Last week on Twitter, one of the people whose feed I follow posted that it annoyed her when people refer to vaginal birth with analgesia as “natural birth”. I replied that I am annoyed when people, including health care practitioners, refer to any vaginal delivery, regardless of any interventions, as a “natural birth.” Looking back, I think she was reacting to Beyonce and Jay Z’s press release that their baby was “delivered naturally”, which may have been in response to rumors that the singer had a scheduled elective cesarean.

It is bad enough when the term is used by lay people. I have seen countless residents and even attending physicians conduct an obstetrical history on a patient by asking “was that a cesarean or natural birth?” (I’ve even seen it done in Spanish – cesario or parto natural?) Since I have been guessing others’ motives this whole post so far, I’ll throw in another assumption. I think these history takers are avoiding the term “vaginal” because of some level of squeamishness or decorum. I have yet to see “natural birth” instead of “vaginal delivery” on a medical history template, thank goodness.

It’s a nonspecific euphemism that means something different to everyone, and, to some, carries judgment or bias. It is not a medical term, and does not belong in a medical history. I don’t begrudge Beyonce and Jay Z’s people for using the term, but it does bother me when it is used by someone in the health care profession.

Or, someone who used to be in the health care profession. Especially when it is used to capitalize on the judgment tied in with the connotation purposely. The more imprecise and loaded a term is, the easier it is to demonize it.

So, when Amanda Marcotte linked to an article on Grantley Dick-Read being a misogynist, I clicked through unwittingly. I was halfway through the article when I began to get suspicious by the familiar straw man argumentation tactics. Then I scrolled up and saw who the author was.

Now, I am not here to defend the so-called father of natural childbirth and his views on the modern woman of the 1940′s any more than I feel the need to defend all of Margaret Sanger’s views. Dr. Tutuer’s claim that the central tenets of so-called natural childbirth advocacy is therefore built on sexism and racism is as ridiculous as saying modern reproductive rights advocacy has central tenets of racism and eugenics.

Like the terms we use to describe childbirth itself, the discussion of birth advocacy and birth choices is improved with nuance, not sweeping generalizations, stereotypes and villainization. Speaking as someone who considers herself to be part of the birth advocacy cloud, I have never, ever heard a privileged, first world so-called natural birth advocate use Read’s arguments about the pain of childbirth being a punishment for uppity career seeking women who don’t know their place as baby factories. It is hardly a central tenet in the movement. In fact, one of the most common criticisms of opting for an analgesia free birth is that one is choosing to suffer like a primitive woman from a developing country, with frequent conjuring of women of color squatting in huts, and batting about of the term “animal”. I find those comparisons to be more sexist and racist than advocating for birth choices.

I also don’t agree that a central tenet of so-called natural birth advocates that the pain of childbirth is “empowering” (which contradicts the argument that it is a punishment for being empowered). I do think that autonomy in birthing choices and true informed consent can be empowering. Accomplishing something thought of as difficult, such as an unmedicated labor and birth, can feel empowering to some women. But, the actual pain? No. Is a longer labor more “empowering” than a precipitous labor? Persistent occipital posterior with back labor the most empowering? Ridiculous.

Finally, although I do think planning on an analgesia free birth with preparation makes it a more tolerable experience than, say, having a analgesia free birth when one planned on an epidural but is somehow unable to receive one. But, do most “natural” childbirth advocates say that adequate preparation means a pain free labor? Absolutely not. That is a fabrication, as Dr. Tuteur deems it to be, but it is a fabrication on her part that it is a common claim in the “natural” community. I had two analgesia free labors, and they hurt. A lot. And, again, this contradicts with what she says is the other central tenet of “natural” birth advocates, that the pain is empowering. Is the labor pain free or is it painful and therefore empowering? Boy, we “natural” birth advocates sound like idiots!

Dr. Tuteur would be hard pressed to find contemporaries of Dr. Dick-Read who were not sexist and racist, considering how sexist and racist American society was at the time. If you read articles written at the time about twilight sleep, the main standard of care for “pain free” birth, you will also see troubling justifications and, frankly, fabrications. From the linked article “Twilight Sleep: the Dammerschlaf of the Germans” in the Canadian Medical Association Journal:

One can imagine what a special paradise of salvation this promise conveyed to that vast number of women who, as matrimonial candidates, are consciously unwilling, or unfit, for the claims of parturition; that vast array of modern womankind with no physical or mental training for the demands of motherhood; who are enmeshed, as Walt Whitman so well describes it, “in the incredible holds and webs of silliness, millinery, and every kind of dyspeptic depletion.” For such a prospective mother this method afforded a glimpse into a maternal paradise.

The article also presents claims that twilight sleep analgesia in labor reverses the biblical curse of original sin on women. The author also acknowledges the technique is inconsistent and does not always provide an actual pain free experience, but that the amnesiac qualities of the scopalamine solved that problem. Considering many of these women would receive episioproctotomies and mid to high forceps deliveries, I doubt the recovery was easy or pain free, much less a glimpse into maternal paradise. Does this mean that obstetric analgesia is built on central tenets of sexism and fabrication?

There is no such thing as “natural” birth. There is spontaneous onset of labor, there is labor without augmentation, there is labor and birth without analgesic medication, there is spontaneous vaginal delivery, there are births in which the moms are allowed to position themselves freely, there are births in which the moms push at will instead of being coached or forced into closed glottis Valsalva pushing, there are births where the cord is allowed to pulsate and blood transfer is allowed to occur instead of immediate clamping, there are births in which the baby is delivered on to the mom’s skin instead of a blue “sterile” drape and then is whisked to a warmer.

My first birth, I went into labor on my own. I was given Pitocin augmentation, labored on my back in a bed with continuous monitoring, amniotomy, had coached pushing, also on my back, immediate cord clamping, and my baby was taken from me immediately, and I didn’t get to see or hold him for more than four hours. I sure didn’t have any medical analgesia, and it hurt like hell. I didn’t feel empowered, and don’t think the term “natural” applies to that birth. My second birth, I went into labor spontaneously, I was able to change positions, I had no augmentation, had intermittent monitoring, but I pushed the baby out flat on my back, against my will with no urge to push, while being yelled at to hold my breath and push for a count of ten. Was that more “natural”? More empowering?

I think I share motives with many in the birth advocacy community. I think women should have autonomy in their birth choices. I think the burden of proof should be on interventions, which should ONLY be employed when medically indicated, and then should be offered with adequate informed consent. If I had to rank my priorities or “central tenets”, I am much more concerned about early elective inductions, forced repeat cesareans in good candidates of trials of labor after cesarean, routine episiotomy, routine deprivation of oral nutrition during labor, routine amniotomy, routine continuous monitoring, routine augmentation, routine episiotomy, aggressively coached Valsalva pushing without laboring down, and routine pushing in the lithotomy position than I am worried about epidurals. I am much more worried about women simply being told that Stadol “will just take the edge off” and epidurals “don’t affect the baby”, both of which I have heard as the entire informed consent for each.

ETA: Sorry I ended it so abruptly, but lunch break was over at the clinic.

We need more nuance, not more generalization. We need more empathy, not more vilification. I am all for critiquing historical figures through the lenses of feminism and anti-racism. But, let’s focus on truly empowering women instead of tearing them down.

So, yeah, 2012. Lots of big stuff lined up this year. More interviews. Step 2 clinical skills board exam – my last medical school board exam. Rank list. Match. Graduation. (if all goes according to plan for those last two!)

I finished an interesting month at my local residency institution. It was great. I was pleasantly surprised with how much the residents and attendings liked to teach. I have an iPad now, and when I access my blog from it, the cover picture is the one from Papanicolaou Way. It always makes me smile.

I am now doing a family med rotation, one of my last core rotations. When I went through the requisite getting to know you questioning with the other people at the site, someone made a “yuck” face when I said I was going into obstetrics and gynecology. As usual. I don’t get it. There are plenty of specialties I would not enjoy, some of which I would be grossed out by if I had to do them. Dentist? Uh, no way. Heebie jeebies. But, I am sure happy that there are people who enjoy that line of work, and would never stick my tongue out and grimace like a kid who just ate cod liver oil if someone told me that’s what they were planning to do! I swear, it happens all the time. Even worse, it’s pretty evenly distributed, regardless of gender. Let’s not hate on our vaginas so much, ok?

Finally, the cool thing. Planned Parenthood has a series about STIs that included this article about intestinal parasites. Never thought of them as STIs. And wow, that capsule on a string with the bag that hangs out in your intestines until you fish it back up? SO COOL!

As you may have expected, both of these posts had lively comments sections. I only got involved in the second post. Yes, I haven’t just been MIA here, I have been MIA in the interwebs in general. However, I tend to jump in when I actually get a chance to read something, and then see someone creating straw men arguments or grossly misinflating aspects of the conversation in order to make a point, which happened a few times in the second comment thread.

My first comment was in regards to informed consent. A few commenters acted as if there is an exact formula for informed consent, and it includes presenting every worst case scenario, even if the risks of that scenario are diminishingly rare. Also, some commenters were treating the one verdict and award in this very specific case as the totality of case law on informed consent.

ACOG has a Committee Opinion on Informed Consent which discusses the complicated and amorphous subject of malpractice case law and informed consent. This opinion, which I recommend that you read, like I recommend you read all of the links I am including (yeah, I know, you haven’t got all day, but still), states that first of all, informed consent is more of an ethical issue than merely a legal issue. Secondly, the adequacy of disclosure, which is the issue that the huge malpractice payout in the original Unnecesarean post hinged on, has been judged by different criteria in different cases. In recent history, “common practice of the profession” was the most common trend for judgments. That could be troublesome, because standard of care in different areas can be quite variable, and not necessarily evidence based or best for the patient. Now, the trend seems to be moving towards the “reasonable person” criterion, which can also be troublesome. Especially if the all the commenters on these threads are “reasonable people.” Ahem.

Physicians are notoriously poor at presenting risk (pdf) in a way a reasonable person can understand. Many practitioners will very selectively and erratically present risk, sometimes exaggerating, downplaying or completely omitting risks or benefits in order to lead the patient in a certain direction. Ignoring that, statistics are still highly complicated even with the best of intentions. This article recommends using “natural frequencies”, such as saying three to five people out of ten taking Prozac will report some sexual dysfunction, as opposed to saying there is a 30 to 50% probability of sexual dysfunction. Many people will assume the latter will mean that every time they have a sexual encounter, there will be a 30 to 50% chance of there being a problem. Percentages or other comparative methods (__ times more likely) can be tricky.

For example, in Liu et al’s Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term, one of the outcomes measured was any hysterectomy. I picked this specific outcome because it is a good example of how to discuss the numbers, but also because one of the commenters grossly misrepresented this particular risk, stating it was ONLY a risk of vaginal birth, and not at all associated with cesarean section.

In this retrospective study, there were 27 hysterectomies in 46,766 cesarean deliveries, and 376 hysterectomies in 2,292,420 vaginal deliveries. That is the same as 0.6 per thousand cesareans, and 0.2 per thousand vaginal deliveries. The adjusted odds ratio of any hysterectomy is 3.2 higher odds for cesarean than vaginal delivery. So, three times higher, or 320% higher. Sounds huge, right? But, the absolute risk difference is 0.4 per 1,000. Or, four hysterectomies per 10,000 cesareans. Does increased risk of hysterectomy need to be part of the informed consent for cesarean section? Does it need to be part of the informed consent for vaginal delivery? How frequent does an adverse event need to be for it to deserve a mention? Does an adverse outcome such as nerve injury resulting in foot drop, usually due to epidural or spinal anesthesia, which only appears in isolated case reports, not even in large studies such as this, need to be mentioned?

I still haven’t touched on the topic of how to counsel a patient who is near term and has high estimated fetal weight. This is a complicated topic, and I don’t think I am going to cover it in this post. Based on the evidence, including the ACOG position statements on the topic and UpToDate’s review of the literature, shoulder dystocia is unpredictable and unpreventable. Prophylactic cesarean section does not prevent nerve injuries or neonatal death. Induction of labor (which is disappointingly common in these cases) actually increases neonatal poor outcomes. Instrumental vaginal delivery (use of vacuum extraction or forceps) increases the risk of shoulder dystocia. Estimated fetal weight is a tool with poor accuracy, given a rating of I for insufficient evidence to support its use by the United States Preventative Services Task Force. This list does not even take into account the maternal history and characteristics.

I think informed consent for any pregnant person should include the chance of a shoulder dystocia. I think as the risk factors increase (estimated fetal weight greater than 4500 g, gestational diabetes, prior macrosomic baby, prior shoulder dystocia, male fetal gender, small maternal pelvic size), that increased risk should be presented. If a practitioner is acting out of fear of a lawsuit in the extremely rare case that there is a very poor outcome, the practitioner should mention this fear.

Eek.

I have four interviews scheduled so far. I would like more. I am thinking of applying to more programs. I haven’t gotten an invite to my local program yet, which will most likely be my top choice. But, I am doing a full month there next month, and they invite and interview late.

I am preparing for the interviews, clothing wise and mentally wise. I have no idea what to wear to a mixer with the residents.

I just wish I could fast forward to match day.

In the meantime, it seems like I may be taking a leave of absence this month. I am entitled to a vacation month, which I wanted to take this month, but I was assigned to emergency medicine this month, and I have February and April still open. While my site was willing to have me switch my ER month to February, but my school has a policy that you can’t change your months without actually switching with another student. But, no other student will have a vacation month they set up and then want to switch. So, I am finagling it as a one month leave of absence. I will work out the details tomorrow. And then, I’ll get to interview twice this month, and even spend Thanksgiving with my kids!

I’m really excited and nervous. So, to distract myself, here are some observations:

1. One of the streets bordering the hospital is named “Papanicolauo Way.” Yes, I will be taking a picture at some point.

2. They sell “The Club”, the old school car security device here in the security office. Geez, maybe I should have put my purse in my trunk.

3. When we were cruising through the school corridors among research labs with cool looking beakers, goggled research assistants, and radioactive materials and biohazard warning signs, there was a water fountain with an old, worn sign stating “This water is SAFE for drinking and cooking.” If there was no sign, I wouldn’t have been suspicious. Now, I’m not so sure.

I’ll be back with more clinically relevant observations.

I actually slept 10 hours a few nights ago. It was incredible. I still feel sleep deprived, and I am not a sleeper. I usually say “Sleep is for the weak,” which proves I am meant to do obstetrics. But, even I have my limits.

It is really exciting to be at a point in my educational path at which I can focus on obstetrics and gynecology. I still have core rotations in family practice and emergency medicine and an elective in cardiology ahead, but my boards are done. Pretty much, it’s ob/gyn, full speed ahead otherwise.

I am going to be spending two weeks at a Family Planning rotation site. This will be my first rotation at my local ob/gyn residency program. Eek.

I am doing a gynecologic oncology rotation this month. It has been great, but really busy. I have been working from before sunrise every day until after sunset most days. And this is Florida, so the days are long here. I was getting a touch of seasonal affective disorder / sleep deprivation crankiness last week. I had this weekend off, so I am feeling a little rejuvenated. We have seven surgeries scheduled tomorrow, so I am going right back into the fire.

I have one interview invite so far. I don’t have my letters of recommendation in yet, so I’m not completely freaking out. Yet.

I got my USMLE Step II scores back. (I am a DO student. I took both the COMLEX and the USMLE because I will be doing the MD match. If you want to read more about this, I wrote about it here) Since I talked about my scores for Step I to of how well I did, I guess I’m going to this time around.

I did really well. Very well. Much better than I thought I did. It should make it a bit easier to get interviews at MD programs, I hope. Now I am going through the application process and getting ready for elective rotations.

I would feel some relief, but that just means I need to get my applications to residency in, and then start the interview process.

Eep.

Wish me luck, please, for all of the above.

NPR has been rockin’ lately. First, I heard Morocca say “hula doula” on Wait Wait, Don’t Tell Me” recently. They have been running a really great series on birth called “Beginnings: Pregnancy, Childbirth and Beyond”. It included a great piece on elective inductions that provoked a lot of comments when I shared it on my Facebook page.

NPR’s Facebook feed also tipped me off to a new report by the Institute of Medicine, “Clinical Preventative Medicine for Women: Closing the Gaps” which recommends mandating insurance coverage of contraception,” since it is preventative medicine. To quote Rachel from Women’s Health News, “Duh!”.

In addition to copay-free coverage of birth control, the Institute recommended:
screening for gestational diabetes:

*human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30
*counseling on sexually transmitted infections
*counseling and screening for HIV
*lactation counseling and equipment to promote breast-feeding
*screening and counseling to detect and prevent interpersonal and domestic violence
*yearly well-woman preventive care visits to obtain recommended preventive services

Hear, hear.

Anyway, I should be studying. Wish me luck.