When routine care is not evidence based care

I am studying for my shelf exam (my end of rotation exam, for those of you not well versed in the jargon) on ob/gyn. I am using one of a popular series of board review books. Every single question in the chapter on intrapartum fetal monitoring had the use of an intrauterine pressure catheter (IUPC), and most mentioned a fetal scalp electrode.

Shudder.

I am not sure what the prevalence is of IUPC use. I have not seen it in most of the labors I have been to, but I have definitely seen them used. In one labor I went to, the IUPC and/or fetal scalp electrode had to be replaced three times because of problems.

As far as I know, there is no evidence supporting their use. I found this article, which is a rare randomized trial with a significant number of subjects. There seems to be no advantage to using them. When that is the case, I think it is only ethical to use the less invasive intervention, which would be external monitoring.

There are a few quotes I find interesting in this article. Here’s one:

“The American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) advise the use of internal tocodynamometry in selected circumstances, such as when the mother is obese, when one-on-one nursing care is not available, or when the response to oxytocin is limited. The Dutch Society of Obstetrics and Gynaecology recommends its use in all cases of induction or augmentation of labor.2″

Well, I have never seen one to one nursing in labor and delivery in a hospital. Never.

Also, here’s another one:

“Induction or augmentation is necessary in approximately 20% of all deliveries, and internal monitoring is thought to quantify the frequency, duration, and magnitude of uterine activity more accurately than does external tocography.1-3″ (Emphasis mine)

Wow, really? Unfortunately, there are poor statistics on the prevalence of interventions in labor, but Listening to Mothers cites an induction rate of 48% for first time moms, and “Only 41% of the women had a labor that began on its own.” This link didn’t have the statistic for augmentation, but from what I remember, more than 70% of labors were augmented by oxytocin.

So, 20% of that is necessary, and what does that make the rest? Depends on who you ask. Some practitioners will say it is active management, aka “doing what we can to get the baby out…that’s what you’re here for.” I call it excessive interventions that lead to possible iatrogenic risk.

Defending breastfeeding

I think I have been quiet on here longer than I have been for well, ever. I am doing a family practice rotation and trying to set up elective rotations and plan for applying to residency. I am also just busy and tired out in general. I can’t write about much of what I see day to day without discussing my patients or my attending physicians and residents in a way that might be ethically questionable.

But, I do want to write about something that happened today.

A patient came in with a complaint that wasn’t life threatening or earth shattering. My attending physician wanted to treat it empirically. The patient is breastfeeding exclusively. The physician, without even looking up the medication, told her to stop breastfeeding.

I usually don’t challenge what my attending physician recommends. The patient said she would do what she always does, and call her baby’s pediatrician. When we did look up the medication, it did not have a contraindication for breastfeeding, but had a typical “well, we just don’t know if this is safe” disclaimer. This wasn’t a book specifically dedicated to medications and lactation. There are books like this available.

I told the attending physician that the patient was exclusively breastfeeding, and breastfeeding is hard enough to pull off in this society as it is. I said that, barring a contraindication during breastfeeding, most medications are safe, and a little research on the topic and possible alternatives may be a good idea. The attending said that, in today’s litigious society (which is the topic of many lectures by many attendings), we just can’t take those kinds of chances these days. She apparently tells any breastfeeding patient to stop breastfeeding with any medication.

I hope I can take these kinds of chances one day. I respect my attending physician’s choices in balancing her medicolegal risk and the way she cares for her patients, but I hope to be able to strike my own balance one day that is more supportive of breastfeeding.

Done with ob/gyn

I am done with ob/gyn, at least for now. I absolutely loved it. I loved the births, which I knew I would already. I loved the OR. I got to close a cesarean! Squeeeeee! I loved the procedures. Most of all, I loved clinic, especially prenatals. I have no qualms about the field I have chosen. The hours were long, but I loved it.

I can’t believe I have to go back to doing other rotations before I can be all ob/gyn, all the time. I still have two months of family medicine and two months of rural rotations, which will both luckily involve a lot of ob/gyn, pediatric ER and regular ER, and then it’s all electives. Whoooo!