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Academic OB/GYN isn’t just about me blathering on about current literature and interviewing folks – its about YOU too! If there is any way I can help you, I want to know. Send research questions, and I’ll try to answer them. Need a video of some kind of surgery, I’ll try to make it. Want a place to publish your ideas about our field, the blog’s all yours. Wanna get some ideas from your colleagues that read the blog? We can do it.
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Categories: Academic OB/GYN Podcast, General, General OB/GYN Topics
Academic OB/GYN 
A patient of mine had ovarian cancer, she’s brought her 13 year old in for a consultation regarding various issues of irregular menses. As an aside she wants to know how soon we should start getting CA125s. I posted on Medscape, but no comments! Dont’ think their site gets too much discussion for the most part, ha ha! Have an answer/opinion for exactly how young to start?
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See http://bit.ly/1Jg7kx
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Please take a look at the video on the right panel on
http://www.novaresurgical.com/realhand-hd-instruments/overview/
Can you acquire video footage of those instruments used in real life?
Thanks
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I put up a video showing the instruments you asked about.
https://academicobgyn.com/2009/11/22/academic-obgyn-answers-realhand-instruments/
Nicholas Fogelson, MD
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Dr. Fogelson,
I know you addressed a tiny slice of this question in your post about protracted labor, and I do understand that it’s a huge question, but I have to ask this.
I work as a doula, and have been scouring the literature that’s aimed at doulas and childbirth educators, and some that is aimed at obstetricians/nurse-midwives.
Why is there such a huge discrepancy between what we learn and what you learn? And more specifically, why is there such a huge discrepancy between what we learn is best practice and what is actually going on in hospitals?
My working conditions are a bit out of the ordinary, since I work in Hungary, so some of this may not apply to the US. But this country, for example, has a 75-90% episiotomy rate for first-time mothers, and the practitioners are CONVINCED they are doing this in the mothers’ best interest. Absolutely convinced. And they are baffled why women would want to avoid the procedure because they are CONVINCED that the women are thus risking a 4th degree tear, they are risking a lifetime of incontinence, a lifetime loss of sexual pleasure. It’s maddening for me! I don’t understand WHY there is such a difference between what *I* read as a doula and childbirth educator and what they appear convinced of. I’m sure there are countless other interventions like this.
And of course, for me, the most pressing question is how can I maintain a good working relationship with health care staff if I completely disagree with many of their standard procedures?
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I think we are all convinced that we are doing the right thing. Otherwise, how would we go on with our day?
As for episiotomies, all I can say is that the data would not support the way the doctors you work with are practicing. Episiotomies have been shown to increase the rates of fourth degree lacerations, not prevent them. Having been trained in the post-episiotomy years, I have a hard time imagining why someone would believe them to be protective. It doesn’t take much physics to see that cutting a rip in a linear resistance structure weakens that structure dramatically. One can try it on a piece of paper, and find the force required to tear the piece of paper in half is sharply reduced by the creating of a small rip in the linear top surface.
As for your comments on literature, I think that we tend to write we already believe, for the most part. When I read the midwife and doula literature it all seems slanted towards preconceived notions characteristic to that field. No doubt the medical literature seems that way from the outside as well. Doctors train doctors and doulas train doulas, so whatever ideas our fields have will tend to be perpetuated. As for doula based literature, to be honest it isn’t given a lot of thought in the medical world, at least not in the parts of the US where I have practiced. If doulas want their literature read by physicians, they are going to have to publish in mainstream medical journals, and meet the epidemiologic and statistical standards that those journals have. I admit that I don’t read your journals a lot, but when I have seen articles from those journals, I have noticed that some lack the scientific rigor characteristic in medical journals. Maybe we should read those journals more. Its not part of the MD culture at this point.
As for episiotomies, there are lots of articles in both allopathic (medical) and midwife/doula areas that pretty strongly suggest that they aren’t good things. Whether or not doctors read doula or midwife journals is irrelevant here, as there is plenty of data everywhere on this. If people are still cutting “preventative” episiotomies, they’re just not reading at all (or don’t believe what they read.)
As for how to maintain the relationship? I don’t know. Perhaps some docs would respond to placing some good articles in their mailbox. Perhaps a suggestion that they perform a randomized trial in your hospital to see what the effects of episiotomy are. Such a randomized trial would never pass IRB in the US, given the data we already have, but given your practice environment it would be justified.
Thanks for your comments!
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Thanks for your reply!
My first thought upon reading it was one of surprise: There are scientific journals specifically for doulas? So I went and had a look at PubMed, it seems that “our” journals would be Midwifery Today’s International Midwifery, Journal of Midwifery, Journal of Perinatal Education, etc. At first glance, it doesn’t appear that these journals were meant to consist mainly of the kind of rigorous scientific articles that could be published in, say, the Journal Obstetric and Gynaecological Research. Of course, it wouldn’t hurt if they did hold themselves to those standards. At any rate, thanks for the heads up, I will be sure to follow these journals in the future.
Most of the studies I’ve read or read about actually do come from the rigorous scientific literature (or so I think), which is why it’s baffling to me that doctors and birth advocates are not on the same page. For example, have you seen this blog: http://www.scienceandsensibility.com? Or read some of the authors’ books, like The Thinking Woman’s Guide to Childbirth? I’ve only begun to actually seriously look at the articles they cite to support their points – I had previously taken their statements at face value, but I now realize that I have to actually look at the studies themselves and come to my own conclusions, which is going to take some time. So I would love to read what you think; did they cherry pick studies that support them and ignore the ones that don’t? Or do you think they are fair in their presentation of the scientific literature? (And yes, I realize that both the book and the blog encompass an enormous range of practices, I’m just looking for your general impression.)
As to practices in Hungary – I hate to say this, but they are behind the times. When I moved here in 2001, I was fresh out of grad school as a research psychologist, and I was appalled at the state of psychology research, which seemed to be about 100 years behind what I was studying in the States. Since I’ve started working as a doula and a lactation consultant, I’ve run into the problem of health care staff simply not keeping up with current recommendations, and being very dismissive of them. “I’ve been in this field for 17 years, and I think it works better this way.” It’s very discouraging. Even when I have the Hungarian Pediatric Association’s official protocol on infant feeding to back me up, I still get head pediatricians in hospitals telling me that nothing about their patently wrong breastfeeding policies need to be changed. It’s very frustrating.
At any rate, thanks for your patience. Your discussion of evidence-based obstetrics is a breath of fresh air, and I’m sure it will gain you a loyal following of midwives and doulas and birth advocates. (I hope that counts as a good thing.)
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Wouldn’t it be great if there could be a little cross training between these groups! not that doulas should act as docs and docs act as doulas, but just to walk in the other’s shoes for a bit! I also think docs should observe/shadow an out of hospital midwife as a requirement prior to practicing as an OB…just because it is a great chance to watch physiological birth in action, something that few new OBs have had a chance to really see up close!
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I really enjoy your blog because it has great info for both fellow medical professionals and laypeople. Most importantly, you discuss in a respectful way that encourages dialogue and mutual understanding.
Here is a topic suggestion 🙂 I’m curious about cervical lips. How common and serious are they, and what is the best way to deal with them?
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Cervical lips? I think what you are referring to is the way a cervix will sometimes dilate in a way that it leaves a bit in front of a babies head on one side only, delaying delivery for some additional period of time. I don’t think of this as a problem, just part of the process of labor in some cases. Anterior lips are particularly common in OP presentation babies. The best way to deal with them is to wait for them to go away. Some people think putting the mom on her side, on the side of the lip, might help the baby push against the lip a little more.
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Thank you for your answer. It seems some birth professionals see them as a problem and have various ways of dealing with them. Some claim that a woman can tear her cervix with the uncontrollable urge to push with a cervical lip. Some advocate manually pushing back the lip.
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