Reply turned post, second verse, same as the first

Dr. Dangerpartum Von Deathtrap (ha ha ha ha, Jill!) is at it again at The Unnecesarean.

The replies are flying quickly, and the manure is flying even more quickly. Dr. Amy is in poor form, misquoting abstracts and using the death due to shoulder dystocia baby card for babies within normal weight range. Huh?

Anyway, I can’t reproduce all my replies, because they are flying too fast and furious to keep up with.

When I told of a personal experience of being at a frustrating delivery that involved a protracted labor due to an induction in a first time mom, I pointed out that her normally sized baby (8 lb 11 oz) had no shoulder dystocia problems. And, evidence on the subject, including UpToDate, agrees that fetal weight below 4500g (that baby was below 4000g) is not associated with shoulder dystocia.

Dr. Amy’s response:

MomTFH:

“He ended up being 8 lb 11 oz, and there was no problems delivering the shoulders.”

So what? Do you think that’s a defense suitable for court: “the last woman with a big baby didn’t have a shoulder dystocia”?

What would you do if you were RESPONSIBLE in the event that a baby died because you didn’t do everything you could to prevent it? Would you shrug it off? Would you tell the mother, “Too bad things didn’t work out, but it’s more important that fewer women have C-sections than that you have a live baby?” How well do you think that would go over?

Oh, OK, because when I say he didn’t have any shoulder delivery problems at all, what I meant was, the baby died and I shrugged it off, and all I care about is practice patterns, not live and healthy babies.

Here is my reply

Wow, I guess that’s what happens when I comment without reading the other comments.

Dr. Amy – She had NO risk factors or indications for a macrosomic baby and the baby did not have macrosomia. Are you proposing if, in 3 years when I am a practicing obstetrician, I do not section all similar patients, I am risking killing their babies?

Here is a quote from Up to Date:

Fetal macrosomia — Studies have consistently shown that macrosomia is a major risk factor for shoulder dystocia [2,3]. Fetal macrosomia is best defined as an estimated fetal weight (EFW) of greater than or equal to 4500 grams, as morbidity and mortality increase above this level [4,5]. The overall prevalence of birth weight over 4000 grams in the general obstetric population of the United States is 10 percent [6], but falls to 1.5 percent for birth weight over 4500 grams [4].

Her baby was more than 500 g below this threshold, and did not have an EFW above that threshold.

What do you think of the idea of doing an induction at 39 weeks with a Bishop’s score of 2 on this low risk patient? Based on ACOG Practice Bulletins and other online materials on quality care, my interpretation of the risks and treatment decision tree is pretty spot on. How much more do you think the baby would have grown if her physician waited for her due date at least, and how much would that increase her risk of shoulder dystocia?…

Have you read this article yet? The Obstetrics and Gynecology Risk Research Group still thinks obstetricians are misrepresenting risk to patients, to the detriment of women and their babies. You do it also, repeatedly. You have this citation from the thread from more than a week ago. You proceeded to cite a study from the same group the very next day, so you must think it is a good source.

Then the good doctor wanted to set some baseline “facts” about defensive medicine:

Let’s go back to the facts that I set out.

1. Most parents of a baby who dies will contemplate suing the doctor.
2. Many parents will consult a lawyer.
3. The ONLY way to prevent a lawyer from filing a lawsuit is to convince him that he can’t win.
4. The ONLY way to convince a lawyer that he can’t win is to demonstrate that everything possible has been done.

Do you agree?

I responded (in a tag team with hostess Jill):

Right, because obstetric litigation is actually due to substandard care (note the use of citations, Dr. Amy).

One documented way to decrease obstetrics litigation is to DECREASE unnecessary interventions by following evidence based protocols. Funny, one of those protocols was on induction, which is what I was complaining about upthread. Not only did these evidence based algorithms decrease interventions, including cesarean sections, and improve outcomes (preventing those preventable deaths), but they also reduced litigation. Imagine that. With a citation.

Watch Dr. Amy completely invent imaginary conclusions contrary to the actual studies I posted, and then dig her heels in when I present her with the actual conclusions of the studies, and she can’t provide any quotes.

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.

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!

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?

Reply turned post, did I say walk away?

OK, OK, I didn’t walk away. I did, actually, for 24 hours. But then I came back to the Stuff White People Like: Talking About Birth post at the Unnecessarean.

Both of the problem posters resurfaced, and both misrepresented other posts in order to make their points.

One poster is a lost cause and a selfish embarrassment to the online birth community, who I refuse to link to anymore, and the other is Dr. Amy.

Here is my response to Dr. Amy: (I just realized none of my links are live, since I forgot to copy my formatted comment. If you want any of the links to the original studies or stats, please follow the link to the original thread above.)

Dr. Amy, if you have to misrepresent what people say in order to be right, something is wrong with your argument. “THE cesarean rate” (which is a meaningless term without more qualification) is not what was being discussed. You of all people shouldn’t be chastising others on precision in statistics. Hospitals have crossed the 50% cesarean mark. In fact, a few in Miami-Dade County have. So, what is the problem with that statement of fact? Nothing.

Medicine has to define what is within physiologically normal range in order to know when to intervene. It is the central premise of all medicine, including obstetrics. Why has ACOG had to make statements saying that elective inductions and elective cesarean sections should not occur prior to a definitive confirmation of 39 weeks gestational age? Because NOT delivering before that point is physiologically normal, and the evidence indicates that the trend of “modern obstetrics” to induce and do elective cesareans before that point was to the detriment of both mothers and babies, and has made our outcomes worse recently, instead of better.

No one is saying all medical interventions are bad. You keep on repeating that we have lower poor outcomes due to modern obstetrics. You are the only one arguing about this straw man argument. Modern obstetrics as a whole is not monolithically good or bad. All of its practices need to be examined to see how they effect outcomes, just like the New England Journal of Medicine did, if you follow my link above, and just like the US Preventative Services Task Force did, and just like the birth advocacy community will continue to do.

Your crusade against this examination of evidence of individual interventions and intentional exaggeration of risks is still “neither evidence-based not patient centered, often to the detriment of both women and infants”.

And, what happened to the conversation about privilege? No one is saying we need to educate women of color to follow our luxury of caring about natural birth. We want to include their voices in the conversation, and both Tamika and Mai’a have confirmed that we need to listen better. We also need to make sure they are included in our attempts to improve practices and outcomes, while not assuming their values and social contexts are the same as the dominant culture.

Reply turned post, need to walk away style

Well, if anyone is up to following the drama, plus some new drama, please head on to the next thread on The Unnecesarean: Stuff White People Like: Talking About Birth.

If you want to take a controversial topic like birth advocacy and throw in something MORE to argue about, talk about privilege in birth. I love Jill’s original post, and I totally agree that we, as women of privilege, whether it is neurotypical privilege, cis privilege, able bodied privilege, heterosexual privilege, married privilege, socioeconomic privilege (the only one many people are able to acknowledge, if any), attractive non overweight body privilege, dominant culture and language privilege, another privilege I am too privileged to know I have or simple race privilege, have a responsibility to examine that privilege and try to see how it intersects with topics about which we are passionate.

Well, if you want some good, on topic discussion, read Jill’s post, my comment, and a few of ther subsequent comments. Then, in walks Dr. Amy with what seems like a much more reasonable tone, but if you read between the non-ranty lines, she is still painting evidence based non interventionist birth advocates as a convenient straw woman, (B3 on Mommy Wars Bingo), and then tears it down as only a reasonable woman could by saying “Why can’t we get along and non-judgmentally respect these choices?”, as if that is how she has ever approached this topic. If you need to refresh your memory about her typical approach to this discussion, just go back one thread or try the google with her name and the term “home birth”.

And then, Feminist Breeder, a commenter I have had issues with regarding race on my own blog to the point I had to ask her to stop posting on the subject (here, here, and here) showed up, and engaged in privilege denialism. Strong black women in her community have more control and faith in their bodies, and reject those unnecessary interventions that white women don’t have the sass to refuse. And the rich white women drive to a poor neighborhood to use their awesome midwifery clinic! We are so totes post racial, birth wise, folks!

So, I replied. I was SO relieved not to see a flame war on there…yet. I would love to have some women of color (or other nonprivileged points of view, for that matter) come and represent their own perspective, but I know that the amount of anger and annoyance I feel at the same tired arguments about privilege are probably multiplied exponentially when they read them, and it is not their job to educate the ignorant and argumentative.

Anyway, here was my reply:

Dr. Amy, I appreciate the nicer tone you are taking on this thread as opposed to the thread you have ditched like a rat leaving a sinking ship.

However, I have thought and said almost all of the things you have written about how all mothers are worthy. And, I am sure I am not the only one.

You are still creating a straw man, or woman, for that matter. I am not, Jill is not, and many birth advocates are not people who think women who choose less interventions are somehow more noble or better mothers. That is a simplistic, shallow, ridiculous point of view, and I don’t have it, and it is not the point of view of the birth advocacy movement.

Sure, you can find examples of such caricatures of holier-than-thou crunchy moms if you look hard enough on certain message boards, but it is just as easy to find moms on much more conventional mommy message boards mocking anyone who doesn’t opt for an epidural. In a country where 85% + of women who deliver vaginally have an epidural, and less than 1% have a home birth, I have a really hard time when people cast the women who get epidurals as the underdogs and women who fight to refuse one as the oppressors.

You may have chosen one quote of Kukla’s that seems to support that view. (By the way, way to embrace an opinion piece in a peer reviewed journal right after you criticize me for doing so). I prefer this work of hers, “Finding Autonomy In Childbirth.

Here is a quote:

“For all women, however, finding autonomy in birth requires access to safe modes of delivery that are appropriate to their personal and social circumstances and their values and sense of integrity and dignity, and circumstances that enable them to experience themselves as the primary (albeit relationally embedded) agents of their own birthing process.”

I think it’s fairly obvious by this quote, the article and her other works, like Mass Hysteria, she does not throw the baby out with the bathwater, to make a bad and somewhat inappropriate analogy. Just because some person with a natural mom goodness ruler may cast judgment in some circles (and I argue that is NOT the most prevalent attitude, regardless of the hand wringing about it by Kukla and many others), that does not mean the evidence based natural birth advocacy movement is somehow flawed.

Also, Feminist Breeder, I have seen the exact opposite of what you describe, and although I am not in Chicago, I find it unlikely that women of color have more birth advocacy there than white women, or feel like they have more control over their bodies than white women. And women of color are not exercising their increased advocacy thinking that “no one is going to tell them they can’t do something.” I’m sorry, that is a caricature of the sassy angry black woman, and it is just not the reality of most women of color. You and I have clashed on this issue before, and that’s all I am going to say.

In both of these arguments, you can see one of my pet peeves is seeing the underdog cast as the privileged. Women who breastfeed are not oppressing women who don’t or can’t by breastfeeding, and breastfeeding advocacy is not tainted by a mom who has been anecdotally judged for that. Women who advocate for less non-evidence based unnecessary medical interventions in the birth process are not telling mothers who chose an epidural she has failed as a mother, or that her child is going to be different as a teenager. And women of color are not enjoying their increased autonomy over their bodies.

Reply turned post, Dr. Amy is still there? style

Doesn’t Dr. Amy know a good take down when she reads one?

Sigh.

Well, I guess she does to a certain extent, since she mostly ignored it, other than to tell me I called the Obstetrics and Gynecology Risk Research Group article a scientific study, which I didn’t. I called it a peer reviewed article and an excellent source, which it is, and which is something she has yet to produce in about a dozen comments she has made on the derail from hell on The Unnecessarean.

Even though she has ignored the substance of my comment, she has continued to bicker with many other commenters on the thread. Jill, the intrepid hostess of the blog, has decided to sit aside, eat popcorn, and referee the worst shit-throwing while allowing people to interrogate Dr. Amy.

So, here is my next reply:

Thanks Jill. I actually wish the thread ended with my last comment, but I guess Dr. Amy came back later and ignored it.

Dr. Amy, what is your response to the Lyerly et al article about the values, or lack thereof, of intentionally distorting risk and ignoring women’s values and well-being in order to push non-evidence based and non-patient centered care? Can you find a comparable consensus from as prestigious and relevant a group on risk and pregnancy that supports your tactics and point of view, or criticizes ours?

Have you ever wondered why you seem to be willing to dismiss the risks of procedures that are not women centered and exaggerate the risks of interventions or standards of care that are woman centered? Especially when it comes to the point that you have to ignore the actual evidence of levels of risk of these interventions. What is your opinion on the patriarchal paradigm of patient care, and can you find any sources supporting it?

How many more people can ask you for a source for your misrepresentations of risk on this thread? You had no problem quoting the Farm as the source for numbers in one of your numerous comments, (a source which you distorted and misquoted). Citations only take one line, and less time than your protracted comments that artfully ignore all the best points and questions (like” “source?”) of the thread.

Why are you here? Why show up in communities that seem to be populated by people with a different point of view than you, and seem to be able to support it much better than you can support yours?

Why do you dehumanize women who care strongly about their autonomy in what is the MOST IMPORTANT DAY OF THEIR LIVES by trying to pretend they are a homogenous straw woman, this pretend selfish upper class privileged white Western woman who just needs Dr. Amy to come tell her some fake statistics and exaggerate a few risks to scare her for her own good and the safety of her baby?

Oh, one more:

What is the difference between physiology and pathology? Which do you need to treat?

Moving during labor

Amy at Lamaze’s Science and Sensibility is hosting the second Healthy Birth Blog Carnival. This one is about Lamaze’s Second Healthy Birth Practice: Walk, move around, and change positions throughout labor.

Amy did a great job explaining how natural birth advocates are constantly asked to prove that what is physiologically normal, like being free to move during labor, is better than an intervention, when it should be the other way around. Here’s a great quote from her anticipatory pre-carnival post:

Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice. While many of us believe that encouraging a laboring woman to move when and how she wants to is healthier and safer than making her stay in bed, waiting for evidence that it produces better health outcomes is putting a burden of proof on normal birth that has never been applied to routine intervention. Besides, lack of evidence of harm, less pain, and maternal satisfaction are valid and important outcomes in and of themselves, and provide the justification we need to reject routine policies and practices that restrict maternal movement.

I had a similar argument with a commenter on this post. Many elective cesarean advocates seem to want to present vaginal birth and cesarean birth as two equal options, not a physiologically normal event and an intervention.

So, since Amy already handled this angle well, I am going to talk about my own experience, and give a little advice at the end.

When I had my first child, I thought I was well informed. Hell, I had read every page in What to Expect When You’re Expecting. I read Mothering and Parenting magazines (both sides!), hired a midwife, took a childbirthing class, and thought I would have a “natural birth” as long as there wasn’t any unexpected emergencies.

Well, soon after I arrived at the hospital, I was told they didn’t have a birthing tub (I never thought to ask ahead of time, dangit) but I was told I could labor in the shower. After the shower, which was probably 20 minutes at the most, I was told I needed an IV with Pitocin. I had no idea what that was, but since my midwife recommended it, and everyone knows midwives always favor natural births over interventions, I didn’t even think of refusing. Well, I was told as soon as the Pitocin was started that I needed to be on continuous external fetal monitoring. Huh? Then, my midwife told me I had to stay in my bed(!!!), since the baby was showing signs of distress. I was not told before being administered the Pitocin that it would require being tethered to the machine, and I wasn’t told it may cause fetal distress, even after my fetus was apparently diagnosed with fetal distress. I wasn’t even told it may not be necessary, considering I had only been in active labor for about an hour when it was administered.

Fast forward several hours and I was flat on my back, pushing too soon, leading to a swollen cervix. No, no alternate positions were encouraged for my three hours of pushing, either.

So, my advice? Ask your practitioner(s), ahead of time, what their positions are on intermittent monitoring and movement in labor. Don’t just assume that what seems basic and normal will be encouraged or allowed.

More on fat bias and pregnancy

Jill at The Unnecessarean linked to this frustrating but great birth story at My Best Birth. “A Curvy Gal’s fight for a Natural Childbirth” is full of head exploding details, such as baseless threats from her midwife, recommendations for risky procedures with a lack of adequate informed consent, and suggestions of medical approaches that would actually increase the risk of adverse outcomes, not decrease them.

Here is a choice quote:

After some research, I called my midwife to say that I did not want a Miso induction, and that I wanted to wait and go into labor spontaneously. She said, “Well, in my experience, women with BMIs higher that 26 tend to have cervixes that won’t dilate without chemical induction.” Okay—first I was being pressured into induction because of the increased risks of a long gestation to m y baby and NOW she’s saying that because I am a curvier gal, my body is somehow clueless about giving birth (by the way, I had NO other risk factors in this pregnancy—no gestational diabetes, no elevated blood pressure, etc) I have since searched high and low for ANY medical study that supports her belief and have come up with nothing. I argued with her that I’d like to give my body the chance to go into labor on its own—at least through the weekend (agreeing to the postponed induction with the foly (sic) catheter instead). She was condescending and doubtful, but ultimately said it was up to me.

Rrrrrrgh.

The good news is that she did her research, refused the inductions, and ended up going into labor spontaneously and having a quick and easy birth.

Sick and leaning on the mute button

So, I am sick. Sick sick sick sick. I hurt everywhere. I have a fever and I am lightheaded. Runny nose, cough…the works. Blegh.

I am planted in front of the computer and the TV. I watched these Bill Nye videos about genetically modified foods. I just happened to get a link for them by being a fan of Slow Food USA on Facebook. It was interesting timing (not ironic, huh CableGirl?), since I just got in an annoying argument with commenters on on Dispatches from the Culture Wars. First of all, I am no fan of people who use snotty insults when they’re arguing on a site. Not necessary. Sarcasm is fine. But, if you’re going to go there, you better be right. I also don’t think blindly accepting technological advances is any more reasonable or educated than being blanketly afraid of all technology.

So, while I was tooling around on the internet, I had the Travel Channel on mute. Anthony Bourdain was visiting Ted Nugent. I could never listen to that much douchebaggy conversation, but I left it on in case there were any exciting gun accidents. Not that I wish that on anyone, but still, it’s exciting.

Now I am watching Birth Day. I wish I had the mute on here, too. I have heard “vertex position is NECESSARY” for a vaginal delivery. Also, I heard about a woman who had been in a long labor, and when her nurse introduced the next shift nurse, she said “And Amy has been with us forever.” Nice. She ended up with a fever after several hours of an epidural, and of course they discussed ZOMG infected baby!! but didn’t mention the link between epidurals an fever. The baby was born by “abdominal rescue” (wha??) and then was immediately taken to the well child nursery. Wait, I guess they don’t think there is a big risk this baby is infected. Then they talked about how it’s just great that she had a healthy baby.

I did get to see a successful external version (I cheered!) but I was surprised to see she got a neck down epidural for it, and then they induced labor immediately. I don’t know that much about external versions, however. The baby has distress now. They think it’s from the version. But, can it be from the Pit?

There is a woman who is one day past her due date (the horror) and was told her baby is “big” and she needs a cesarean. Oh, but she’s a hemophiliac. How does this sound safer? Her bleeding time test did not look good from my amateur eye. Why cut her without good indications?