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 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 on her 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!

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, 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?

Reply turned post, Dr. Amy style

Some of you shuddered when you read the name “Dr. Amy”. Some of you have never heard of this plague of the internet. I will not link to her blog, but you can find it by clicking on her name on her comments on the original post. Don’t say I didn’t warn you.

If you have spent any time in the internet birth advocacy community, you have run into Dr. Amy. She claims to be (I am not casting aspersions on her credentials, I am just saying anyone can say she is anything on the interwebs) an ob/gyn, and is a, ahem, vocal opponent of home birth and natural birth advocates. She not only blogs about it at her own spot, which is entirely her right, but she shows up in spaces enjoyed by natural birth advocates and proceeds to show the worst examples of how to distort, selectively apply and and ignore evidence and freely engage logical fallacies to argue her points.

Well, she messed with a friend. And, she is wrong. Wrongity wrong wrong.

So, feel free to read the comment thread here at Jill’s The Unnecessarean. Dr. Amy makes many outrageous statements in several comments, including using the term “or die trying” twice when discussing giving birth without pain medication (implying there is a risk of death by avoiding an elective intervention that actually carries risks) and claiming “the risk of neonatal death from ruptured uterus at VBAC is quite significant”.

So, here is my response, wayyy down on the second page of comments:

Wow, lookie what I missed.

Dr.Amy, I am a research fellow at a medical school researching obstetrics. You are not providing any sources, and you are not providing a reasonable interpretation of the data available on birth. You are also dodging the questions asked of you. Your language choice is biased and awful. The complete lack of ethical balance you bring to these conversations is frankly appalling.

Most “natural” birth advocates, including the one whose blog you are on (Hi, Jill!), advocate for responsible application of medical intervention in situations that the evidence shows warrants such interventions. Otherwise, pregnancy, labor and delivery, and post partum should be allowed to be phsyiologically normal. No one (here, at least) is saying that all women should be forced to forgo pain medication, that medically necessary cesareans should be avoided, or any other of the straw man arguments you continuously create.

As long as you insist on being involved in these discussions, here’s a little reading for homework:

Risk, values, and decision making during pregnancy by Lyerly, et al. It was published in Obstetrics and Gynecology, the journal of the American College of Obstetrics and Gynecologists, in 2007. I’d be happy to email you a full text copy, if you don’t happen to have access to this publication. In fact, I have a hard copy sitting in my lap.

Here is the abstract:

“Assessing, communicating, and managing risk are among the most challenging tasks in the practice of medicine and are particularly difficult in the context of pregnancy. We analyze common scenarios in medical decision making around pregnancy, from reproductive health policy and clinical care to research protections. We describe three tendencies in these scenarios: 1) to consider the probabilities of undesirable outcomes alone, in isolation from women’s values and social contexts, as determinative of individual clinical decisions and health policy; 2) to regard any risk to the fetus, including incremental risks that would in other contexts be regarded as acceptable, as trumping considerations that may be substantially more important to the wellbeing of the pregnant woman; and 3) to focus on the risks associated with undertaking medical interventions during pregnancy to the exclusion of demonstrable risks to both woman and fetus of failing to intervene. These tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants.”

Here is one of my favorite quotes from the peer reviewed article:

“Although rates of delivery-related perinatal death are indistinguishable between VBAC and primary vaginal delivery, there is a genuine differential in the rate of uterine rupture–related hypoxicischemic encephalopathy. Such perinatal morbidity is indeed devastating. It is also extremely rare. In a recent large prospective study, the probability of this outcome was 0.00046 in infants whose mothers underwent a VBAC trial at term compared with no cases in infants whose mothers underwent repeat cesarean delivery.”

The authors are members of the Obstetrics and Gynecology Risk Research Group, which is sponsored by grants from some of the most prestigious universities and foundations in the United States. It was also presented as a poster at the 54th Annual Clinical Meeting of the American College of Obstetrics and Gynecology. I DARE you to call this a poor quality source.

So, that’s how you provide evidence supporting a point of view without taking over a blog.

Do us all a favor. Stay on your own blog if you want to spout off biased nonsense. Stop recommending “care that is neither evidence-based nor patient centered, often to the detriment of both women and infants” in our space.

Reply turned post, conscience clauses can be OK style

I am starting to grow weary of being the contrary voice. I duck out of many confrontations, believe it or not. But, sometimes I still speak up.

More than once, a liberal, pro-choice site has taken a stance against conscience clauses in general. Although I am a pretty vocal pro-choice commenter in the interwebs, I find myself defending conscience clauses in these conversations.

This time, I replied on a Feminists for Choice post asking if conscience clauses were ethical:

I am a medical student and a member of Medical Students for Choice.

I strongly believe in conscience clauses and plan on refusing to perform certain procedures and to dispense certain medications when I am a physician. I think every physician follows her conscience, and am afraid anti-choice activists are using this important part of medical ethics to refuse to provide services that are in the best interest of the patient.

I plan on refusing to perform unnecessary procedures that are requested all the time as an ob/gyn. I will not perform any genital mutilation, male or female. This includes any routine newborn male circumcision, or elective vaginoplasties. This of course does not extend to any medically indicated procedures, which would be in the patient’s best interest.

I will refuse to do labor inductions because a mother is sick of being pregnant or because I am going on vacation. I will refuse to do non medically indicated cesarean section because a mother is afraid of the birth process or wants to have her baby on a certain date, or because I want to get home in time to have dinner with my family on a day I am being paid to be on call.

I think practitioners that are truly ethical do not use conscience clauses as an excuse to deny medical treatments to their patients or clients because of some idea that premarital sex is immoral. It is easy to find work in an area that does not involve refusing to provide necessary medical care. Most of these people who are refusing reproductive health care want to make an issue out of their refusal to control women’s sexual autonomy, not to support their own ethics, and it’s a shame.

There are two students in my medical school class who have stated they will refuse to prescribe birth control. Both identify as Catholic. One was more than happy to take handfuls of condoms our club was passing out for when he has sex with strippers (I wish I was kidding). He said he is using them for disease prevention, not birth control, so he is not a hypocrite.

I hope he goes into radiology, or urology.

The other is a Jesuit priest. He is planning on going into psychiatry, so most likely won’t be in a position to be a birth control prescriber often. He is also honest and out in regards to his homosexuality, and is an activist to change the Catholic position on homosexuality. So, he thinks some rules are meant to be changed.

The point of these two stories is to say, ethics mean different things to different people. Physicians and other health care practitioners are too diverse a group to force into one group of practices. However, we can encourage responsible application of conscience clauses and try to make sure essential health care does not get refused in the process.

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?

Newest, bestest KALI questionnaire, annotated

Here is the annotated survey, with an attempt at dividing the questions into domains and scaling them. So, the domains so far are K=Knowledge, A=Attitude, B= Barrier, P=Practice pattern, and Y=Autonomy of the patient. If a question says “Reversed” after it, then it is phrased in the reverse or negative compared to the evidence cited.

Sorry about the messed up formatting; I swear it looks OK in Word. I will try to edit it later today when I have more time.

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] Male [2] Female

2. Age:
[1] 20 – 29 [5] 60 – 69
[2] 30 – 39 [6] 70 – 79
[3] 40 – 49 [7] 80 – 89
[4] 50 – 59 [8] 90 or older

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] White / Caucasian [4] Native Hawaiian / Pacific Islander
[2] African American / Black [5] Native American Indian /Alaskan
[3] Asian or Asian American [6] Other:_______________________

6. How would you describe the location of your ob/gyn residency?
[1] University
[2] University affiliated
[3] Community
[4] 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 –
[a] Large partnership (four or more partners)
[b] Small partnership (two or three partners)
[c] Solo practice
[5] Military / government
[6] Other:____________________________________________

9. Do you currently practice obstetrics?
[1] Yes
If yes:
[a] Average clinical time spent with prenatal clients:______________(%)
[b] 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. All questions will have this scale available for you. Please choose whether you:

[1] Strongly agree
[2] Agree
[3] Neither agree nor disagree
[4] Disagree
[5] Strongly disagree

1. _____Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.(K)1 Reversed

2. _____Elective cesarean section should not be performed on a woman desiring several children.(K)2

3. _____Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.(K)3, 4

4. _____Episiotomy should be avoided if at all possible. (K, A, P)1, 5

5. _____The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery. (K)6

6. _____In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries. (K)7, 8 Reversed

7. _____Insurance should not reimburse use of doulas for labor and delivery.9 (A,B)Reversed

8. _____I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used. (K,P,B) 3, 10 Reversed

9. _____Fear of liability claims limit the options I present to my obstetrical patients.(B,Y,P)11, 12 Reversed

10. _____Liability insurance company policies forbid me from performing VBACs. (B,P) Reversed

11. _____Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes. (K)1, 13 Reversed

12. _____The use of continuous EFM does not result in a reduction of cerebral palsy. (K)6

[1] Strongly agree [2] Agree [3] Neither agree nor disagree [4] Disagree [5] Strongly disagree

13. _____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. (A,P,K)1, 14 Reversed
14. _____Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.(Y,A,K)3 Reversed

15. _____I regularly employ episiotomy to shorten the second stage of labor and delivery. (B,P,A)15 Reversed

16. _____Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.(K,A,Y)6

17. _____Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.(K)2, 8

18. _____Mediolateral episiotomies result in less postpartum pain than median episiotomies. (K)16, 17 Reversed
19. _____Prior to an induction, patients should be counseled about the possible need for reinduction or cesarean delivery.(K,Y)18

20. _____The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.(B)6 Reversed

21. _____Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.(K,P)1, 19Reversed

22. _____I regularly employ episiotomy to prevent pelvic floor relaxation.(K,P) 3, 5, 16, 17Reversed
23. _____Hospital policies forbid me from performing VBACs.(B)20-22Reversed

24. _____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.(A)7, 23, 24 Reversed
25. ¬_____I have made changes to my practice because of the risk or fear of liability claims. (B)11, 12 Reversed
26. _____Childbirth is only normal in retrospect.(A)3Reversed

27. _____Clinical guidelines are useful tools for me in daily clinical practice.(A,P)25

28. _____I regularly employ episiotomy to prevent perineal trauma.(K,P)5, 15, 17Reversed

29. _____The use of continuous EFM reduces perinatal mortality.(K)6Reversed
[1] Strongly agree [2] Agree [3] Neither agree nor disagree [4] Disagree [5] Strongly disagree

30. _____ Labor induction for non-medical indications (psychosocial or logistical) should only be attempted after establishing a gestational age of 39 weeks. (K,P)18

31. _____I encourage my patients to try alternative or upright positions during the pushing stage.(A,B,P)1, 13, 26, 27

32. _____Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care. (A,P)28 Reversed

33. _____I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.(B,P,K)29, 30 Reversed

34. _____Women should have the right to refuse an episiotomy.(Y)12, 29, 31, 32

35. _____I recommend that most patients use a doula for their labor and delivery.(A,P,K)1, 9

36. _____I feel that it is a woman’s right to elect to have a caesarean section even if there are no clear maternal or fetal indications.(A)3, 28 Reversed

37. _____There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.(K)6

38. _____Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.(B)33 Reversed

39. _____I discuss the risks and benefits of episiotomies with my patients prior to delivery.(Y)31, 32

40. _____Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery. (K)1, 14

41. _____If a patient asks if she could use a doula for her delivery, I would encourage her.(Y,A)1, 4
42. _____ Time and scheduling pressures affect the way I manage labor and delivery.(B) Reversed
43. _____Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.(K)34

44. _____Episiotomies increase the risk of third and fourth degree tears.(K)5, 16, 17

45. _____Clinical guidelines are overly rigid and difficult to adapt to individual patients.(B)25 Reversed

How often do you consult the following sources regarding obstetrical practice?

[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!

Reference List

(1) Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008 November;199(5):445-54.
(2) ACOG Committee Opinion No. 394, December 2007. Cesarean delivery on maternal request. Obstet Gynecol 2007 December;110(6):1501.
(3) Reime B, Klein MC, Kelly A et al. Do maternity care provider groups have different attitudes towards birth? BJOG 2004 December;111(12):1388-93.
(4) Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007;(3):CD003766.
(5) Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Jr., Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005 May 4;293(17):2141-8.
(6) ACOG Practice Bulletin. Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Obstet Gynecol 9 A.D. July.
(7) Gunnervik C, Sydsjo G, Sydsjo A, Selling KE, Josefsson A. Attitudes towards cesarean section in a nationwide sample of obstetricians and gynecologists. Acta Obstet Gynecol Scand 2008;87(4):438-44.
(8) NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens State Sci Statements 2006 March 27;23(1):1-29.
(9) Green J, Amis D, Hotelling BA. Care practice #3: continuous labor support. J Perinat Educ 2007;16(3):25-8.
(10) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK. Physicians’ beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. CMAJ 1995 September 15;153(6):769-79.
(11) Hyer R. ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates. MedScape Medical News 2009 May 9.
(12) Florida Liability Lowdown. American College of Obstetricians and Gynecologists; 2009 Aug.
(13) Gupta JK, Hofmeyr GJ. Position for women during second stage of labour. Cochrane Database Syst Rev 2004;(1):CD002006.
(14) Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev 2007;(4):CD006167.
(15) Low LK, Seng JS, Murtland TL, Oakley D. Clinician-specific episiotomy rates: impact on perineal outcomes. J Midwifery Womens Health 2000 March;45(2):87-93.
(16) ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol 2006 April;107(4):957-62.
(17) Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009;(1):CD000081.
(18) ACOG Practice Bulletin No. 107: Induction of Labor. Obstet Gynecol 2009 August;114(2 Pt 1):386-97.
(19) Wei SQ, Luo ZC, Xu H, Fraser WD. The effect of early oxytocin augmentation in labor: a meta-analysis. Obstet Gynecol 2009 September;114(3):641-9.
(20) Lyerly AD, Mitchell LM, Armstrong EM et al. Risks, values, and decision making surrounding pregnancy. Obstet Gynecol 2007 April;109(4):979-84.
(21) Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. Changing policies on vaginal birth after cesarean: impact on access. Birth 2007 December;34(4):316-22.
(22) Coleman VH, Erickson K, Schulkin J, Zinberg S, Sachs BP. Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists. J Reprod Med 2005 April;50(4):261-6.
(23) Bettes BA, Coleman VH, Zinberg S et al. Cesarean delivery on maternal request: obstetrician-gynecologists’ knowledge, perception, and practice patterns. Obstet Gynecol 2007 January;109(1):57-66.
(24) Wu JM, Hundley AF, Visco AG. Elective primary cesarean delivery: attitudes of urogynecology and maternal-fetal medicine specialists. Obstet Gynecol 2005 February;105(2):301-6.
(25) Vinker S, Nakar S, Rosenberg E, Bero-Aloni T, Kitai E. Attitudes of Israeli family physicians toward clinical guidelines. Arch Fam Med 2000 September;9(9):835-40.
(26) Difranco JT, Romano AM, Keen R. Care Practice #5: Spontaneous Pushing in Upright or Gravity-Neutral Positions. J Perinat Educ 2007;16(3):35-8.
(27) Gilder K, Mayberry LJ, Gennaro S, Clemmens D. Maternal positioning in labor with epidural analgesia. Results from a multi-site survey. AWHONN Lifelines 2002 February;6(1):40-5.
(28) ACOG Committee Opinion No. 395. Surgery and patient choice. Obstet Gynecol 2008 January;111(1):243-7.
(29) Fenwick J, Gamble J, Hauck Y. Reframing birth: a consequence of cesarean section. J Adv Nurs 2006 October;56(2):121-30.
(30) Goodall KE, McVittie C, Magill M. Birth choice following primary Caesarean section: mothers’ perceptions of the influence of health professionals on decision-making. Journal of Reproductive and Infant Psychology 2009 February;27(1):4-14.
(31) Simpson KR, Thorman KE. Obstetric “conveniences”: elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions. J Perinat Neonatal Nurs 2005 April;19(2):134-44.
(32) Helewa ME. Episiotomy and severe perineal trauma. Of science and fiction. CMAJ 1997 March 15;156(6):811-3.
(33) Block J. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. New York: Da Capo Press; 2007.
(34) ACOG Practice Bulletin #54: vaginal birth after previous cesarean. Obstet Gynecol 2004 July;104(1):203-12.

Reply turned post, failed induction style

I wrote a reply on Amy Romano’s Science & Sensibility blog for Lamaze International. (By the way, wish me luck. I am trying to finagle a way to go hear her speak at the Lamaze Annual Conference.) She wrote a post asking if there was any profession guidelines to determine when an induction has failed.

I didn’t find anything on how to determine if they are way too off the Friedman Curve (which is a pile of junk as a guideline anyway, but that’s a whole ‘nother post). The other reason I would think an induction would fail would be fetal intolerance to the augmentation or induction agents, due to hyperstimulation. This is associated with both Cytotec and Pitocin, from what I understand.

Here is my reply:

There is some information in ACOG’s Practice Bulletin #106 on Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General management Principals. But, I don’t think it is exactly what you are looking for or anywhere near adequate.

At some point in the bulletin, the authors state that the term “hyperstimulation” and “hypercontractility” should be abandoned (both would be used to describe one of the complications of an induced labor). They prefer the term “tachysystole”. This is first of two times there is even a sideways referral to induction / augmentation of labor. They write: “The term tachysystole applies to both spontaneous and stimulated labor. The clinical response to tachysystole may differ depending on whether contractions are spontaneous or stimulated.”

Well, spontaneous onset of labor can still lead to stimulated contractions, since there is a difference between induction and augmentation. Induction usually involves continuous augmentation, and both can lead to hypercontractility and/ or tachysystole, but they should not be grouped together as if they were synonymous. The terms “induction” and “augmentation” do not appear in the document.

In fact, it does not appear in the section on patients who are “high risk” and should be candidates for continuous external fetal monitoring as opposed to intermittent monitoring. As far as I know, almost every labor and delivery unit in hospitals, even ones that allow intermittent monitoring, say augmentation with Pitocin mandates continuous external fetal monitoring. Well, not in this practice bulletin.

Neither do the words “Pitocin”, “Oxytocin” or “Cytotec” or “Misoprostol” show up anywhere in the document, for that matter. Interestingly, the section on drugs that may influence fetal heart tones has a noticeable lack of any of these induction or augmentation agents.

But, even more interestingly, the very first recommendation under the section on what can be done with non-reassuring (Category II or Category III) tracings is “Discontinuation of any labor stimulating agent.”

Really? Why would that be? Because according to the list of agents we should suspect, none of those agents have a high index of suspicion for affecting fetal heart tones. But, someone seems to think they have enough of an effect that the very first recommendation is that they should be immediately suspended.

You are also supposed to check her labor progression (dilation, effacement, station, etc). What to do with this information? Not a word.

And then what? Has the stimulation (which may be an induction) failed? Do you proceed to cesarean? Do you allow the drug to wash out and hope the fetus will recover with other techniques of intrauterine resuscitation? They discuss using tocolytic agents and beta agonists and amnioinfusion. I would think amnioinfusion would not be done if a cesarean was imminent.

Anyway, they talked around failed induction a lot without ever actually discussing it.