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Tuesday
May102011

"An Obstetrician's Lament"

The Unnecesarean has initiated a discussion of the Obstetrics & Gynecology commentary entitled "An Obstetrician's Lament" by Annette E. Fineberg, MD. I've got the article in .pdf, but thought if the group of us were going to discuss this, we should have the entire piece available to us. Here it is. Please join in as the posts unfold throughout the week.

A few weeks ago, during a prenatal visit, a woman pregnant with twins told me she would love to have a home birth, but did not have the $4,000 cash required upfront to do so. She was afraid of potential interventions in the hospital. After a discussion of her fears as well as potential complications that can abruptly occur in a twin birth, she admitted she would prefer a hospital birth if she could maintain some control over the situation. This is not a woman who cares more about the birth experience than the baby, but she was tempted, and in some ways I can understand her concerns. My cousin's wife had her twin induction halted at 4 cm because the new obstetrician on call did not do breech extractions for second twins. Her only option became cesarean delivery.

I recently received a phone call from a woman 2 hours away who had planned a home birth for her second baby after having an easy first birth. When the fetus, which was anticipated to be a little smaller, was found to be a breech, the midwife sent the woman to the local obstetricians. They would only deliver the fetus by cesarean delivery. The midwife offered the woman a home breech birth, but admitted she had only delivered one breech (stillbirth) in her career. The woman appropriately questioned the safety of this, and was referred to us. She met the criteria for our vaginal breech protocol, and had an easy vaginal breech birth in our hospital. Unfortunately, this is becoming a rarity. A colleague of mine in another state watched the residents she was supervising emotionally bully a young woman and her mother into a cesarean delivery. The young woman had a rapidly progressing active labor with a normal-sized frank breech fetus. Had the residents been open to the idea, my colleague easily could have taught them how to deliver a vaginal breech.

The running joke in our community is that the only way to get a vaginal birth after cesarean delivery (VBAC) is to have the birth at home. Unfortunately, this is a reality rather than a joke. Our small community hospital, owing to regional liability insurance constraints, stopped allowing VBACs in 2002 after many years of  successfully offering them. This has led many women to risk home birth rather than travel to a tertiary care center to attempt VBAC. I recently counseled a woman against having a cesarean delivery who had a BMI of 52 and who arrived in active labor at over 35 weeks of gestation with two previous successful VBACs. I spent the following months defending that recommendation, despite her considerable operative risks and high likelihood of success.

Recent news and media excitement about the benefits and increased safety of home birth over hospital birth have made the former seem like a very attractive alternative. A growing notion among women in our region, and perhaps across the country, is that hospitals and obstetricians are a more risky option than lay-home midwives for birth. Although my initial reaction is disbelief, perhaps we should look at how we, the  obstetricians, contribute to this trend.

Each of these women deserves an honest discussion about the fetal and maternal risks of each birthing option. However, our lack of experience as obstetricians colored by our fear of liability is narrowing women's choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions. I sense a mounting tension, because many obstetricians do not have the willingness, time, or skills to provide maternal choices.

I believe we are at a crossroad in maternity care in this country, and I am saddened that obstetricians are considered the culprits. Our contracting skill set as obstetric providers, as well as the prevailing risk-adverse culture among physicians and hospitals, have given support to home birth. We can all agree that VBAC, twins, and breech should not be managed at home, yet we frequently demand complete control of the situation and eliminate some appropriate choices in the hospital. I understand that it can be very unnerving to be ultimately responsible for the outcome, as we are, and yet pushed into situations outside of our comfort zones. However, our unwillingness to budge in these situations is causing us to lose the battle regarding what is really important to most obstetricians: safety for mothers and babies.

Certainly, we can be proud of the dramatic decrease in maternal mortality in the last century. But, despite the highest per capita expenditure of health care in the world, infant and maternal mortality rates in the United States are higher than in all of western Europe. We have the third-highest cesarean delivery rate in the world.

According to a recent study, nearly half of all primigravidas attempting vaginal delivery are induced, and half of cesarean deliveries for dystocia are done before 6 cm of dilation, presumably before active labor. It is amazing how many women begging for elective induction change their minds when told it doubles their cesarean  delivery risk.

We need to draw lines around patient safety, but must they be so rigid? Most midwives know from experience that Friedman's curve is too strict. A recent study validates that knowledge. I sincerely hope it is taken seriously. Expectant management of ruptured membranes at term has been declared unsafe and of no benefit. The study that settled the question did not account for the number of vaginal examinations women received, and group B strep was not treated, both important variables. Most women do go into labor in 24 to 72 hours. The Cochrane systematic review concludes that, because the differences in outcome are not substantial, women need to be given the appropriate information to make a decision. This very rarely occurs in the hospital setting. The Term Breech Study closed the door on vaginal breech delivery even for the lowest-risk women in most obstetricians' minds (including the residents I mentioned above). This, despite the opinion of the College that it may be appropriate in carefully selected situations. In any case, vaginal breech delivery is not completely avoidable, and should not be relegated to the history books with vaginal delivery for previa and high forceps.

Our mission has become more difficult in the last 20 years as mothers have become older, heavier, and of lower parity. Many women, admittedly, do have unrealistic expectations. Although I am eternally grateful for the obstetric skills I learned in residency, I have been amazed in my 14 years of practice to see much of the dogma I also absorbed disproven with experience and patience (both my own, my colleagues', and the midwives I have worked with in the hospital setting). Collaborative practice with midwives is a good start, but in order for obstetricians to be more than providers of cesarean deliveries (a thankless and, in most cases, technically simple procedure) we need to have conversations with our patients that are not one sided and allow for true informed consent. Many of the obstetric disasters we have all seen and which color our  perspective (which David Grimes has called "numerators in search of denominators") are at least in some part iatrogenic if examined deeply enough. That failed induction for convenience with early artificial rupture of  membranes and chorioamnionitis. The first cesarean delivery done at age 15 after 2 hours of pushing with an epidural that then leads to the fifth cesarean years later, and then accreta and life-threatening hemorrhage, are both typical examples. We need to recognize and own those aspects of obstetric management that are driving our skyrocketing cesarean delivery rate but having no positive effect on maternal or infant morbidity and mortality.

Admitting what is truly evidence based versus what is tradition and culture is a good start. It is essential that we offer real choices to our patients. We need to recover and disseminate the skills that make obstetrics an art and a privilege. Seek out mentors skilled in forceps, vaginal breeches, and breech extractions before it is too late. Then learn to be patient, so that you very rarely need to use them. 

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Reader Comments (23)

Amen! Can this person be my OB?

May 10, 2011 | Unregistered CommenterRachael

"A colleague of mine in another state watched the residents she was supervising emotionally bully a young woman and her mother into a cesarean delivery. The young woman had a rapidly progressing active labor with a normal-sized frank breech fetus. Had the residents been open to the idea, my colleague easily could have taught them how to deliver a vaginal breech."

The thing I'm taking away from this bit is that there is a lot of collusion protecting bad practice. If a supervisor will stand back and watch during an episode of abusive provider conduct, how much power do the lesser beings in the form of nurses and midwives have to protect women? I can't help but theorise that this supervisor did not file a complaint against the residents' conduct, and since the cesarean was cut, it does not seem that she attempted to intervene in the face of illegal medical battery.

From what little I've read about the history of obstetrics, and the abuses that occurred during the formative years, especially of the poor-house women who were not allowed to say "No!", it seems that little has changed about bedside manner besides the death rates.

May 10, 2011 | Unregistered CommenterJanice

Brilliant observations, Janice. I'm ashamed I didn't make the same connection. Thank you for speaking up.

May 10, 2011 | Registered CommenterNavelgazing Midwife

Amazing! I love this piece, and can't wait to hear more!

May 10, 2011 | Unregistered CommenterJen B

Dr. Fineberg is a forward-thinking OB. We need more of these, and I'm grateful she's out there practicing.

That said, I still sense overtones of the OB culture's effects on her in comments such as, "We can all agree that VBAC, twins, and breech should not be managed at home..." Um, no, we don't all agree on this one. Yes, hospitals pose a risk to some women in these sots of situations, and that compels those mothers to birth in out-of-hospital settings. Yes, I agree that hospitals should seek to emulate certain aspects of out-of-hospital settings which are presently missing from the hospital environment. But research evidence says that home birth is an acceptable option for many women - and VBAC, multiples and breech are not the only factors which should be considered when doing risk assessment.

Furthermore, if care provides are helping women to make truly informed decisions, and those decisions are documented appropriately, fearing a mother's the ultimate choice of birth place (or anything else, for that matter) is pointless, and possibly only adds unnecessarily negative/defeatist sentiments to a birth situation.

I understand that the US is a litigious society; I am certain there are law suits in which the care provider did everything in his/her power to honor a mother's choices and still got burned. It's wrong. But there has got to be a better solution to this problem than removing options from the women who will not pursue legal action if their own informed choices end in a negative outcome. I'm not trying to be hard on OBs, here - but I really get tired of the sound of sphincters slapping shut when out-of-hospital birth is mentioned.

May 10, 2011 | Unregistered CommenterDonna

The commentary was written in an OB/GYN Journal, so I am pretty darn sure they all *do* agree that breeches, twins and VBACs shouldn't be done at home. WE might not agree, but most OB/GYNs do.

May 10, 2011 | Registered CommenterNavelgazing Midwife

I think the overtones mentioned had to do with her audience. She is trying to show the OBGYN community that she is not a radical, so they will listen. A beautiful and important piece, and I am so glad she is brave enough to take her colleagues to the mat.

May 11, 2011 | Unregistered CommenterKristina

"We can all agree that VBAC, twins, and breech should not be managed at home, yet we frequently demand complete control of the situation and eliminate some appropriate choices in the hospital."

We can!? Shocker... nice to hear it said out loud....

Exactly this is written to and For the OB world... and THEY Do believe that is the only way to deliver unusual presentations....

May 11, 2011 | Unregistered CommenterDee

I was pondering this piece earlier, and realized that she mentions "lay-home birth midwives" . I wonder what she means here- is she intentionally limiting her topic to lay midwives, or is she conflating CM/CNM with lay midwifery? Does she assume that no CNM does home births? has she ever heard of CM? If she is intentionally only speaking of lay midwives here (CPM, etc.), does that change what she means? Is homebirth with CNM better or the same?

Just some thoughts.

jen

May 11, 2011 | Unregistered CommenterJen B

Everyone is getting upset that she said VBACs, breeches and twins should be delivered in hospital. She also said they could and should be delivered vaginally! (when they meet certain criteria)

Don't let the perfect be the enemy of the good. For every woman who births at home because no OB will let her have a shot at a vaginal birth, there are hundreds more who accept a repeat c-section because they aren't comfortable with the risks of homebirth or cannot find a midwife. Getting VBAC, vaginal breech and vaginal twin birth back in hospitals would be a wonderful thing for women.

And she's saying OBs share a good chunk of the blame and need to "heal themselves" before they blame women for their choices.

But if you'd rather nitpick, go ahead and nitpick.

May 11, 2011 | Unregistered Commenterchingona

In regards to the comment about whether Annette Fineberg understands the difference between CPM's, CM's and CNM's, I can assure you she does. I am in practice with her, an she has up close and personal experience with all of the above. I can also assure you that she tries very hard to be welcoming when we get transfers from the CPM's in our area, and has offered to take women in transfer from some of our home-birth CNMs who desire breech birth, and is quite successful. I really appreciated chingona's comment about that.

May 11, 2011 | Unregistered Commentermidwifebcs

Wow... Thank you Barbara, for posting that! It warms my heart to see how much this woman cares for the women she serves. It's good to see that she expresses an understanding for WHY things are as they are, and that they need to change.

Truly a beautiful and worthwhile piece.

May 11, 2011 | Unregistered CommenterDiana

Everything I know about medical training I learned from blogs, TV, and eavesdropping while on hospital bedrest. But I thought it was fairly hierarchical. I'm kind of baffled that an attending would stand by and let them bully a woman in that manner. What are they there for if not to stop the residents from majorly fucking up patient care??

May 11, 2011 | Unregistered CommenterBranwen Maeve

I agree about the bullying. I had to read the sentence several times to figure out who the players were, disbelieving it was the Attending that let the Residents bully the laboring woman and her mother. Disgusting.

May 11, 2011 | Registered CommenterNavelgazing Midwife

Isn't it an attending's job to, you know, attend? Teach, supervise, etc. Really, really disgusted whoever the dr was didn't tell the residents that bullying patients was unacceptable & then tell them they were going to get a chance to learn how to assist in a breech delivery.

I'm impressed that she's speaking out and I hope it moves at least a couple OB's more in the right direction, but imo most of what she wrote is still far too influenced by all the wrong parts of the OB mindset

May 11, 2011 | Unregistered CommenterLisa

I'm very proud of Dr. Fineberg. She is in a practice with three of the best midwives I've ever had the pleasure of meeting (midwifebcs in particular, who responded above, is my midwife). I like to think that because of this, she knows and values all types of midwifery, as well as obstetrics.

There are some views that most OBs will share, some more radical in the belief than others. I for one am very glad to hear an OB think this way, especially with being very familiar in the "Dr" Amy Tuteur way of thinking.

May 12, 2011 | Unregistered CommenterAutumn

Wow! What a refreshing and exciting perspective!!! I hope you shout this message from the rooftops and I sincerely hope your OB colleagues listen to you! This is a great post. Thank you SO much for your open mind and your illuminating words! :)

June 7, 2011 | Unregistered CommenterLily

I never cease to be amazed at how few OBs seem to have actually read Friedman's book and examined his research. He charted dilation in many labors, thousands actually. I do not have the book in hand to give the exact number. He then cherry-picked the 200 labors that seemed to sort of make a curve showing an idealized rate of dilation in labor. Even so it was a far from perfect curve. If you see the actual graph with the real labor dilation numbers you will be shocked at how this could end up in a labor curve that women for decades have been expected to reproduce in their own labor. All the interventions and "criticism" dumped on women trying to labor at an unrealistic rate of dilation! It still gets my goat thirty years after first studying his book.

June 7, 2011 | Unregistered CommenterRose Marie

what a pleasure to see an article like this posted in an OBGYN production for the masses of og/gyn's in this country.

interesting reply commentary.

one line that needs exploring further, or could be eliminated in the future, because it is a myth, is:

"This is not a woman who cares more about the birth experience than the baby".

most of what has been practiced in the hospital has been found through extensive research to be dangerous to mother and baby.
the birth experience leads to the babies well being, or not, quite frequently. and the training and experience of the birth attendant also leads quite frequently to the birth experience and babies well being, or not.
and mainstream and research have barely gotten into this aspect of the birth research.
statistically speaking homebirth with essentially healthy moms and pregnancies has better outcomes for mother and baby...........hands down. and conversely, hospital births have such poor outcomes that aren't even on their radar: post partum depression and PTSD directly related to the birth experience is one example. unsuccessful breastfeeding statistics, and vaginal births...................

June 7, 2011 | Unregistered CommenterKaren Beesley cnm

Thank you so much for posting the full letter.
I am so happy that this OB is standing up and speaking the truth. She sees the harm that is being caused and she can read the research that shows what is better. I hope her colleagues respond appropriately.

June 7, 2011 | Unregistered CommenterElizabeth

hmmm... so i'm confused i read the whole thing, and to me it says that they all still feel like VBAC and twins are not safe to do at home am i right about that? and ok well so what else is new i mean we all know they don't like home births.....

June 7, 2011 | Unregistered Commentereunice

It would be wonderful to hear of more 'Dr. Finebergs'. As a childbirth preparation, infant care, and breastfeeding teacher as well as an RN with years of experience in high-risk LD & postpartum, I have been called on the "carpet" by the cheif of OB at our small hospital for giving too much information too enthusiastically about natural childbirth and the choices women should have. When in our discussion I mentioned the words 'natural childbirth', he stated with disgust that natural childbirth is equated to a bear dropping scat in the woods! Despite the studies showing the harm to women, episiotomies are cut on a regular basis, young and first time moms-to-be are convinced they should be induced, they are threatened with fear-filled thoughts, and arom is done frequently even before 4cm dilatation to 'commit' them. Our C/S rate is equated with that of the State's rate - approx. 35%!! Last year I became certified for lactation consultant and in that course the instructor told us "Right now, in this county, there are three doctors who are 'writing the book' so that all births are done by cesaerean by 2020!! (UCSD) . Does anyone know about that? With the high cesaerean rate across the nation, it will not take much to reach that rate! Although there are varying changes in women who are getting pregnant, ie, age, fertilization, etc., women's bodies have not changed that drastically physiologically or anatomically since 1965 when the C/S rate was 4-5%. We, as professionals, must work harder, band together stronger, teach louder, and stand up longer for the truth to be implemented in our patient care. We can do it!! Thank you Dr. Fineberg for seeing the need and helping us to join hands in that effort!
Barb S.

In regard to Barb S.'s post: I remember my delight when I read the February 2005 AAP new policy statement on breastfeeding which stated plainly that the healthy newborn should be placed skin to skin with its mom immediately for an hour or so until the baby latched and nursed. Silly me, I thought that meant that I would soon see this happening in the two hospitals in my city that have L&D units. Now, six years later, I see both praise skin to skin, say they do it, but obviously never read that it actually entails continuous skin to skin. It just is not that mysterious and hard to teach or to learn. I don't know what to do anymore. For my own clients, when the nurse asks for the baby, I can say to my client, "You can hang onto your baby if you want. You don't have to have it weighed this minute."

June 11, 2011 | Unregistered CommenterRose Marie

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