Moving during labor
Amy at Lamaze’s Science and Sensibility is hosting the second Healthy Birth Blog Carnival. This one is about Lamaze’s Second Healthy Birth Practice: Walk, move around, and change positions throughout labor.
Amy did a great job explaining how natural birth advocates are constantly asked to prove that what is physiologically normal, like being free to move during labor, is better than an intervention, when it should be the other way around. Here’s a great quote from her anticipatory pre-carnival post:
Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice. While many of us believe that encouraging a laboring woman to move when and how she wants to is healthier and safer than making her stay in bed, waiting for evidence that it produces better health outcomes is putting a burden of proof on normal birth that has never been applied to routine intervention. Besides, lack of evidence of harm, less pain, and maternal satisfaction are valid and important outcomes in and of themselves, and provide the justification we need to reject routine policies and practices that restrict maternal movement.
I had a similar argument with a commenter on this post. Many elective cesarean advocates seem to want to present vaginal birth and cesarean birth as two equal options, not a physiologically normal event and an intervention.
So, since Amy already handled this angle well, I am going to talk about my own experience, and give a little advice at the end.
When I had my first child, I thought I was well informed. Hell, I had read every page in What to Expect When You’re Expecting. I read Mothering and Parenting magazines (both sides!), hired a midwife, took a childbirthing class, and thought I would have a “natural birth” as long as there wasn’t any unexpected emergencies.
Well, soon after I arrived at the hospital, I was told they didn’t have a birthing tub (I never thought to ask ahead of time, dangit) but I was told I could labor in the shower. After the shower, which was probably 20 minutes at the most, I was told I needed an IV with Pitocin. I had no idea what that was, but since my midwife recommended it, and everyone knows midwives always favor natural births over interventions, I didn’t even think of refusing. Well, I was told as soon as the Pitocin was started that I needed to be on continuous external fetal monitoring. Huh? Then, my midwife told me I had to stay in my bed(!!!), since the baby was showing signs of distress. I was not told before being administered the Pitocin that it would require being tethered to the machine, and I wasn’t told it may cause fetal distress, even after my fetus was apparently diagnosed with fetal distress. I wasn’t even told it may not be necessary, considering I had only been in active labor for about an hour when it was administered.
Fast forward several hours and I was flat on my back, pushing too soon, leading to a swollen cervix. No, no alternate positions were encouraged for my three hours of pushing, either.
So, my advice? Ask your practitioner(s), ahead of time, what their positions are on intermittent monitoring and movement in labor. Don’t just assume that what seems basic and normal will be encouraged or allowed.
More on fat bias and pregnancy
Jill at The Unnecessarean linked to this frustrating but great birth story at My Best Birth. “A Curvy Gal’s fight for a Natural Childbirth” is full of head exploding details, such as baseless threats from her midwife, recommendations for risky procedures with a lack of adequate informed consent, and suggestions of medical approaches that would actually increase the risk of adverse outcomes, not decrease them.
Here is a choice quote:
After some research, I called my midwife to say that I did not want a Miso induction, and that I wanted to wait and go into labor spontaneously. She said, “Well, in my experience, women with BMIs higher that 26 tend to have cervixes that won’t dilate without chemical induction.” Okay—first I was being pressured into induction because of the increased risks of a long gestation to m y baby and NOW she’s saying that because I am a curvier gal, my body is somehow clueless about giving birth (by the way, I had NO other risk factors in this pregnancy—no gestational diabetes, no elevated blood pressure, etc) I have since searched high and low for ANY medical study that supports her belief and have come up with nothing. I argued with her that I’d like to give my body the chance to go into labor on its own—at least through the weekend (agreeing to the postponed induction with the foly (sic) catheter instead). She was condescending and doubtful, but ultimately said it was up to me.
Rrrrrrgh.
The good news is that she did her research, refused the inductions, and ended up going into labor spontaneously and having a quick and easy birth.
White fat, black art
A Canadian friend recommended the show White Coat, Black Art from CBC Radio. I have enjoyed several of the shows. There’s one on burnout, which is supposedly worst in ob/gyn. She wanted me to listen to the show on obesity. (Link to mp3 of “Fat Doctors”.)
I was kind of napping while I listened, but I played it twice and I think I got most of it. I think they thought they were showing “both sides of the issues” by having advocates for bariatric surgery, and someone who lost weight through diet and exercise. But, it was a very judgmental show. No one argued that not all obese people need to be fixed, either with surgery (which they started the show with) or diet and exercise, which the other two segments suggested.
I was struck by some of the people in the support group. Like, the one who was talking about how you could never tell a heroin addict to just take it 3 times a day in small amounts, but we expect people with food issues to self regulate food consumption. I am happy the doctor at the bariatric center emphasized that no one chooses to be morbidly obese, and no one gets morbidly obese by making poor choices.
I also kind of related to the doctor at the end who talks about being overweight and struggling with weight loss and her self image, which I am sorry to say. I feel a lot of self hate and guilt (and I have gained even more weight. I am afraid to weigh myself.)
I loved it when she said she secretly thinks “I would hate to live like that” when people give her weight loss advice and discuss strict, boring diets. I admit, people tell me about getting their “butts kicked” by their spinning instructor, and it makes me wonder if sedentary life isn’t worth it. But, I felt better about myself when I was in better shape. I like many types of exercise. It doesn’t hurt to fit in my clothes, either.
I guess it made me feel a lot of self hate, but I didn’t realize it at the time, because I am surrounded by that attitude constantly. I was just reading a maternal mortality review (pdf) today, and they were analyzing trends of BMI and maternal complications. But, I know this is a multi faceted issue. Obese women get more unnecessary interventions, including more inductions and more cesarean sections. And, the maternal mortality rate is much higher for African American women, who are more likely to be obese when of childbearing age.
I am afraid I may get passed over for a residency spot because I am obese. Spots are competitive, and are based on interviews and personal interactions with people on the team at the site. I know some people don’t think obese people make good doctors, some people think a person who is forty and obese may not be a good investment for four years, since I may succumb to some sort of fat complication, die young, and be a waste of their training. And even more people have unconscious negative reactions to fat people. We do worse in interviews, period.
Anyway, thanks for the recommendation. It was definitely worth the listen and gave me a lot to think about.
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.
Laughing while my head explodes
I don’t know if the entries at My OB said WHAT?!? are more funny or head-exploding inducing. I sputter and smile simultaneously with each one.
I think my favorite so far is this one: “Your baby may end up being retarded if we don’t do this test” was one nurse’s way of performing informed consent about a fasting blood sugar test.
Lamaze blog carnival is up
The first Healthy Birth Blog Carnival is up: Let Labor Begin on Its Own. This is the first of six blog carnivals based on the Six Lamaze Healthy Birth Practices. I am hoping to submit an entry for each one.
I still have to read all of the entries for this one. This is a perfect first practice, since it happens at the beginning of labor. I have read up to 40% of labors are induced now.
The induction is the gateway to what is commonly referred to as the “cascade of interventions” that eventually lead to a cesarean section in many deliveries. When a woman is induced, she may be given Pitocin, and her water may be intentionally broken. The labor augmentation drug Pitocin, along with some induction drugs, like Cytotec (misoprostol) usually cause stronger contractions. That’s their point, but these contractions can be stronger and more painful than early labor would be, which makes pain relief measures like opiates or epidurals more likely.
Most hospitals include Pitocin augmentation and/or induction in their list of conditions that require continuous monitoring. Having ruptured membranes usually starts a clock ticking that limits how long this avenue of infection can be open. Depending on hospital protocols, this may be 12 hours or 24 hours, and then the woman is given a cesarean section for “failure to progress”.
Or, the Pitocin is turned up to make contractions that didn’t start on their own exist, and the fetus goes into distress, and the woman is rushed to have a cesarean section.
Or, if the woman does progress to the pushing stage, as the my link in the carnival suggests, Pitocin can contribute to shoulder dystocia.
Anyway, letting labor begin on its own means the fetus and the woman’s body are both ready for the birth process. Go check out the carnival.
CIMS response to The Today Show
The Coalition for Improving Maternity Services has written a fantastic response (pdf) to the horrid hit job disguised as journalism that was the Today Show’s The Perils of Midwifery (link to video) . I am reposting it here:
Sept. 23, 2009
Dear Producers of The Today Show,
The Coalition for Improving Maternity Services (CIMS) and the undersigned organizations are disappointed with The Today Show’s misrepresentation of midwives and home birth that aired on Sept. 11, in a segment titled “The Perils of Midwifery,” later changed to “The Perils of Home Birth.” This biased and sensational segment inaccurately implied that hospitals are the safest place to give birth even for low-risk women and mischaracterized women who choose a home birth with a midwife as “hedonistic,” going so far as to suggest that these women are putting their birth experiences above the safety of their babies. Neither could be further from the truth.
Unfortunately, The Today Show did not do its homework on the evidence regarding the safety of home birth and midwifery care. The segment featured an obstetrician who presented only the American College of Obstetricians and Gynecologists’ (ACOG) position in opposition to home birth, but it did not make any attempt to present the different viewpoints held by the many organizations that are committed to improving the quality of maternity care in the US. We are deeply saddened that the show did not take the opportunity to note that both CIMS and The National Perinatal Association respect the rights of women to choose home births and midwifery care, and that the respected Cochrane Collaboration recommends midwifery care because it results in excellent outcomes.
There is no evidence to support the ACOG position that hospital birth for low-risk women is safer than giving birth with midwives at home. What the research does show is that the routine use of medical interventions in childbirth without medical necessity can cause more harm than good, while also inflating the cost of childbirth. However, the current health system design offers little incentive for physicians and hospitals to improve access to maternity care practices that have been proven to maximize maternal and infant health.
“Birth is safest when midwives and doctors work together respectfully, communicate well, and when a transfer from home to hospital is needed, it is appropriately handled,” says Ruth Wilf, CNM, PhD, a member of the CIMS Leadership Team.
That is why the national health services of countries such as Britain, Ireland, Canada, and the Netherlands support home birth. In those countries, midwives are respected and integrated into the maternity care system. They work collaboratively with physicians in or out of the hospital, and they are not the target of modern day witch hunts. These countries have better outcomes for mothers and babies than the US.
Childbirth is the leading reason for admission to US hospitals, and hospitalization is the most costly health care component. Combined hospital charges for birthing women and newborns ($75,187,000,000 in 2004) far exceed charges for any other condition. In 2004, fully 27% of hospital charges to Medicaid and 16% of charges to private insurance were for birthing women and newborns, the most expensive conditions for both payers. The burden on public budgets, taxpayers and employers is considerable.
As US birth outcomes continue to worsen, it should come as no surprise to The Today Show that childbearing women are seeking alternatives to standard maternity care. After all, American women and babies are paying the highest price of all—their health—for these unnecessary interventions, which include increasing rates of elective inductions of labor and cesarean sections without medical indication.
To the detriment of childbearing families, the segment “The Perils of Midwifery” totally disregarded the evidence. Although the reporters acknowledged that research shows home birth for low-risk women is safe, that message was overshadowed by many negative messages, leaving viewers with a biased perception of midwifery care and home birth. CIMS makes these points not to promote the interests of any particular profession, but rather to raise a strong voice in support of maternity care practices that promote the health and well-being of mothers and babies.
One of the ten Institute of Medicine recommendations for improving health care is to provide consumers with evidence-based information in order to help them make informed decisions. The Institute recommends that decisions be made by consumers, not solely by health care providers. The Institute maintains that transparency and true choice are essential to improving health care. We remain hopeful that the medical community will soon recognize the rights of childbearing women when it comes to their choices in childbirth and will respect and support these choices in the interest of the best possible continuity and coordination of care for all.
We urge The Today Show to provide childbearing women with fair and accurate coverage of this important issue by giving equal time to midwives, public health professionals, researchers of evidence-based maternity care, and especially to parents who have made choices about different models of care and places of birth.
Sincerely,
Coalition for Improving Maternity Services
Academy of Certified Birth Educators
Alaska Birth Network
Alaska Family Health and Birth Center
American Association of Birth Centers
American College of Community Midwives
American College of Nurse-Midwives
Bay Area Birth Information
Birth Network of Santa Cruz County
Birth Works International
Birthing From Within, LLC
BirthNet
BirthNetwork National
BirthNetwork of Idaho Falls
BirthNetwork of NW Arkansas
Choices in Childbirth
Citizens for Midwifery
Doulas Association of Southern California
Evansville BirthNetwork
Harmony Birth & Family
Idaho Midwifery Council
Idahoans for Midwives
InJoy Birth and Parenting Education
International Childbirth Education Association
International MotherBaby Childbirth Organization
Island Families of Micronesia
Lamaze International
Madison Birth Center
Midwives Alliance of North America
Motherbaby International Film Festival
Nashville BirthNetwork
National Association of Certified Professional Midwives
North American Registry of Midwives
Ohana Island Care-Guam
Oklahoma BirthNetwork
Our Bodies Ourselves
Perinatal Education Associates, Inc.
Reading Birth & Women’s Center
Rochester Area Birth Network
Sage Femme
The Big Push for Midwives Campaign
The Tatia Oden French Memorial Foundation
Triangle Birth Network
Truckee Meadows BirthNetwork
About Us
The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and wellbeing of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. The CIMS Mother-Friendly Childbirth Initiative is an evidence-based mother-, baby-, and family-friendly model of care which focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.
References:
1. The Perils of Home Births, http://www.msnbc.msn.com/id/21134540/vp/32795933#32795933
2. Birth Can Safely Take Place at Home and in Birthing Centers, http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2409129&blobtype=pdf
3. Offers All Birthing Mothers Unrestricted Access to Birth Companions, Labor Support, Professional Midwifery Care, http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2409134&blobtype=pdf
4. ACOG Place of Birth Policies Limit Women’s Choices Without Justification and Contrary to the Evidence, http://childbirthconnection.com/article.asp?ClickedLink=790&ck=10465&area=27
5. Ratifiers and Endorsers of The Mother-Friendly Childbirth Initiative, http://www.motherfriendly.org/ratifiers.php
6. Choice of Birth Setting, http://www.nationalperinatal.org/advocacy/pdf/Choice-of-Birth-Setting.pdf
7. Position Statement on Midwifery, http://www.nationalperinatal.org/advocacy/pdf/Midwifery.pdf
8. Midwife-led versus other models of care for childbearing women, http://cochrane.org/reviews/en/ab004667.html
9. Evidence-Based Maternity Care: What It Is And What It Can Achieve, http://childbirthconnection.com/pdfs/evidence-based-maternity-care.pdf
10. Lamaze Healthy Birth Practices, http://www.lamaze.org/ChildbirthProfessionals/ResourcesforProfessionals/CarePracticePapers/tabid/90/Default.aspx
11. Millennium Development Goals Indicators, United Nations, http://mdgs.un.org/unsd/mdg/Data.aspx
12. National Vital Statistics System, Birth Data, http://www.cdc.gov/nchs/births.htm
13. Induction By Request, http://www.marchofdimes.com/prematurity/21239_20203.asp
14. Cesarean Birth By Request, http://www.marchofdimes.com/prematurity/21239_19673.asp
15. Crossing the Quality Chasm: A New Health System for the 21st Century, http://www.iom.edu/CMS/8089/5432.aspx
16. The Mother-Friendly Childbirth Initiative, http://www.motherfriendly.org/mfci.php
The KALI questionnaire
This is the survey on labor interventions that will be my research project for my fellowship. Many of these are taken from other studies, position statements, practice bulletins, and meta-analysis conclusions. There is also a demographics and practice description portion of the questionnaire, which I did not include in this post. The target population will be practicing ob/gyns in a certain geographical area. Please let me know what you think.
Keep in mind that the question are supposed to be mixed to prevent bias based on how they ordered are in conjunction with other questions on the same topic, and they are mixed in positive and negative phrasing, and mixed in whether they are talking about practice, knowledge, attitudes or future intentions.
Here it is:
Please rate the following statements about obstetrics as accurately as possible. All questions will have this scale available for you to choose to most appropriate response:
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.
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. Insurance should not reimburse use of doulas for labor and delivery.
8. I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used.
9. Fear of liability claims limit the options I present to my obstetrical patients.
10. Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes.
11. The use of continuous EFM does not result in a reduction of cerebral palsy.
12. All women in labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact.
13. Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.
14. I regularly employ episiotomy to shorten the second stage of labor and delivery.
15. Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.
16. Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.
17. The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.
18. Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.
19. I regularly employ episiotomy to prevent pelvic floor relaxation.
20. If you or your partner were pregnant for the first time, would you choose / recommend an elective cesarean delivery for yourself or your partner in the absence of any medical or obstetrical indication?
21. I have made changes to my practice because of the risk or fear of liability claims.
22. Childbirth is only normal in retrospect.
23. I regularly employ episiotomy to prevent perineal trauma.
24. The use of continuous EFM reduces perinatal mortality.
25. I encourage my patients to try alternative or upright positions during the pushing stage.
26. Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care.
27. I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.
28. Women should have the right to refuse an episiotomy.
29. I encourage patients to use a doula for their labor and delivery.
30. 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.
31. There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.
32. Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.
33. I discuss the risks and benefits of episiotomies with my patients prior to delivery.
34. Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery.
35. Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.
36. Episiotomies increase the risk of third and fourth degree tears.
37. Clinical guidelines are useful tools for me in daily clinical practice.
38. Clinical guidelines are overly rigid and difficult to adapt to individual patients.
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 ____________________________
Research progress
I have been hard at work coming up with my questionnaire for my survey of local obstetricians and gynecologists about birth interventions. I am planning on posting the completed survey when I am finished, unless there are some concerns with that. I don’t think any of my subjects read my blog, so I doubt it will add any bias to the results. Besides, it’s not like these issues are new to these practitioners. It’s not like a blog post with questions about these interventions will suddenly make them relevant to their practice.
The wording of some of the questions is based on the survey in this study by Reime et al, and many others are taken directly from ACOG position statements, USPSTF evidence based conclusions, and the like.
So far the interventions I will definitely be asking about are:
Doulas (Continuous Labor Support)
Episiotomy
Vaginal Birth After Cesarean (VBAC) and Trial of Labor (TOL) after Cesarean Section
Cesearean Section Without Medical Indication (CWMI) and Cesarean Delivery on Maternal Request (CDMR)
Upright Pushing Stage
Continuous External Fetal Monitoring (EFM) vs Intermittent
Restricting Oral Nutrition During Labor (Solid and/or Liquid)
Interventions that may be included in the survey include:
Estimation of Fetal Weight (EFW) (based on 3rd trimester ultrasound)
Routine Early Amniotomy (Artificial Rupture of Membranes (AROM) )
Oxytocin (Pitocin) Augmentation of Labor
I would like to ask about all of them. We need to make sure the survey is brief enough for the subjects to want to take the time to finish, and I plan on asking multiple questions on each intervention. I think the first list is more directly a balance of evidence based medicine and patient autonomy (which is a much more difficult concept to define than I thought, but that’s a whole ‘nother post). The second list is more practices that lead to the cascade of interventions. For example, oxytocin augmentation usually necessitates continuous EFM.
I didn’t include out of hospital births, even though I think they are an important and relevant point. I wanted to only cover practices under direct control of the obstetrician. That is also why I didn’t include skin to skin contact after delivery. I think that may more depend on the hospital policies and nursing / pediatrics team.
I just need to come up with a few questions about how they keep up with the current standards of care, and then it’s time to whittle it down.
Then, I need to work on my justification. I need to talk about patient empowerment and autonomy without sounding like too much of a militant feminist. Heh, wish me luck with that.
