Research progress

I have been hard at work coming up with my questionnaire for my survey of local obstetricians and gynecologists about birth interventions. I am planning on posting the completed survey when I am finished, unless there are some concerns with that. I don’t think any of my subjects read my blog, so I doubt it will add any bias to the results. Besides, it’s not like these issues are new to these practitioners. It’s not like a blog post with questions about these interventions will suddenly make them relevant to their practice.

The wording of some of the questions is based on the survey in this study by Reime et al, and many others are taken directly from ACOG position statements, USPSTF evidence based conclusions, and the like.

So far the interventions I will definitely be asking about are:

Doulas (Continuous Labor Support)
Episiotomy
Vaginal Birth After Cesarean (VBAC) and Trial of Labor (TOL) after Cesarean Section
Cesearean Section Without Medical Indication (CWMI) and Cesarean Delivery on Maternal Request (CDMR)
Upright Pushing Stage
Continuous External Fetal Monitoring (EFM) vs Intermittent
Restricting Oral Nutrition During Labor (Solid and/or Liquid)

Interventions that may be included in the survey include:

Estimation of Fetal Weight (EFW) (based on 3rd trimester ultrasound)
Routine Early Amniotomy (Artificial Rupture of Membranes (AROM) )
Oxytocin (Pitocin) Augmentation of Labor

I would like to ask about all of them. We need to make sure the survey is brief enough for the subjects to want to take the time to finish, and I plan on asking multiple questions on each intervention. I think the first list is more directly a balance of evidence based medicine and patient autonomy (which is a much more difficult concept to define than I thought, but that’s a whole ‘nother post). The second list is more practices that lead to the cascade of interventions. For example, oxytocin augmentation usually necessitates continuous EFM.

I didn’t include out of hospital births, even though I think they are an important and relevant point. I wanted to only cover practices under direct control of the obstetrician. That is also why I didn’t include skin to skin contact after delivery. I think that may more depend on the hospital policies and nursing / pediatrics team.

I just need to come up with a few questions about how they keep up with the current standards of care, and then it’s time to whittle it down.

Then, I need to work on my justification. I need to talk about patient empowerment and autonomy without sounding like too much of a militant feminist. Heh, wish me luck with that.

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13 Comments

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13 responses to “Research progress

  1. Sounds really interesting and I am very excited to see the results of your research!

  2. If you would like, I can give this survey to my Docs and they will fill it out because I will give them food. My email address is on my blog. So just send the survey.

    • MomTFH

      Ha, thanks Pinky. I am starting with the ob/gyns in my area (tri county South Florida) as my target population. I would be happy to send you a copy. I may just post the whole questionnaire on here. Data sets from other areas would definitely be interesting, but may not make it in my initial paper.

  3. What a great list! I look forward to seeing what comes of it

    Any thoughts on cord clamping? I know you’re trying to keep the list brief, so maybe adding that would start to be a bit much, though.

    • MomTFH

      Yes, cord clamping is an interesting issue, and it is tied to how the neonate is handled immediately following the birth, overlapping with the skin to skin contact issue. I think both are wonderful and should be done in all deliveries when the baby (or mother) don’t need immediate medical attention. Like skin to skin contact, this is leaving the time in which the ob/gyn is the main practitioner (when it is an ob/gyn delivering, of course) and enters the realm of the labor and delivery nurse and / or the pediatrician team.

      Also, my questions are based off of mainstream ob/gyn literature and position statements. Believe it or not, there is lots of fruitful material already that goes against many mainstream practices, even in the position statements of ACOG or in the Cochrane Database. I haven’t seen much literature on cord clamping, and even my Varney’s Midwifery treats it with a pro / con list. For this study, I have to have good literature to back up whatever I am asking about, not just my personal preferences.

      • There have been at least two articles in our ‘throwaway’ journals in the recent months. The first was an editorial by either Lockwood or Barbieri in Contemporary OB/Gyn or OBGyn Management respectively. It was an article that said, here are a few things we all SHOULD be doing…and delayed cord clamping was one of them. For the life of me I can’t seem to put my hands on it right now.

        This is an excerpt from the March issue of OBGManagement. You can find the full article online. So, us OBs are getting messages that delayed cord clamping should be standard. It’s just been hard to get it adopted.

        March 2012 · Vol. 24, No. 3

        EXAMINING THE EVIDENCE
        Does the timing of umbilical
        cord clamping at delivery
        affect an infant’s long-term
        iron status?

        And I’d be very curious to see the answers to your poll questions. I’m certain you’ll find that the more interventions there are, the less willing to accept what we think as standard ,the higher the c-section of complication rate.

        Glen
        D. Glen Elrod, MD
        Sleeping Lady Women’s Health Care, LLC
        Wasilla, AK 99654

        • Thanks for commenting! Yes, I have heard and read evidence in support of delayed cord clamping since I posted this comment. Dr. Fogelson of Academic Ob/Gyn presented a grand rounds on the topic, and posted a video of it.

          I am still working on getting my biostats interpreted so I can write up my results. I will post on here when I get it done, and hopefully published.

  4. With Pitocin, you’d want to ask about induction and augmentation and personally I’d like to know what they know about the difference is between Pitocin and oxytocin. I’d also ask about “physiological pushing” as opposed to upright, because that would encompass not being coached, no breath-holding and the mother positioning herself as it feels right (which might be hands and knees or side-lying, not just upright). Also, do they see pushing as something that starts at 10 cm or when the mother feels the urge.

    I think you may have a problem with the cesarean section without medical indications issue. Some OBs justify them in their own minds and then have something they can document: a few decels, the “rest and be thankful” period being interpreted as failure to progress, an opinion about the size of mother’s pelvis or baby’s head–it doesn’t really matter–it will be an indication to some OBs.

    Agree with dou-la-la about timing of cord clamping being important, although this is about mothers’ autonomy and early clamping can profoundly affect the baby, it’s also about keeping baby and mother in contact with each other. While it’s not the OBs responsibility once baby is born, keeping the cord intact brings the peds team to baby, rather than baby to the peds team.

    Very much looking forward to what you find!

    • MomTFH

      Physiological pushing, without the Valsalva manuever (filling the lungs, holding the breath and bearing down) and without counting is a great point, with some good studies recently. I considered adding it to the list. The reason I didn’t was that, at most of the deliveries i have been to, it has been the labor and delivery nurse who directs the pushing, not the ob/gyn. I wanted to focus on practices they have direct decision making control over. Of course they could tell the nurse “let’s try this one without bossing the mom around just to get worse outcomes”, but the other practices I am asking about really are under the sole domain of the ob/gyn.

      Yes, this study will not be identifying cesarean sections that are ordered after labor starts, but without adequate medical indication. I wanted to draw a distinction between elective cesareans that are suggested by the physician and maternal request cesareans. One fine point in much of the research is that it is hard to tell the difference between these two scenarios after the fact by medical records. But, fine tuning my questions about attitudes of physicians will hopefully draw a distinction between the two practices. It won’t give us any numbers of prevalence of doctor encouraged elective cesareans versus maternal requested ones, but it will give some idea what physician’s attitudes are about it. A lot of the chatter defending the skyrocketing cesarean rates tries to blame mothers for requesting them, but, at least in what I have observed, many physicians bring it up and recommend the cesarean delivery without being prompted by the mother.

  5. I think you’re right that one question can cover others.

    How about:
    What is your rate of induction? What number of weeks gestation are you comfortable with in a normal pregnancy?

    Do you provide backup for homebirth midwives?

    I also find late cord clamping covers a great many other questions.

    If there were only two things I could fix in obstetrics tomorrow it would be letting pregnancies go past 42 weeks and leaving the cord intact.

    • MomTFH

      Yes, all important issues. Inductions are a difficult topic. It’s hard to ask simple questions about it. There are indications for inductions. I couldn’t just ask general questions about inducing. I have tossed this around a little. It would be very fitting with the rest of the study to include a question about inducing for suspected macrosomia, inducing before 39 weeks, or inducing with a poor bishop’s score.

      But, most of my questions and background are coming from position statements and meta- analysis of evidence, and the statements are multi leveled and complex. For example, the statements support that induction is not warranted for suspected macrosomia, but then goes on to say, go ahead and section them under these circumstances (suspected weight over 5,000 g for GD mom and suspected weight over 4,500 g for a GD mom). So, I can’t cherry pick the part about inductions without “testing them” on their adherence to sectioning these moms.

      And, as much as I support letting moms have flexible postdate deliveries with reassuring non-stress tests and biophysical profiles, the literature supports inducing by 41 3/7 weeks or 42 weeks, so I would have to use those sources.

  6. Kudos on this project and thanks for sharing the link to your blog. It is now on my favorites list. If there is room, consider a simple straighforward question about attitudes toward vaginal breech delivery and why. You knew that a vocal group such as ours cannot resist putting in their two cents. Lets keep in touch. Stuart

    • MomTFH

      Thanks! I have to admit I thought I knew what ACOG’s position statement was on vaginal breeches, against it, but after watching your interview I may have to consider putting that in the study. Thanks again.

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