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.

1 Comment

Filed under Uncategorized

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.

3 Comments

Filed under Uncategorized

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!

5 Comments

Filed under Uncategorized

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.

4 Comments

Filed under Uncategorized

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.

5 Comments

Filed under Uncategorized

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.

29 Comments

Filed under Uncategorized

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.

1 Comment

Filed under Uncategorized