Tag Archives: Fellowship

Physicians’ attitudes and knowledge influence their practices – who knew?

My data from the KALI questionnaire is shaping up nicely. I guess it isn’t a big surprise, but, at least in the group I have interviewed, their knowledge about and attitudes toward labor and delivery interventions do seem to influence their reported practice patterns. And, as recent research indicates, practice patterns don’t necessarily follow the current body of evidence, expert opinion, or professional organizational guidelines, although many do. As of right now, I will most likely be looking at the associations between obstetricians and gynecologists’ knowledge, attitude, practice, professional guidelines and existing evidence on four interventions: episiotomy, elective cesarean, doulas, and upright positioning in the second stage.

I have more data on more aspects and more interventions, but I think this will make for the cleanest, most easily explained and supported outputs (e.g. poster and paper). I may use some of the other data on barriers, autonomy, VBAC, litigation, demographics, etc., in the future in other projects.

And, since I promised more poop jokes, I’ll have you know I was wandering around the house today singing Surfin’ Bird by the The Trashmen with the word “turd” substituted for bird. Yeah, I’m mature. At least the kids weren’t home, so I won’t be getting that phone call from school.

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Crunch on these while I crunch numbers

I am working on getting my data analyzed by a friendly professor who knows more about that stuff than I do. Chi square mumble mumble. Then, I am going to be hunkering down and working on my paper and/or poster.

I also have other stuff going on in my personal life that is keeping me occupied, to say the least. I’ll try not to be so mysterious forever, but I am not ready to dump it all out on here just yet. Especially when I get comments calling me a broodsow, and wishing a fatal disease on my children and me. Nice. So, I pat myself on the back for keeping a lot of my personal life off this blog.

In the meantime, here is some stuff to check out:

Dr. Fogelson discusses cesarean closure at Academic Ob/Gyn

The Female Patient(pdf), which I just discovered. That particular paper is on estrogen pharmokinetics and delivery.

Last but not least, Drunk History, Vol. 3. This one is about President Washington’s runaway slave Oney Judge.

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Plugging away

Howdy. I am still working on my various projects. Here’s a little update, mostly because I am excited about a few things, not that I think anyone was pining away without me.

First, I got 50 completions on my survey! In fact, the numbers are still climbing since a wonderful gynecologic oncologist I have been working with on other projects sent out an email plea to his colleagues. Thanks! I was originally hoping for around 80, but it has been incredibly difficult to even get past the office staff of most obstetricians. I am happy for 50 – 60. Analysis starts next week!

Secondly, I am happy to be working on writing two projects, including this one, the VBAC primer proposed on Birthing Beautiful Ideas. I am researching and writing the part on the “immediately available” standard. I have already written about before. I am trying not to be too overly academic about it. We’ll see how it turns out. Of course, I am still reading tons of research to write it, of course. I found this New England Journal of Medicine article (pdf) that was supposedly seminal in discouraging VBAC by looking at uterine rupture rates. It is only one cohort from the late 80s and early 90s, but it has some interesting numbers. For the fetal demise due to uterine rupture, the outcome usually brought up as the worst case scenario and the reason why VBAC should not be offered, the rate was 5.5% of all uterine ruptures. And, uterine ruptures only happened in less than 0.5% of uninduced trials of labor after prior cesarean. I do not think this is where Lyerly et al got their 0.00046 rate number for fetal death due to rupture, since they say it was from a prospective study, and I think the NEJM I link to is retrospective. If anyone has more time than me, feel free to follow that trail in various bibiliographies.

And finally, there is still stuff going on in my life outside of birthy fellowship-y stuff. In fact, I am on my way out to do that now. Wish me luck!

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Reply turned post, Cox really showed J.D. this time, zing!

Do you remember when KevinMD gave Dr. Amy a chance to guest post about VBAC?

Well, there was another post about VBAC up simultaneously. Its comment section has devolved into an argument about external fetal monitoring and whether it reduces perinatal mortality.

I am subscribed to the comments on this post, and every few days I get an email telling me these two commenters are still arguing about this, and instead of looking up the evidence, they are trading sarcastic insults and puffing up themselves like Doctor Cox on Scrubs. I finally couldn’t take it anymore and replied:

Oh my MAUDE this is not an episode of Scrubs, you two. It is not hard to look up what you two are fighting around. As witty as your banter may be, it doesn’t change the state of the evidence on external fetal monitoring during labor, which isn’t even the point of the original post.

Here is the ACOG practice bulletin on continuous external fetal monitoring. If you can’t access it (you may need to be a member of ACOG), let me sum it up for you.

In the introduction, it says: (emphasis mine)

Despite its widespread use, there is controversy about the efficacy of EFM, interobserver and intraobserver variability, nomenclature, systems for interpretation, and management algorithms. Moreover, there is evidence that the use of EFM increases the rate of cesarean deliveries and operative vaginal deliveries. The purpose of this document is to review nomenclature for fetal heart rate assessment, review the data on the efficacy of EFM, delineate the strengths and shortcomings of EFM, and describe a system for EFM classification.

Here is what they have to say about its efficacy:

” * The use of EFM compared with intermittent auscultation increased the overall cesarean delivery rate (relative risk [RR], 1.66; 95% confidence interval [CI], 1.30–2.13) and the cesarean delivery rate for abnormal FHR or acidosis or both (RR, 2.37; 95% CI, 1.88–3.00).
* The use of EFM increased the risk of both vacuum and forceps operative vaginal delivery (RR, 1.16; 95% CI, 1.01–1.32).
* The use of EFM did not reduce perinatal mortality (RR, 0.85; 95% CI, 0.59–1.23).
* The use of EFM reduced the risk of neonatal seizures (RR, 0.50; 95% CI, 0.31–0.80).
* The use of EFM did not reduce the risk of cerebral palsy (RR, 1.74; 95% CI, 0.97–3.11). “

And, their complete, unedited conclusions:

Conclusions

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

* The false-positive rate of EFM for predicting cerebral palsy is high, at greater than 99%.
* The use of EFM is associated with an increased rate of both vacuum and forceps operative vaginal delivery, and cesarean delivery for abnormal FHR patterns or acidosis or both.
* When the FHR tracing includes recurrent variable decelerations, amnioinfusion to relieve umbilical cord compression should be considered.
* Pulse oximetry has not been demonstrated to be a clinically useful test in evaluating fetal status.

The following conclusions are based on limited or inconsistent scientific evidence (Level B):

* There is high interobserver and intraobserver variability in interpretation of FHR tracing.
* Reinterpretation of the FHR tracing, especially if the neonatal outcome is known, may not be reliable.
* The use of EFM does not result in a reduction of cerebral palsy.

The following recommendations are based on expert opinion (Level C):

* A three-tiered system for the categorization of FHR patterns is recommended.
* The labor of women with high-risk conditions should be monitored with continuous FHR monitoring.
* The terms hyperstimulation and hypercontractility should be abandoned.

Not really a glowing recommendation.

Hmm, well, maybe ACOG doesn’t like EFM because it is used to sue physicians. Maybe the Cochrane Database has something on it. Oh, wow, it does!

The unedited conclusions:

Authors’ conclusions: Continuous cardiotocography during labour is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography was associated with an increase in caesarean sections and instrumental vaginal births. The real challenge is how best to convey this uncertainty to women to enable them to make an informed choice without compromising the normality of labour.

Continuous external fetal monitoring, as it is being applied as the most common obstetrical intervention used in birth in the United States, has not been proven to improve neonatal outcomes significantly other than a small reduction in neonatal seizures, which are uncommon and transient. It does free up labor nurses to monitor laboring mothers from a nursing station, and it provides a continuous metric that has a false positive rate of about 99%, and is being used to sue physicians. I am sure it is involved in many more malpractice cases against ob/gyns than a trial of labor for VBAC.

It is amazing to me that it is not condemned with the same vehemence as VBACs. It has definite drawbacks that limit the mother’s autonomy and mobility, and I have never met a woman who thought they were comfortable.

That is one of the reasons I included the use of continuous external fetal monitoring in my research, because I am honestly confused about why some interventions and practices are utilized and supported, while others are not.

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So that’s what the IRB is for

I spent most of today editing and tweaking three institutional review board (IRB) new project applications today. If you are not familiar with the loveliness that is the IRB process, it is a bureaucratic pile of red tape and paperwork that you have to navigate through in order to do research at an institution.

I decided to break away from my computer and help S, my eleven year old, with his science fair project. He is going to a science magnet program next year, and supposedly loves science. But, I was disappointed with his proposal – something about stretching chewing gum after chewing it – and came up with a physiology project idea for him. I suggested that he get some friends together, take their resting heart rates, then compare it to their heart rates after various different activities. He and his friends had fun learning how to take their pulses, and then walking three mailboxes down and back, taking it again, then running three mailboxes down and back, then taking it again. We decided to do a bike ride, too.

I am usually really strict about bikes. I don’t let the kids in the neighborhood jump on each others’ bikes, and am a stickler for helmets. But, it didn’t even cross my mind. I thought briefly how maybe I should get permission from their parents, but these kids play football in the street and climb trees every day. I thought running and riding a bike back and forth a few hundred feet, activities they do every afternoon, wouldn’t be a big deal.

Until one of the kids wiped out on the bike, and banged his head on the pavement pretty hard. I ran inside, told my husband to call 911, and called his mom right away.

Well, I went with them to the hospital. The CT scan was negative, but he has a pretty nasty knot on his head. And, he has a broken wrist. Argh. I feel terrible.

I think I’m sticking with surveys.

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Conversations after the survey

I have been doing a recruitment push for obstetricians to take my survey. I originally planned on doing qualitative interviews with some of the physicians, and using them in the discussion. Although I eventually decided to only do quantitative research, I still get to have some really thought provoking conversations with the physicians once they complete the survey.

I have gotten great responses from the obstetricians. Of course, I wait until they have completed it to discuss it, and let them lead the conversation. I don’t want them to think I have enormously strong opinions in any direction. I discuss methodology, survey validation, and sometimes share anecdotes, but don’t make any soap box speeches.

One physician took the survey today, and said he thought it showed a slant toward midwifery. I found this interesting, since there is no mention of midwifery in any of the questions. I asked him what he meant, and he said that the questions about upright positioning and doulas were the sorts of things that midwives would do.

Now don’t get me wrong, I loved talking to this physician. He showed a genuine concern for autonomy of the patient, was not at all interested in forcing procedures on anyone, and thought “we should be humans first and physicians second” when dealing with patients, especially during pregnancy. I told him “In the same vein, we should treat our pregnant patients like mothers first and patients second.” He said he thought the ideal model for maternity care was the cooperative midwifery based model of care in the United Kingdom.

He also said the most important thing to consider is: the mother is leaving and taking her baby home, regardless of the mode of delivery. She lives with the the birth the rest of her life, not the obstetrician. He said yes, you can get sued for 18 years, but he knows, as do most obstetricians, that most cases don’t end up winning if you didn’t screw up. He thinks the litigation issue is an exaggerated scare story, and he has been sued. He said it’s about doing a job well, not an investigation of the essence of your soul, which is how he sees many obstetricians react.

But, as I complained in this post, those exact practices, upright positioning and using a doula, are more evidence based, according to the non-midwifery based United States Preventative Services Task Force, than the other interventions I ask about (continuous external fetal monitoring, routine artificial rupture of membranes in active labor, episiotomy, etc). But, somehow, simply including them in this survey, with no mention of the word midwife once, makes my survey somehow biased toward midwifery.

He didn’t mention the word “bias”, but another physician did mention the word “bias” after taking the study. (The responses have been overwhelmingly positive. Neither of these two physicians found the amount of alleged bias very problematic). I just think it’s strange. The USPSTF, Cochrane reviews, etc. examined the body of literature and then concluded there are evidence based benefits of doulas and upright positioning, but even asking about that seems questionable to some practitioners.

Well, I was setting out to examine the disconnect between evidence and knowledge and attitudes of practitioners. I guess I have found it.

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My KALI research day presentation

Check out my research day presentation of my progress on the KALI research project.

Wish me luck tomorrow. Not sure how many people will be there, but the auditorium holds more than 200. I hope my suit still fits.

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KALI update

The KALI (Knowledge and Attitudes of Labor Interventions) Questionnaire is launched, and I have almost a dozen responses! But, the physicians aren’t beating my door down to take it. I guess I expected that, but it’s intimidating to have to go out and recruit subjects. I am going to be visiting physician’s offices like a drug rep with no food budget, begging for a few minutes of their time.

I loaded my responses into SPSS. I was able to print out frequency charts for the different questions. Fun!!

I am loathe to make any sweeping statements about the responses that I have already received. I have been pleasantly surprised with the variety and balance in the responses so far. I was surprised that one physician selected “strongly agree” that “I would refer out any patient who wants to hire a doula.” Really? I guess I am naive, but I was hoping for more ignorance of doulas than antipathy. Maybe the question is worded poorly – maybe they have a referral list for doulas? Geez, I have got to stop getting hung up on the wording! Well, the first survey is a learning experience. There is one local hospital that has apparently banned doulas recently, so maybe it’s someone who is there?

I think it is OK to talk about the responses so far without jeopardizing the study if I speak generally and don’t overstep. If there were obstetricians in my area who were reading my blog, that would be a very different story. I wonder if any of them are going to google the name of my study and find this. If they’ve already taken the study, I guess it doesn’t matter. This is getting a little meta.

My very small pool of respondents has a good amount who aren’t huge fans of elective cesarean. Most are fine with it, but I am happy to see it is truly a controversial issue, not just among natural birth advocates but practicing ob/gyns in an area with a high cesarean rate. There is also a variety of opinion on restricting food and water during labor, upright positions, and even intermittent monitoring, which is uncommon to nonexistent in most local hospitals. Good. A monolithic response would mean the survey was poorly written.

I am surprised how low the numbers are on institutional barriers to VBAC. I think most of the responses are from one institution so far, though, and it seems they do not have an institutional policy against VBAC. And, neither does their insurance company. But, now that I think of it, the responses I got on practice types and malpractice insurance coverage were varied, so it is probably a varied group of respondents so far. Hmmm. The respondents so far seem to be more comfortable with VBAC in general than I had expected.

Not a lot of episiotomy defenders in the set so far. I was surprised to see how many said they agreed that episiotomy should be avoided at all costs, and that a patient has a right to refuse an episiotomy. The physician who is the course director for Women’s Health at my medical school gave me feedback on my survey, and he said he found that question very provocative. He would have a serious problem with a woman wanting to refuse any episiotomy.

Most of the doctors so far think Pitocin benefits most laboring women. That matches up with practice patterns I have read.

Anyway, I will am doing an oral presentation at our medical school Research Day. I have two weeks to get more responses and put together a power point. If I can get in front of a group and talk about my preliminary results, I can write about them on my blog, right? Ehhhhhh…..

Anyway, this is an unorthodox entry into the Lamaze Healthy Birth Blog Carnival on avoiding interventions that are not medically necessary. Speaking of unnecessary interventions, I’m off to read the new Cochrane review on restricting food and liquid intake during labor. Thanks for posting about it, Amy.

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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!

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Damn damn damn

I’ve grown accustomed….no, just kidding.

No, it’s worse than that. I made 200 copies of my survey, my mentor distributed about 30 copies, and one was filled out by an obstetrician already.

Then, I figured out that there was a major error. A stupid, little, major error that invalidates any results from those copies. I have the scale on the first page of the obstetrics questions set as strongly agree = 1 to strongly disagree = 5. On pages 2 and 3, it is set to strongly disagree = 1 to strongly agree = 5.

Damn.

So, the silver lining is: I wanted to do it as an online survey anyway. We discovered this while converting it to an online survey. So, hopefully only one physician wasted his time filling it out. And, may be ineligible because of retest bias issues.

I hope I don’t look like too much of a dork to these physicians now.

Grumble grumble grumble.

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