Reply turned post, whoops, I did it again

OK, I am supposed to be working on my chapter for Our Bodies, Ourselves. But some how I ended up commenting on a comment thread that was being derailed (surprise, surprise) by Dr. Amy. It may OK (or worse, somehow?) because the blog I was posting on was of one of the editors of the book, Amy (no relation to Dr. Amy) Romano’s Science and Sensibility. The original post is by Henci Goer, and is about the woman who coded during labor immediately following her epidural, and she and her baby were “miraculously” saved.

Dr. Amy has, predictably, turned this into a condemnation of homebirth. She also accused another poster of a so called “fallacy” of the “lonely fact”, claiming episiotomy was the only little mistake modern obstetrics has ever made.

I replied. Now, back to work, I swear! *Scurries off*

Dr. Amy, (sigh, can’t believe I am doing this)

“Modern” obstetrics has also had routine high forceps deliveries with an episioproctotomy (what an older academic ob/gyn I know said was the norm when he trained…and he still sees it as an ideal), twilight sleep, DES, thalidomide, enemas, shaving, banning family support from the room…need I go on?

Modern obstetrics is not infallible, and does better when it is examined critically. Dr. Archie Cochrane started what ended up being the Cochrane Database because he thought obstetrics was so poorly based on evidence. It is not infallible. Its history of problems is not a “lonely fact”. Why does examining obstetrics critically scare you so much?

If you are interested in logical fallacies, you should look up “Straw man arguments”. I have mentioned this habit of yours to you previously, a few times.

The original post is about a major complication of epidural (intubation is a big deal) whose absolute risk is higher, yet very similar to that catastrophic (leading to fetal death) uterine rupture during VBAC, which you have repeatedly called too risky.

Who is distorting risks again? Both are absolute risks (of the eligible population) of less than 1 in 1000 (the catastrophic rupture risk is 1 in 2400). Epidurals are a lot more common than VBACs. However, there are other documented medical benefits to trial of labor with VBAC, and other documented risks to repeat cesareans, and other risks to childbirth, period. Is there documented risks to not getting an epidural? Is there documented medical benefit to getting one?

There are a lot more risks to epidural anesthesia than a high blockade. I am not saying they should be banned. I am arguing for it to be treated like an elective medical procedure with risks. It’s not a radical proposal. Why do you have to pretend it is? It should not be a moral crusade on either side.

I have personally sat through several cases of so called “informed consent” for an epidural when the entire explanation of risks was “it won’t hurt you or your baby.” I had an anesthesiologist storm off when I asked how common blood pressure drops are, in his experience. I was honestly trying to reassure the couple, who were there on a homebirth transfer and were terrified of the epidural, and were specifically worried about the blood pressure issue. I expected the anesthesiologist to say he does these all the time, and the women were generally fine. I guess he didn’t want to say that to them. I can’t guess his reasons why.

Look, these are anecdotal studies, but what is your point, Dr. Amy? Obstetrics, doctors, anesthesiologists and midwives are not infallible. Obviously there are different opinions out there on how to improve obstetrics. I know we don’t see eye to eye, but downplaying the very real risks of epidurals is not going to improve obstetrics, especially if it’s only to make it fit in with your point of view to what are acceptable risks (interventions that increase the control balance to the physician) as opposed to unacceptable risks (increasing the autonomy of the patient).

Reply turned post, parenting judgment style

I used to write more about mom on mom judgment than I do now. But, every now and then I see a conversation online, and it brings me back into the common discussion of what is acceptable to “judge” and what is not.

On PhD in Parenting, this conversation comes up every once and again, and it did on this post on parenting styles on vacation.

Here is my reply to the cries of “don’t be so judgmental!”:

I think there is a fat line between mommy judgment and deciding which parenting tactics aren’t for you.

I hate it when I see parents yelling at their kids, repeatedly, for doing something when they could get up and do more effective disciplining up close, but are too busy with their own texting or book or conversation that they don’t want to bother. Know where it’s worse? On a school playground. With both of my kids, I observed the playground first before choosing a preschool. If the adults huddled in a corner and yelled at the kids from afar, and missed acts of aggression, you betcha my kid didn’t go to preschool there.

But, I am not condemning parents who I see do that once as “bad parents”. I am not condemning the adults (teachers, teacher’s assistants, whatever) at the preschool [where] I saw this as awful teachers. In fact, I use this “judgment call” “opinion” or whatever you want to call it to catch myself, too. If I am doing something similar, like yelling at my kids repeatedly from my keyboard (who me? never…), I will think “You’re doing that thing you hate” and hopefully get off my tuchus and discipline more kindly AND effectively.

Are we really defending screeching at children from afar? Of course, a parent may have a hurt foot or a disability. Of course, a child may have an immune disorder, and may need stuff wiped down. I am the type of person to travel with snacks, but mostly because 1. the food at resort style places is obnoxiously expensive and 2. it’s usually pure crap. Do I judge parents who let their kids eat it? No, when I can afford it, I splurge a little and relax my standards for my kids. Are we talking about kids with severe allergies here who need their own food? No. And, again, I would never use that as some sort of end-all-be-all judgment of the quality of parenting.

We aren’t talking about exceptions, we’re talking about parenting choices, here. Screeching from afar = poor discipline, and I don’t feel overly judgmental saying that.

I was stuck in a long line at DisneyWorld once next to a mom who had just gotten out of a tour in Iraq. She was with her young son, who was the same age as my older son at the time. I still remember to this day the nasty and sarcastic way she talked to her son the whole time we stood next to each other, and it was the good part of an hour.

I have no idea what it is like to leave your child for a tour of duty in a war. Just thinking about it, and I do often, because I am a ruminating bleeding heart like that, makes me want to weep for our society. I cannot imagine what it would be like coming home and having to reconnect with a child, while dealing with all of the complex feelings and guilt. I am not judging this woman as a parent. What I do know is that the experience in the line for a mere 45 minutes of their life was excruciating to me, and it broke my heart for the boy.

She could be a great parent. I am not saying I am a better parent. I am not saying that I haven’t been bitingly sarcastic or nasty to my children, or that you couldn’t play back a recording of some things I’ve said that would make me cringe. Or that could easily be torn apart on a blog.

There may have been some problematic points in the original post in which she seemed to be guessing at motivations for the behavior, and I can see how that could rub someone the wrong way. But, criticizing screeching, or valuing a scheduled feeding for an infant who is howling on an airplane over just feeding the poor thing, is just looking at a snapshot of an action and reacting. It’s not mommy wars, in my book, and leaves room for a defense of such choices without name calling.

Reply turned post, Academic thoughts on VBAC style

One of my favorite new blogs, Academic OB/GYN, has an interesting post up called Ten Thoughts on VBAC. I encourage you to read the entire post and comment thread. I was especially interested in #7 and #10, which said:

The single most important thing we can do to deal with VBAC issues is to not have them at all, by avoiding the first cesarean section. Many cesareans are absolutely necessary, but when possible we should achieve vaginal deliveries. I’m willing to push some grey cases that others might deliver by cesarean. Sometimes that means being more patients with a slow labor. Sometimes that means operative vaginal delivery. Because of that, more of my patients will have easy multiparous second labors rather than having to worry about VBAC issues. There is a receiver operator curve for cesarean necessity. Most OBs should push their needle a little towards “specificity”.

Here is my reply:

Thanks for a thoughtful post on a controversial issue.

When I selected an article on VBAC for our medical school ob/gyn interest group journal club, our faculty sponsor said we shouldn’t even waste our time, since no one is doing them any more. That is certainly true for our area, where most practices and hospitals refuse to allow trial of labor attempts for VBACs. We are hardly rural. I know of an ophthalmologist who had to hire a concierge obstetrician and pay $10,000 up front to get any obsterician to attend her VBAC. She had one prior successful spontaneous vaginal delivery and a cesarean for twins. Practice patterns are obviously not the same everywhere, especially when it comes to obstetrics. She had her cesarean in another part of the country, and was assured by her obstetrician that she would be a fine candidate for a future VBAC attempt. If she hadn’t moved, it probably wouldn’t have been an issue.

I have another local friend whose physician refused to attend a VBAC attempt she requested (her prior pregnancy ended in preeclampsia, a failed induction and a cesarean at full term). When she showed up a few days before her scheduled cesarean in spontaneous labor, they sectioned her anyway, even though an article in that month’s Green Journal found that emergent cesarean after onset of labor to be the most expensive choice in their study of VBAC with the worst maternal and fetal morbidity. Why not let her attempt the trial of labor, especially since she expressly asked to be able to do so, and prominent medical opinion found it to be not only a reasonable choice, but an easily defensible one?

And, the area primary cesarean rate, which is above 45% in most hospitals, means that less of our primips are “successful” at an attempted vaginal delivery (I put “success” in quotes because I think a safe delivery, even if by cesarean section, is still “successful”) than even the conservative estimates you quote as “success” rates for VBAC attempts in the original post in point #7. (I have usually read of a “success” rate of about 75% in several articles, but outcomes vary.)

But, ACOG’s Practice Bulletin on VBAC says women who are good candidates should be offered a trial of labor. And, practice patterns vary in different parts of the country, and many physicians and hospitals still offer VBACs, and the current literature seems to consider it to be a reasonable option and continues to publish articles on VBAC. But, when I did a history on a woman switching care to a midwife in her third trimester, she said her doctor told her he’d refer her to a psychiatrist before he’d let her attempt a VBAC. So, there’s obviously a wide range in opinions on how to interpret the risks.

This article on explaining obstetrical risk by Lyerly et al is one of my favorite articles I have read on the topic. It states that “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.” (Emphasis mine)

I think that indicated that there is some validity to the argument that anywhere that it is safe to allow a premip to labor and deliver, it should be safe to allow a good candidate to attempt a VBAC. However, some may disagree about where it is safe to deliver at all. Some may find the risk of a home birth not only acceptable but preferable to a medicalized birth experience. Others may only be comfortable with a delivery at a facility with on site 24 hour anesthesia and obstetricians, and a Level IIIC NICU.

I don’t want to paint all obstetricians with one brush, but neither do I want to disregard the possibility that out of hospital births can be safe. Well managed out of hospital births may have risks similar to real obstetrical care in many hospitals, which unfortunately is not always evidence based care optimizing good outcomes. But, women are not always given an unbiased view of true risk, whether it be the risks of a HBAC or the risks of an induced, augmented VBAC attempt or the risks of repeat cesareans. The Lyerly article concludes that “[T]hese 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” when discussing the way obstetricians present these risks. I think the natural birth community can probably be equally possible of have members on the fringes who would de-emphasize the risks of a home birth VBAC or an unassisted VBAC.

Reply turned post, second verse, same as the first

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

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

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

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

Dr. Amy’s response:

MomTFH:

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

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

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

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

Here is my reply

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

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

Here is a quote from Up to Date:

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

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

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

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

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

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

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

Do you agree?

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

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

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

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

Reply turned post, did I say walk away?

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

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

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

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

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

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

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

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

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

Reply turned post, need to walk away style

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

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

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

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

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

Anyway, here was my reply:

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

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

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

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

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

Here is a quote:

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

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

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

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

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

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

Sigh.

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

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

So, here is my next reply:

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

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

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

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

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

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

Oh, one more:

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

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.

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.