Nulliparous psychosocial induction
I have been reading about induction recently, specifically, nulliparous induction for psychosocial reasons with an unfavorable cervix. In English, that is a first time mom, getting a labor induction for non medical reasons, and her cervix is not dilated or softened.
Induction of labor is relatively common. I recently sat with a doula client during her induction with Cervidil (Dinoprostone). (Not a comfortable placement procedure when you have a posterior, undilated cervix. It seemed more painful than any contraction I have ever seen.) Before it was applied, she was chatting with the nurse, who was 38 weeks pregnant. The nurse was happily anticipating her own induction, saying “I want to get her out before she’s too big.”
I briefly mentioned that estimations of fetal weight were not evidence supported and notoriously imprecise. I didn’t feel it was appropriate to mention that, at least according to the textbook we used for our women’s health system, induction was not recommended for suspected macrosomia. In fact, I had to point that out, politely, after class, to our pharmacology professor. She would read from the lecture notes, then pepper the lecture with the story of her own delivery, which was a failed induction for suspected macrosomia. She had a cesarean for fetal distress. The way she told the story, that was a good treatment decision, and suspected macrosomia was an indication for induction. I showed her the section in our textbook, said I thought it seemed contradictory, and suggested she talk about it with the head of the department.
I knew induction + macrosomia has an association with shoulder dystocia. Well, I was trying to find out more information about induction and Bishop score. Although this particular doula client met the ACOG recommendation of reaching 39 weeks gestational age, I was fairly sure a favorable Bishop’s score was more important. I had told this to my doula client when she mentioned the 39 week induction. I understood why she wanted it. She was on strictly limited maternity leave. Her mother was flying in. Anyone who has been pregnant full term or has talked with women who are in their late third trimester knows they are usually extremely uncomfortable and sick of being pregnant. She was no different.
Also, her obstetrician had already predicted, several weeks before, that she would go into labor a full ten days before her due date. Yes, it was the nature of her job that she was on her feet a lot, but who says that to a nulliparous woman with a long, closed, posterior cervix? I certainly don’t mean to imply she was setting the stage for a 39 week induction that she could work around her clinical schedule, but talk of induction started to happen as soon as that ten-days-before-due-date due date passed. I mentioned the Bishop’s score, and she seemed to think her obstetrician thought her cervix was ready. But, when we got to the hospital for the induction, her cervix was closed and posterior. I didn’t hear an exact effacement, but even with a generous guess, there is no way she was above a Bishop score of 8. I don’t think her doctor told her that it meant she had twice the risk of a cesarean. I didn’t think it was appropriate to tell her, since they didn’t do the cervical exam until the Cervidil was ordered and unwrapped, and she was admitted for the induction that she and her physician had decided was right for her at her last prenatal visit, and the physician was managing the induction over the phone.
Well, when researching the decision making that goes into these common inductions, I have read some interesting things. The first was on the Cervidil site I linked to above, that lists “Patients in whom there is evidence or strong suspicion of marked cephalopelvic disproportion” as a contraindication for Cervadil. In other words, suspected macrosomia.
Secondly, on the ACOG website, a recent article about quality improvement by Dr. D. Ware Branch, Jr., says:
“[B]eginning nearly 10 years ago, the program sought to implement a systematic, multi-institutional approach to discourage elective inductions in nulliparous women with a Bishop score of less than 10.
During the first several years of the project, the number of elective inductions in nulliparous women with an unfavorable cervix decreased from approximately 105 per month (15%) to 60 per month (6.7%) in the 11 hospitals that participated. The total number of elective inductions in nulliparous women also declined by two-thirds.
Currently, the proportion of nulliparous women with an unfavorable cervix undergoing elective induction within the Intermountain Healthcare system is less than 5%. Some facilities have even disallowed any nulliparous inductions whatsoever.”
Also, when rereading ACOG’s Practice Bulletin on Induction, (which is problematic for a few reasons) I noticed it states “Although trained nursing personnel can monitor labor induction, a physician capable of performing a cesarean delivery should be readily available.” Hmm, that sounds remarkably similar to the recommendation in their Practice Bulletin on Vaginal Birth After Cesarean, which states “VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”
I am not trying to say that elective inductions should never be done, not even that they should never be done for psychosocial reasons. However, I doubt many nulliparous patients are given a risk explanation for an elective induction that is in anyway similar to the common treatment of VBAC. I am also fairly sure that elective inductions in nulliparous women for psychosocial reasons will not be banned from many facilities, like VBAC currently is. As far as I could tell by this interaction between my client and her nurse, elective induction for nulliparous women seems pretty standard, at least in my area. The quality improvement article from the ACOG website was reassuring, however.
Whole Fools strikes again
Argh, I wish I had known this earlier today, when I went to Whole Foods for the first time since John Mackey wrote this bunch of hooey that says we just need to deny more benefits to enable the insurance companies to make more money….huh, we were supposed to make it better for the public? Hey, look over there, FREE MARKET! *runs from room*
Well, apparently he is still a tool. He is instituting a program at his stores that gives 10% higher discounts to workers who pass certain BMI, blood pressure, cholesterol, or smoking status targets. Don’t worry, BMIs below normal range are rewarded, just as long as you’re not a fatty boombolatty.
According to the Bloomberg article:
The offer reflects his published opinion that most health problems are “self-inflicted” and can be prevented through proper diet, exercise and similar lifestyle changes. Cost savings are achieved by “less government control and more individual empowerment,” he has said.
So, got familial hypercholestemia, idiopathic hypertension, hyperthyroidism, polycystic ovarian syndrome, hypothyroidism, a disability that precludes a lot of exercise, a genetic predisposition to a large frame, a prior eating disorder you don’t want to trigger, a current eating disorder, a medication that causes you to gain weight or retain water, or any of a multitude of other reasons why may not be able to make these cut offs?
You will be fined, slacker. That’ll learn ya.
Something tells me Mackey has got his empowerment mixed up with his control.
Hello, Trader Joe’s? Please build something in my town!
The ultimate KALI questionnaire
This is the absolute last version of the KALI questionnaire. (You can access the previous incarnations here.)
How do I know this? Well, first of all, one of my mentors gave me the lifted eyebrow when I went to him to talk about the wording, again, on Monday. I am particular and a hair splitter, but I also had a good reason to change the wording of this part. I had a problem with it from the beginning, and one of my beta testers also had an issue with it. I was editing the second to last question, and it used to say “How often do you consult the following sources regarding obstetrical practice?” But, I really didn’t want to know how often the physicians literally consulted these sources. No physician furtively looks in a textbook “always” or “often”. I wanted to know how useful these sources were in clinical decision making, how valuable the physicians considered each source to be, and how often they applied the knowledge from these sources to their clinical practice. And, I wanted it to be in one question, since I had three complaints about the length of the survey by beta testers. (This version is also a few questions shorter, and one question is a combination of two previous ones.)
So, I ended up with: “This final section lists potential sources that you may consult to stay up to date on obstetrical standards of care. How often are the following sources useful in making clinical decisions?” Not perfect, but I am accepting it and moving on.
The second reason I know this is the final version, at least for this research, is because I sent out a few email invites yesterday. (Eep! Wish me a good response rate!) I will be phoning ob/gyn offices today, begging for email addresses for the physicians in the practice. (Eep! Wish me good luck getting email addresses!)
So, here is the final questionnaire:
The KALI Project Survey
Thank you for agreeing to participate in the Knowledge and Attitudes of Labor Interventions (KALI) survey. This survey is intended to gather information about obstetrical practice patterns. The survey is anonymous, and should take about fifteen minutes. By completing this survey, you are giving consent to be part of this study.
First, we would like to gather some information about you and your practice. Please answer these questions by either circling your answers or writing your answers in blanks provided. This information will be kept confidential.
1. You are:
[1] Female
[2] Male
2. Age:
____________ years old
3. Do you have children?
[1] Yes
[2] No
4. Ethnicity:
[1] Hispanic or Latino
[2] Haitian
[3] Neither Hispanic nor Haitian
5. Race (choose as many as apply):
[1] African American / Black [4] Native Hawaiian / Pacific Islander
[2] Asian or Asian American [5] White / Caucasian
[3] Native American Indian /Alaskan [6] Other:_______________________
6. How would you describe the location of your ob/gyn residency?
[1] University
[2] University affiliated
[3] Community
[4] Military
[5] Other: ____________________________
7. Year of residency completion _____________
8. Which of the following most accurately describes your practice type?
[1] Public hospital
[2] Community health center
[3] University based practice
[4] Private practice
If private –
[1] Large partnership (four or more partners)
[2] Small partnership (two or three partners)
[3] Solo practice
[5] Military / government
[6] Other:____________________________________________
9. Do you currently practice obstetrics?
[1] Yes
If yes:
9a. Average time spent with prenatal clients:
[1] Less than 20%
[2] 20% to less than 50%
[3] 50% to less than 80%
[4] 80% to 100%
9b. Average number of deliveries per year:________________
[2] No
10. Which of the following most accurately describes your personal practice scope?
[1] General obstetrics and gynecology
[2] General gynecology only
[3] Obstetrics only
[4] Laborist
[5] Maternal Fetal Medicine
[6] Reproductive Endocrinologist
[7] Gynecologic Oncology
[8] Urogynecology
[9] Other: ______________________________
11. Which of the following most accurately describes your current malpractice coverage?
[1] None / I “go bare”
[2] I pay for individual malpractice insurance
[3] My practice pays my malpractice premiums
[4] I am an employee of an institution that pays my malpractice premiums
[5] I am an employee of an organization or institution that provides legal defense but not malpractice insurance
[6] Other: __________________________________________________
Please rate the following statements about obstetrics as accurately as possible. Please choose whether you:
[1] Strongly disagree
[2] Disagree
[3] Neither agree nor disagree
[4] Agree
[5] Strongly agree
1. _____Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.
2. _____Elective cesarean section should not be performed on a woman desiring several children.
3. _____Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.
4. _____Episiotomy should be avoided if at all possible.
5. _____The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery.
6. _____In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries.
7. _____I employ episiotomy routinely, because it is easier to repair than lacerations that
result when an episiotomy is not used.
8. _____Fear of liability claims limit the options I present to my obstetrical patients.
9. _____Liability insurance company policies forbid me from performing vaginal births after cesareans (VBACs).
10. _____Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes.
11. _____All women in early active labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact.
[1]Strongly disagree [2]Disagree [3]Neither agree nor disagree [4]Agree [5]Strongly Agree
12. _____Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.
13. _____I regularly employ episiotomy to shorten the second stage of labor and delivery.
14. _____Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.
15. _____Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.
16. _____Mediolateral episiotomies result in less postpartum pain than median episiotomies.
17. _____Prior to an induction, patients should be counseled about the possible need for reinduction or cesarean delivery.
18. _____The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.
19. _____Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.
20. _____I regularly employ episiotomy to prevent pelvic floor relaxation.
21. _____Hospital policies forbid me from performing VBACs.
22. _____If my partner or I were pregnant for the first time, I would recommend an elective cesarean delivery in the absence of any medical or obstetrical indication.
23. _____I have made changes to my practice because of the risk or fear of liability claims.
24. _____Childbirth is only normal in retrospect.
25. _____Clinical guidelines are useful tools for me in daily clinical practice.
26. _____The use of continuous EFM reduces perinatal mortality and morbidity.
[1]Strongly disagree [2]Disagree [3]Neither agree nor disagree [4]Agree [5]Strongly Agree
27. _____Labor induction for non-medical indications (psychosocial or logistical) should only be attempted after establishing a gestational age of 39 weeks.
28. _____I encourage my patients to try alternative or upright positions during the pushing stage.
29. _____Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care.
30. _____I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.
31. _____Women should have the right to refuse an episiotomy.
32. _____I recommend that most patients use a doula for their labor and delivery.
33. _____Women should be able to have a caesarean section even if there are no clear maternal or fetal indications.
34. _____There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.
35. _____Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.
36. _____Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery.
37. _____I would refer out any patient who wants to hire a doula.
38. ¬¬_____Time and scheduling pressures affect the way I manage labor and delivery.
39. _____Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.
40. _____Episiotomies increase the risk of third and fourth degree tears.
41. _____Clinical guidelines are overly rigid and difficult to adapt to individual patients.
This final section lists potential sources that you may consult to stay up to date on obstetrical standards of care. How often are the following sources useful in making clinical decisions?
[1] Never
[2] Rarely
[3] Sometimes
[4] Often
[5] Always
1. _____ACOG Practice Bulletins
2. _____ACOG Committee Opinions
3. _____Obstetrics and Gynecology Journals (e.g. the Green Journal, the Grey Journal)
4. _____Cochrane Database
5. _____Electronic evidence-based services (e.g. Epocrates, UptoDate)
6. _____Books and/or textbooks
7. _____Professional conferences
8. _____Physicians in my practice
9. _____Physicians in my local community
10. _____Physicians I trained with in residency
11. _____Physicians I consider experts in the field
12. Other sources: ______________________________________________________
Have you ever been the subject of a professional liability claim or litigation?
[1] Yes
If yes – Did the liability claim involve an obstetrical claim?
[a] Yes
[b] No
[2] No
Thank you for your time and participation!
Conversations only med students have
A chat between a friend, who is studying for a block of exams (good luck, LAB!), and me, via an internet messenger:
My friend: **** kitty barfed grassy nastiness all over the 10 hours of renal notes last night
Me: um, that’s just wrong
he could have at least barfed on the GI notes.
My friend: indeed
Mammograms and the USPSTF: it’s the denominator, stupid
There has been a lot of brouhaha over the new mammography recommendations by the United States Preventative Services Task Force (USPSTF). Rachel at Women’s Health News has an excellent round up of posts on the issue, if you feel like you need to do some background reading.
I am also a big fan of Barbara Ehrenreich’s take on it.
Take your time if you need to check out those links, since I highly recommend it. Back? Good.
I have many thoughts on this issue. First of all, I am completely in support of the new recommendations. If you have been reading my blog for long, this may come as no surprise, since I tend to prefer using interventions only when absolutely necessary, and am a big fan of evidence based medicine.
Secondly, I don’t think it is anti-feminist to discuss the anxiety caused by false positive diagnoses, whether it be false positive mammography results or false positive prenatal genetic screening results. Not only is the anxiety potentially substantial to many, but, the false positives also lead to more invasive tests. My mother, who is as low risk as I am for breast cancer (white, has had children and has breastfed, non-smoker, not a heavy drinker, no first degree relatives who have had breast cancer, etc.) is also endowed with huge breasts, as I am. She had at least three biopsies and lots of ultrasounds in her 40’s. None of these came up with anything of concern, but there was plenty of anxiety leading into them. And, a biopsy is not comfortable or risk free. Come to think of it, neither is a mammogram. In fact, the radiation from repeated mammograms may actually cause breast cancer in some women. I know this is an anecdotal story, but my mother is the primo example of who this consensus opinion is talking about. These mammograms are not improving outcomes in typical low risk women in their 40’s, like my mom was when she started getting mammograms and subsequent biopsies.
Third, I had an argument with a fellow student today. He said that the public wants the extra mammograms, and they are too stupid to understand the nuance to the issue. He also said all they want is “the best care.” I said the best care is evidence based care, and that I plan on educating my patients. I do not believe in the can-I-have-fries-with-that-have-it-your-way approach to medicine. I do believe that patients’ values and opinions definitely matter. But, in the end, if a patient insists on a procedure I think will cause more harm than good, I will politely refuse and refer them to a practitioner that will accommodate them, if I know of one.
Fourth, and possibly coolest, I heard a discussion on Doctor Radio that made my nerdy day. The oncologist, Dr. Silvia Formenti, is fully supportive of the new recommendations. She also explained why there is an apparent discrepancy in breast cancer survival rates between the United States and United Kingdom, which is one of the few if only outcomes that appear better in the United States. She explained that this is a false comparison, since the denominator is different. My public health instructor has always harped about the denominator of any rate being key, but I thought it was just a nitpicky instructor thing – sure, you only include women of childbearing age in maternity rate stats, got it – but it’s more important than that. Dr. Formenti said that the reason our rates seem better is that we are currently overscreening younger women, and overtreating in situ cancers. So, our denominator is stacked with low risk women who are not really that sick. In fact, I spent too much time looking over the ACOG site for the article, but I read something recently in one of their publications that showed that a wait-and-see protocol for such cancers led to a shocking remission rate. I remember it being over 20%, but since I cannot find the article, please don’t quote me on it.
So, the denominator matters, and not just in a nit-picky way. Also, I was happy to see that the National Health Service, of which I am a fan, is not failing women with breast cancer, which was bugging me a little. What especially impressed me with her commentary was that not only is she a renowned oncologist and an attending at NYU Langone, but she practices in the United States. She could have easily said “Hooray for my team, hooray for my field, we’re kicking butt.” It’s really refreshing to hear someone value truth over seeming to be the best.
And, finally, I am a little chagrined by how many people are saying that these USPSTF recommendations are going to change the way the insurance companies reimburse mammography, and change medicine in the United States dramatically. I am still waiting for that to happen due to their recommendations of labor and delivery from November of 2008, in which many interventions are panned as inconclusively supported by evidence or detrimental to patients (such as third trimester estimation of fetal weight, denying nutrition p.o. to laboring patients, and episiotomy) and others are highlighted as extremely effective and highly recommended (e.g. upright positioning for pushing and the continuous support of a doula during labor.) I wish there was an uproar following those dramatic recommendations, but there was barely a peep. Hello, sweeping changes? Helloooooooo?
A banner day
Well, it’s been quite a day. My blog got over 1,000 hits in one day for the first time. Not bad for a part time venting project. That may sound like doodley-squat to some bloggers, but that is an avalanche for me.
Foul language warning – push the kiddies out of the room
Also, I got called a “racist cunt” on twitter solely based on this post. Right before that, the so-called feminist criticized me for attacking other bloggers, (project much?) and pointed out how stupid I was because she could see what I was saying about her, because she has a google alert on her name. Except that I already said it on the thread I linked to, (note the reply turned post nature of the post she is so incensed about) a thread she was a part of, not behind her back. And, my post only marginally dealt with her, but she has inflated that to mean it was a post obsessed with her, obviously. And, she linked to my blog (which I can see, duh!) on her twitter page.
Then she called me a racist cunt.
Way to prove a point.
I argue about racial privilege because I care about inequality. She argues about how her personal story about growing up poor is more important than all of these conversations, and twists all of these conversations to malign people of color (I’m not the only one who thinks this, she is even being accused of this by others on her own blog right now), and takes this fight to Facebook and twitter because…”It’s Personal”, according to her Facebook and twitter. It’s a shame that someone who calls herself a feminist would resort to such high school mean girls behavior, especially all in the name of denying racism and white privilege, because it’s not about her.
I am OK with the difference between these two positions. I am proud of why I am arguing what I am arguing, and I really doubt she is. It breaks my heart, a little, because we are both associated with the birth advocacy community, but there is room for both racist cunts and people who call people racist cunts in the community, and people who are both (ahem). I am officially done arguing with anyone who would resort to such tactics, however, and hope we never cross paths again.
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