultures both past and present show the mother on her back in the standard lithotomy position. And they do show her in many other positions, mostly upright and supported! Anyway, thought you might enjoy watching this classic film that demonstrates a bit of the history of birth, over many hundreds if not thousands of years.

        http://injoyvideos.com/mothersadvocate/videos.html

      • Jaynie
        August 17, 2010 at 12:58 am

        Dr. F: With all due respect, I don’t know a single woman who ‘chose’ the lithotomy position for birth. When women are permitted to follow the lead of their body, they rarely choose to be flat on their backs. I do know women who were literally forced onto their backs, and it was only for the convenience of the OB, not what was best for the mom or baby.

      • PrecipMom
        August 17, 2010 at 1:02 am

        Jaynie :
        Dr. F: With all due respect, I don’t know a single woman who ‘chose’ the lithotomy position for birth. When women are permitted to follow the lead of their body, they rarely choose to be flat on their backs. I do know women who were literally forced onto their backs, and it was only for the convenience of the OB, not what was best for the mom or baby.

        I did! I do! I LOVE pushing in lithotomy once the head is coming out. I feel like it lines my pelvis up the best to get my babies out. And I’m a home birthing mother of 5 who happens to love rocking the stranded beetle. :-)

    • Jaynie
      August 17, 2010 at 12:51 am

      VW: Google the rhombus of michaelis. It’s an area right around the tailbone that pushes out as the baby’s head descends, when it’s pointing towards the back, before it goes under the public bone. When women are on their backs, this area cannot open, and baby’s can get stuck. The pelvis does widen during pregnancy and birth, as the hormone relaxin has made all the ligaments nice and stretchy. That is why women get so clumsy late in pregnancy – their pelvis isn’t as stable. You’re probably safer to birth in a hospital, just in case. But, do find a care provider who genuinely understands how the natural process works, and will refrain from interventions unless they are absolutely medically necessary. If you can avoid the epidural and not be flat on your back, you may not have SD. I recommend a good hypnosis for birth program, as the intense relaxation techniques help women stay comfortable throughout labor and birth.

  166. doctorjen
    August 16, 2010 at 4:22 pm

    Lithotomy is in not the only position you can deliver with an epidural. One reason to avoid lithotomy is that many women find it uncomfortable. Also, anecdotally, I find that it encourages providers to spend all their time staring at the perineum and fiddling – doing frequent checks, stretching and pulling on the perineum, etc, because access is so easy. Especially for a primip, pushing with an epidural often takes a while – and frequently poking at the mother doesn’t seem to speed it up or help anything out other than eventually causing swelling and irritation and I’ve even seen docs cause little tears during pushing by stretching and pulling. Moms can birth in a variety of positions with an epidural – the simplest is side lying, and requires no lower body strength at all. Many moms with epidurals in my practice adopt more upright positions with a little help. Hands and knees is possible for most patients, and squatting for many with a little assistance (to save our backs, we don’t hold up completely numb women in our setting!) I frequently find that changing positions throughout second stage seems to help wiggle the baby loose – and prevents the mother from having terrible muscle soreness the next day, especially with an epidural where it is possible to uncomfortably overflex the hips for too long since mom can’t tell you when she’s getting uncomfortable or needs a stretch.
    It takes some practice for nurses and docs to assist a mother with an epidural to assume a different position, but it’s quite possible and should at least be available if mom prefers to be able to move. Especially in a long second stage, staying in one position, lithotomy or otherwise, is just hard, as it would be to hold any position for a prolonged time even when not in labor, and moving around, even if just side to side helps keep mom from getting muscle cramps and muscle exhaustion.
    According to the Cochrane database, there are some benefits to upright positioning for second stage, including a small but measurable decrease in pushing duration, and decreased report of severe pain, as well as reduction in episiotomy (maybe because it’s hard to reach?) and 1 trial showing decrease in abnormal fetal heart rate tracing.
    Entertaining that this comment thread is still going after all this time – and has wandered so far from the original topic!

  167. Aly
    August 17, 2010 at 4:27 am

    Can’t find the relevant portions to quote, since I’m reading through email. But:

    RE: lithotomy position. Women are about as likely to lay down on their own giving birth as they would going to the bathroom. It’s not comfortable when one is in pain. A big thanks to Dr. Jen to highlighting the benefits and research.

    RE: pitocin vs oxytocin. It’s certainly plausible that oxytocin is released in concert WITH something else that makes it easier for women to deal with (endorphins, or something else). Anecdotal, I’m know, but surely you have noticed women have a harder time dealing with pitocin induced contractions? Not to mention, there MUST be a difference (not in the chemical composition, I agree) because pitocin causes the cesarean section rate to rise. If pitocin is identical to oxytocin in all ways, why should induced/augmented labors be more carefully monitored? The difference may not be in the “what” but in the “when, how much, what with.” Different people may release different amounts of oxytocin, for example, based on what is needed for that individual person, something impossible for the synthetic version. Or perhaps there is a biofeedback loop that turns the oxytocin “off” when it has reached the peak benefit/risk ratio. (You unknowingly mentioned this possibility with the pit to distress comment- perhaps our bodies recognize the “too much” alert BEFORE our babies go into distress). Now, I’m supportive of the pitocin injection after the baby is born, but clearly there must be a medical reason in labor. Just speculating.

    Finally, RE: whole foods. It’s extremely accepted that whole foods generally provide a more accesible version of vitamins and minerals than supplements, not so much because of the chemical composition, but because of bioavailability, the pairings of different nutrients, and the fact that supplements are more likely to be urinated out of the body rather than used.

    http://www.mayoclinic.com/health/supplements/NU00198

    In short, Dr. F, with these three issues, I believe you are showing your own bias that technology and reductionist science is more likely to enhance outcomes, while someone like me (and trust me, I disagree with 50% of ncb dogma) believes in only intervening when it is proved necessary/ beneficial by *research* not anecdotes. IOW, natural functioning of the body should be the default, unless proven otherwise. Neither extreme ideology (nature vs technology) is helpful. However, I apologize if I misinterpreted your stance.

    • August 17, 2010 at 4:43 am

      >> If pitocin is identical to oxytocin in all ways, why should induced/augmented labors be more carefully monitored?

      They are identical, but its a matter of amount. There’s no question that one could create unnaturally strong contractions with very high doses of IV pitocin, contractions that likely could not be achieved with natural oxytocin release. We are trying to achieve that natural level of contractions, but there is no doubt it gets overshot sometimes. We feel OK not monitoring a labor that is off pitocin because it seems very unlikely that the natural pitocin release is going to be strong enough to injure the fetus.

      Sometimes I see big fetal decelerations in a fetus that is laboring naturally, and have to step back and ask “is this a real danger? Is nature really choosing to snuff out this child? Mostly likely not, so lets just watch and see.” I’m more likely to be worried if those contractions are man made, because whatever the system is that evolved in us, we have short circuited it with external influences.

      >> Or perhaps there is a biofeedback loop that turns the oxytocin “off” when it has reached the peak benefit/risk ratio.

      Oh no doubt. There is such a system in the hypothalamic pituitary interaction that occurs with natural pitocin release.

      Pitocin is a potentially dangerous drug. We can give way too much of it and lead too fetal injury, or even fetal death. That doesn’t make it a different substance than natural oxytocin. It just makes a potential for there to be more of it.

      Perhaps this is a part of the reductionist thinking you speak of. Some people are saying that ‘natural oxytocin’ is different than Pitocin, but what they are really saying is that ‘natural oxytocin’ is delivered to the uterus in some way that is different than how Pitocin is delivered, not that they are different molecules. This I can completely agree with.

      >> in only intervening when it is proved necessary/ beneficial by *research* not anecdotes

      We’ve all got biases. There is only so much research to go by, and some of it is pretty poor quality. We are always left with practicing by a combination of what we believe the research to show and our experiences. There are all kinds of things that I routinely do because of positive and negative anecdotal experiences. I’ve made mistakes in my career that I will never make again because I now do something that will prevent that mistake. I didn’t make that change because of research, I made it because I empirically learned something. Evidence based medicine doesn’t mean one doesn’t continue to learn from experience.

      Remember –

      1 anecdote – “in my experience”
      2 anecdotes – “in our series”
      3 anecdotes – “in case after case after case”
      :)

  168. Jaynie
    August 17, 2010 at 8:52 am

    You believe this not because of some data, but because it is your fundamental philosophy. From a scientific point of view I don’t know if this is true or not. I don’t fundamentally believe that just because it sounds good.

    I’ve studied nutrition for many years, so I can say that it’s true. Most supplements are excreted through the urine, which is why you get florescent yellow urine. Although, supplements made from whole foods are better assimilated by the body than synthetic ones. Overall, the best way to get nutrients is by consuming them. Digestion is really an amazing process.

  169. August 30, 2010 at 6:42 am

    I appreciate this article. This may have been said before but I don’t have time to read all the comments. ;)

    Maybe the c-section is ‘necessary’ based on the circumstances but had the circumstances been different, one may find it would not have been a necessary outcome of labor.

    For example, a woman is induced. Cervical ripener, pitocin, amniotomy, fetal monitoring . . . needs a c-section due to decels in the heart rate. Had the woman not been induced and/or not had one or more of those ‘unnatural’ things happen to her, the c-section may not have been necessary. Making it a likely ‘unnecesarean’.

  170. Tamrha
    September 18, 2010 at 9:50 am

    Nicholas Fogelson :
    Who claimed 100% proof? I just said what I think.

    But you are still speaking for others, and you can only speak for yourself, what you do and how YOU practice, communicate with your clients. You don’t know every OB out there and you don’t know how they practice or whether or not they lie to their clients. A reworking of your language in the post above would clarify things.

  171. Becky
    October 18, 2010 at 1:37 pm

    Heather : Even so, my homebirth was MUCH less stressful, because I knew for sure that the midwife wasn’t going to try to do things I didn’t want done.

    As someone who has had a homebirth with a CPM and who has many friends in the homebirthing community, I can tell you that this is NOT universally true. I used a CPM with one of my four births, she wanted me to take cytotec to “get this over with.” I was much better attended by the nurses and residents when I delivered in hospital, though my favorite experience was with CNMs in a birth center. Bad midwives exist, too, it is not just doctors.

  172. Aurélie
    November 8, 2010 at 1:07 pm

    Admittedly, I didn’t read all the comments. But I have a bona fide question. The rate of c sections in my home country (France) is around 20 percent, which many people claim is too much (including the French Hospital Federation). In the meanwhile, the infant mortality rate is 4.2/1000. In the US, where the cesarean section is over 30 percent, the infant mortality rate is 6.3/1000. If ALL the cesarean sections performed in the US are absolutely necessary, how come the infant death rate isn’t lower?

    • November 10, 2010 at 9:22 am

      Who said all the cesareans are medically indicated? Lots of them are appropriate (by our medical standards), but some are not. Many are done for medicolegal reasons, to eliminate tiny risks that if hit would lead to a massive and indefensible lawsuit.

      Edit –

      Not that this is a good thing, or something any physician tries to practice (I certainly don’t). But it is a reality of the situation at times. France has a very different medicolegal climate.

      • Susan
        November 11, 2010 at 12:23 am

        Thanks for the clarification. I had been about to comment that you hadn’t said that *you* performed C-sections for those reasons, just that they are sometimes performed for those reasons, sadly. I suppose a case in point would be the hospital in my home town in KY, where there’s a de facto ban on VBACs, not because of hospital policy, but because none of the doctors will perform them. I assume (though could be wrong) that this at least in part due to malpractice insurance and such.

  173. CypeEfferee
  174. Crystal
    May 19, 2011 at 4:07 am

    I really have a problem with your wording here I am afraid. There are in fact many unnecessary cesareans being performed every single day in this country. Why has the cesarean rate gone up this far in percentages while the mortality rate has not improved, and in some studies gotten worse? You can say that you cannot know what would have happened if the cesarean was not performed, but in many instances you can have a good idea what would have happened from similar situations handled a different way.

    My first baby was born by cesarean. It was in fact an “emergency” cesarean. Do I believe it should have ended that way? Not a chance. By the time the cesarean was performed it may well have been necessary, but only because of what the hospital staff did leading up to that point. I was young and naive and unfortunately got most of my information about birth from “What to Expect When You’re Expecting”. It never crossed my mind that I would have a cesarean and was not prepared for all the interventions and the risks of them when I went to the hospital. I went in to the hospital when my water broke, when contractions were just barely starting. No one bothered to tell me that this could take a really long time being my first baby and that I should go home for a while and wait until contractions were closer together. Also, I tried to avoid an epidural, but once the pain started getting bad and being asked all the time if I wanted it, I consented. Of course after that I was stuck in bed which really slows labor down and the doctor naturally insisted on pitocin (one of the most widely overused drugs there is). Then the contractions got to be too much for the baby due to the drugs and his heart rate kept dipping. Eventually they rushed my to the operating room because of this. I never dilated past 7 cm. The whole thing took around 24 hours.

    I have since had 3 VBACs, 2 of them in hospitals, my last one at home with a midwife. 2 of the 3 were unmedicated, and they all took time. My labors ranged from 12 hours to 18 hours. I know women that had a similar experience with their first baby and were so convinced by medical staff that their bodies were broken that they believed it and just scheduled repeat cesareans to avoid it all. My first one would have been a normal delivery as well had I simply not stepped foot in the hospital. I am sure of it.

    Now, birth is rarely a medical emergency and if hospitals treated women like they were only doing the most natural thing their body can do rather than treating them like they have a condition, like they’re “sick” and having the attitude that their own bodies are not able to have a baby the way they are made too, unless proven otherwise, the cascade of ridiculous interventions would not happen and they would not end in so many cesareans. The few women who do need to have cesareans, or should give birth in a hospital and need to be monitored are real and necessary situations. But they really are very few.

    I also need to mention that the women who are “appropriately counseled” and then “choose” a repeat cesarean over VBAC are very much in the minority. Here is what most of them get when they ask about VBAC with their doctor… “Yes, that is an option, but you have to understand the risk of it. Here is our consent form because there is a 1% chance of uterine rupture and if that happens you could end up with an emergency hysterectomy and your baby could be either mentally disabled or he/she could actually die if that happens, so we need you to sign these forms relieving us of any responsibility if that happens” or… “Our hospital doesn’t do VBACs because of all the risks involved so we have to schedule a repeat cesarean” or… “Why would you even want to try? Remember your first birth? Do you really want to go through that again? Wouldn’t it be easier to just schedule a cesarean and avoid all that?” and the list goes on. Very few doctors in very select areas will actually encourage a VBAC and the rest scare them so bad they don’t even want to try. Also, no one in my experience has ever mentioned the real risks of cesarean and the fact that it is much worse to have several cesareans and that there is a much higher risk of cesarean complications than uterine rupture, which is actually between 0.4% and 0.6% possible when you do not use induction medications.

    I just have a problem with you actually saying that there are no unnecessary cesareans and in the same breath talk about there being too many elective cesareans. That doesn’t even make sense. How is it that our numbers are so high and our mother and baby outcomes so poor? There are a huge number of countries with better mortality rates than us. Why is that? Quite simply, too many cesareans, or more specifically before the cesarean is performed, too many ridiculous interventions. That is the bottom line and physicians need to start admitting it.

  175. May 20, 2011 at 2:49 am

    Dr Fogelson I have to disagree with you. I live in South Africa where our C Section rate in private hospitals is at a national average of 70%. In johannesburg, where I live it is over 80% and there are two hospitals that have a 90 – 95% rate. I know many women who were told as early as the beginning of their 2nd trimester that they were having a c sect for reasons ranging from breech to high blood pressure to small pelvis. How is it possible that the affluent people in my country are so unable to birth vaginally while the poor – who are forced to use state hospitals – have a 10% c section rate. One of my school friends was told she would have to have a section because both of her sisters had had sections. Please Dr Fogelson, rethink your rather patriarchal stance. Just because we didnt go to medical school does not mean we dont know when we’re being screwed by the medical system.

  176. May 20, 2011 at 4:12 am

    Bronwyn – It sounds like the hospital you describe does a lot of unindicated cesareans, meaning that they could not be prospectively justified.

    I think a lot of folks have failed to understand the meaning of my post, which is to demonstrate the inappropriateness of the word “uneccessary”, which implies that we know what would have happened if the cesaraen would have been done.

    An appendectomy performed for a suspected appendicitis sometimes results in the removal of a normal appendix. We consider this acceptable because we aren’t willing to miss infected appendixes. We don’t call those unecessary, even though that particular patient would have done fine without the surgery.

  177. May 23, 2011 at 2:10 am

    Hospitals Dr Fogelson, in the plural. Every single private hospital in our country has the same problem. At Sandton Clinic (that’s one of the 95% ones) there are only two doctors who will “do” a natural birth. And then it’s induction/ eft/ lithotomy and a 6 hour limit from onset of contractions to get the baby out – which as we all know practically guarantees a section.

    With respect, the difference between “unindicated” and “unnecessary” is pure semantics on your part. The c section epidemic in my country is an issue I am passionate about. And even though I have never been to medical school I believe I can safely say that MOST of the c sections in South African private hospitals are unnecessary.

    • May 23, 2011 at 6:13 am

      I think we can look at a cesarean rate of 40% and say categorically that many of the cesareans were unecessary. I don’t think you can look at any single cesarean and say that. You can only say it was unindicated. You may call this semantics, but we can only make change in a prospective manner. We cannot change the future crying about the cesareans that were already done. We have to evolve our indications for cesarean in order to _safely_ achieve more vaginal deliveries.

  178. Staceyjw
    May 23, 2011 at 5:11 am

    THANK YOU! great article. I had a CS and it was both indicated AND necessary, and I am happy I had it because both me and my son ended up healthy and unharmed.

  179. SSB
    May 24, 2011 at 3:35 am

    Dr. Fogelson, bless you for keeping your cool in the face of personal attacks. Aria, did you really just ask an OB if he knows what surfactant is? Sheesh- your disdain of physicians so predicates each of your comments that it is difficult to take you seriously.

    I have had 2 c-sections, both of which I feel were indicated. Would I have preferred to deliver vaginally? Absolutely. Do I regret moving forward with the sections? Never. I have 2 amazing, healthy children to show for it.

    I was not lied to. My physician did not say, “You must have a c-section, or your baby will die.” I was told, “We’ve tried to let your body deliver your child naturally, but it just isn’t happening, and things are going in the wrong direction. (indeed, they were!) I think we should consider delivering your baby by c-section before things get worse. What do you want to do?”

    I resent the implication by many in the birthing/AP community that I am somehow less of a mother because my children came into the world through my abdomen rather than my vagina, I chose to have pain control, I vaccinated them, sent them to daycare so I could support them financially, and let them cry while I took a shower.

    I resent the implication that the above occurred because I was improperly educated, unempowered, or fooled by the “man”. I knew exactly what I was doing, and I thank my physicians, nurses and midwives for their expertise and support when I needed them.

  180. Ronda
    May 25, 2011 at 3:19 am

    I would just like to say thank you Dr Fogelson for such an article and opinion that is too often (particularly lately) criticized.. and thank Goodness for cesareans! My mother died during child birth 32 years ago. Had she been having that child today in a western country with the option of a cesarean birth, she would no doubt be still alive. It saddens and angers me when western women complain about the incidence of cesarean births in their country. Try telling an undernourished, impoverished woman in a developing country that you are so hardly done by because you were given a surgical procedure that enabled you to have a live child and stay alive yourself. This argument is wrong on all levels. Not only does it imply that women that do not give birth naturally are somehow inferior and should feel guilty or ripped off, it also suggests that most obstetricians are wrong and spiteful in their professional decision making. Woman need to realize that it’s not how you birth the child that matters so much, but how you mother that child throughout their life. I only wish a cesarean had been an option for my mother, so she could have had the option to mother her child (me) throughout my life. I feel that those woman who complain about their cesarean delivery’s as if it’s the most traumatic and unethical thing to happen to them need a reality check..how can you be more lucky than to have your child and still be alive yourself. There is nothing to blame on anyone here, I for one don’t see the problem in a surgical birth, it’s not the way in which you deliver that’s the perfect outcome..the perfect outcome is the living child you get to hold in the end.

  181. May 25, 2011 at 3:54 am

    Thank you for your stories. I think its important to hear.

  182. LK
    June 26, 2011 at 12:55 pm

    I agree with you. Tale of two L&D by two best friends.

    Mine: Beyond the subchoronic bleeds in the first trimester (resolved) and the last trimester very little fetal movement (monitored 3 xs), my L&D was fantastic. Great epidural, great staff, etc. I didn’t have the doc I wanted due to my OB had her daughter in the ER. So it was what it was. I had two demands: no students and do whatever is necessary for this baby. My water broke at home full gusher (first baby). I went to the hospital on time, etc. However, hardly any contractions,so they did pitocin. Fine by me. Everything was fine then I started pushing after 14 hours. Again, all was fine. My husband is the one who noticed the monitor/heart going down. Doc wasn’t worried. Other nurses though? They told him I probably will or should get a C. Something is obviously up. But no. Doc told me to push. We’re talking a “sunny side up push”. WIth the epidural, I didn’t feel anything really. But then my son came out like a cannonball. Woosh. But I didn’t hear crying. I didn’t think anything of it because I heard some babies don’t cry right away. No one said anything. Doc told my husband to cut the cord. And then I heard “Apgar score 1″. Followed up by “sir, turn off the cameras.” My heart left my body as well as my soul. I started praying so hard for that little guy. I heard nurses say “come on breathe…get him moving” all I saw was a lifeless, blue, very still child. I went through infertility treatments for this? I waiting 9 months and finally felt good to be happy for this? They intubated him. Suctioned him. Meconium was in his lungs. After 40 min. I was in a daze/shock and I couldn’t tell you what was next but I held him finally. Looking back at his pics you can see the red outline of his lips and how pale he was. I received his medical records months later and saw how close he was to having oxygen issues. He was .5 away from having brain damage. The cord was also wrapped around his neck, his wrist, and his leg.

    Now my best friend, she’s tiny. Her baby? 10lbs. He was stuck in her pelvic bones and wasn’t advancing. She demanded a natural birth. She fought the nurses/ob all the way. She didn’t want pitociin and epidural; she didn’t even want IV fluids to prevent dehydration. She wound up with all that and an emergency C section because her baby’s heart dropped so many times. To this day she swears the hospital we both went to was the worse hospital ever and she will never go again. She said that everything was unnecessary and unfortunately is still having traumatic birth experiences. However, while she is my best friend, I also think that her fighting them the entire time enhanced her chances for traumatic birth.

    Looking back, if it would have prevented an Apgar 1 in my son, I would have demanded a C section.

    • June 26, 2011 at 1:52 pm

      LK – I have also seen a pattern of women who come to the hospital with an inherent mistrust of medicine and leave feeling that they had a very negative experience. Unfortunately, some of them go on to be deeply angry and hurt, when at least part of that negative experience was brought in with them. One can’t please everyone.

      I’ve also had women come in with a similar background and have great hospital experiences, often because of some very good nursing and a compassionate and flexible staff.

  183. July 3, 2011 at 4:29 pm

    Amy Tuteur, MD :
    “A biopsy isn’t a major surgery cutting the body wide open, cutting through many muscles, then cutting through a major organ.”
    You don’t cut through any muscles in a C-section.

    Um, excuse me, “Dr” Amy, who went to Harvard… the uterus IS a MUSCLE, more specifically smooth muscle known as the myometrium.

  184. July 7, 2011 at 7:37 pm

    Dr Nic…

    I would love for you to jump over to the Navelgazing Midwife’s Blog and read her recent post on Birth Abuse. I believe that if you take a few moments to do so, you might better understand the concept of Birth Abuse and Birth Rape.

    I hope you will read it and comment there and here.

    http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2011/4/13/birth-abuse.html?lastPage=true&postSubmitted=true

    • July 11, 2011 at 8:10 am

      Here’s what I have to day about it –

      I think its important that physicians and nurses respect the desires and wishes of a woman, and attempt to give her the experience she wants. It is equally important that the woman respects the expertise of the care team, and that the team’s goals are to optimize the chance of a healthy delivery.

      It is important for women to recognize when their birth plan is not consistent with the obstetric model of labor and delivery, and to seek care with a midwife when that is the case.

      It is important for obstetricians to recognize when they are working with a patient that is seeking a type of care that they cannot or will not deliver, and that they can recommend another provider in those cases.

  185. February 28, 2013 at 3:51 am

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  186. Kristen
    May 29, 2013 at 10:04 am

    I’m just going to point out that WHO recommends between a 10-15% cesarean rate, any higher contributes to increased morbidity and mortality. The US’s cesarean rate is over 30%. Thus, unnecesareans must exist.

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  1. August 1, 2010 at 7:41 am
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