Aggressive ob/gyn vs midwife care

[MacGyver]

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You know me, I'm the midlevel hater guy.

However, I'm hard pressed to respond to the many studies out there showing that ob/gyns are way too aggressive about c-sections and that these interventions are associated with higher infant mortality.

yes I know that those studies have lots of confounders and are not ideal, but I want some ammo from the ob/gyns out there.

First off, is there any REAL EVIDENCE that ob/gyns are assigned to higher risk patients at baseline? I'm not talking about shifts from midwife to OB care during pregnancy, I'm talking about funneling before all the pregnancy complications arise. We all know that ob/gyns have higher rates of fetal distress, oligo, etc but its hard to know whether this was related to pre-pregnancy issues or not.

During my ob/gyn rotation, I found that ob/gyns would let a woman "hang out" for a maximum of about 4-5 hours at a certain dilation before deciding that pitocin must be started. Is there any real evidence to back up this practice? Whats the harm in just watching them? I'm talking about babies that are totally fine with no concerning features of fetal distress. Pitocin is associatd with a host of complications and worse outcomes.

EFM is an absolute joke and totally non-validated yet its routine practice. EFM is also associated with increased complications and higher c-section rates (yes I'm aware of the whole "incident to" vs "association" distinction).

Midwives claim they can avoid episiotomies with certain lubricants and stretching maneuvers. Any validity to this claim? Episiotomies are a non-trivial source of morbidity, and my experience is that ob/gyns use them a lot more frequently.

I'm not claming to be an expert in this area, and I'm well prepared to be shot down on these claims. But I need some evidence to fight off these midwives and so far I havent been able to find anything to beat them back with.

 

[hilseb]

This is a good website to start with...

http://www.childbirthconnection.com/

 

[Ypo.]

Have you tried doing a literature search? Most Ob-gyns are going to be too busy to do one for you.

 

[Trillgirl]

Have you tried doing a literature search? Most Ob-gyns are going to be too busy to do one for you.

You're right. I'm not going to do your lit search.

That being said, IMHO (and experience) our patients are older, fatter, with many many more comorbidities than the usual midwife patient AND more than they have ever been before. Therefore, they have more complications during pregnancy and intrapartum.

I have many patients starting their pregnancies over 35, with Type 2 diabetes or chronic hypertension and a starting weight well over 200 lbs. Some have had infertility issues (usu PCOS) and we even have some that have had gastric bypasses. And I am not a perinatologist - I am a generalist.

That being said, our hospital does watch our c/s rates (as an individual, group and hospital), especially our primary section rates. They keep an close eye on what percentage of our elective inductions (too many patients beg for one) turn in to sections. We also have very strict policies about when we can use pitocin and when we can't or it needs to be turned off.

Is it "defensive medicine" to section my patient when the baby has repetitive late decelerations, bradycardia or persistent tachycardia? I don't think so, but I am certainly paying attention to that pesky EFM! If my patient "stalls out" and her MVUs are adequate, yes, I am going to cut her. There is usually a good reason, be it maternal or fetal, why she is not progressing.

Medicine is both an art and a science. And as was pointed out, the "science" of EFMs, etc. is limited. As an attending I try to back up all my decision with science. But sometimes, delivering a baby, and knowing when to "call it" is an art.

BTW, there was a good article a few years ago in the Green Journal about the use of episiotomies with resident physicians and attendings and how the trend has changed over the years, especially in teaching programs. Look it up. 🙂 I use them from time to time when a patient has an especially long perineum that is not stretching, a hymenal remnant or if I think she is going to rip herself into shreds. It can be easier to repair a controlled cut than some spontaneous tears. That being said, I try to avoid doing them, as do my partners.

Midwives, just like the rest of us, have their own agendas. We all want to back up the choices and decisions we make. We ALL have our soapboxes we like to stand on...

 

[MacGyver]

That being said, IMHO (and experience) our patients are older, fatter, with many many more comorbidities than the usual midwife patient AND more than they have ever been before. Therefore, they have more complications during pregnancy and intrapartum.

Thats what I thought too, and then I found this:

http://www.ncbi.nlm.nih.gov/sites/entrez

Table 1 Characteristics of physician and certified nurse midwife delivered births: United States, 1991
All deliveries
Singleton, vaginal deliveries 35–43
weeks gestation
Physician Certified nurse midwife Physician
Certified nurse
midwife
Number of births 3892192 167706 2634550 153194
Per cent of total births* 94.7 4.1 93.2 5.4
Infant mortality rate† 8.8 4.1 3.6 3.1
Neonatal mortality rate† 5.6 1.6 1.2 0.8
Postneonatal mortality rate† 3.2 2.5 2.4 2.3
Low birthweight (<2 500 g) (%) 7.3 3.2 3.5 2.5
Mean birthweight 3333 3404 3390 3416
Preterm birth (%) 11.0 7.2 6.0 5.0
Mean weeks of gestation 39.1 39.5 39.4 39.5
Delivered in hospital (%) 99.7 94.3 99.6 94.1
Single births (%) 97.5 99.6 100.0 100.0
Vaginal deliveries (includes vaginal births
after caesarean section) (%) 76.2 99.4† 100.0 100.0
Non-Hispanic white (%) 64.5 51.4 65.3 52.0
Non-Hispanic black (%) 16.3 18.8 15.5 18.4
Asian and Pacific Islander (%) 3.5 3.7 3.7 3.7
American Indian (%) 0.9 3.1 0.9 3.1
Hispanic (%) 14.9 23.1 14.8 23.0
Maternal age <20 years (%) 12.7 17.2 13.3 16.9
Maternal age 35+ years (%) 9.4 8.3 8.6 8.5
Birth order 4+ (%) 10.4 12.9 10.7 12.8
Unmarried (%) 29.1 38.5 29.0 38.0
Smokers (%) 17.8 18.3 17.7 18.0
Maternal education <12 years (%) 23.3 32.3 23.6 31.8
Maternal education 16+ years (%) 18.3 14.3 18.4 14.8
Prenatal care began in 2nd or 3rd trimester
(%) or no care 23.1 34.2 23.1 33.4
No prenatal care (%) 1.8 2.2 1.7 2.0
Medical risk factors/delivery complications
Abruptio placenta (%) 0.6 0.2 0.2 0.1
Breech/malpresentation (%) 4.0 0.4 0.5 0.3
Fetal distress (%) 4.4 1.7 2.1 1.6
Hydramnios/oligohydramnios 0.7 0.5 0.5 0.5
Precipitous labour (<3 hours) (%) 1.8 2.8 2.2 2.8
Premature rupture of membrane (>12 hours) (%) 3.3 3.4 2.4 3.3
Seizures during labour (%) 0.04 0.02 0.02 0.02

Its an extremely large data set, and indeed it shows more women on the ob/gyn side had pregnancy and perinatal complications.

HOWEVER, it also showed that the ENTERING patient baseline was equivocal in terms of risk factors. In fact, the midwives did BETTER than ob/gyns for women with zero prenatal care.

This study excluded women who were transferred from midwife to ob/gyn care, so its not biased by the transfer effect of sicker women going to the ob/gyn service.

 

[MacGyver]

They keep an close eye on what percentage of our elective inductions (too many patients beg for one) turn in to sections.

The problem with this is that inductions, EVEN WITHOUT C-SECTIONS, have been linked w/ labor complications as well as poorer neonatal outcomes. Given that, its absolutely irresponsible to let women "choose" to induce.

 

[Global Disrobal]

MacGyver,

A couple of points: I've enjoyed your posts in the past and value your opinion, so please don't take my comments as personal attacks! However with respect to your last post, be careful with your conclusions. You are making "absolute" statements without apparent basis.

1. You can't classify a woman's choice to induce as "irresponsible" as a whole. I can give you numerous examples where the decision is in fact logical and within reason.

2. I fail to recall the evidence behind your statement that inductions (regardless of cesarean delivery) are associated with labor "complications" and "poorer" neonatal outcomes! The exisiting literature, correct me if I'm wrong, has linked elective inductions to more intrapartum interventions (not complications), cesarean deliveries (moot in this discussion), as well as a vague association with shoulder dystocias. Neonatal outcomes where not shown to be different in most studies I've seen. Do you mind sharing with us the evidence you used for your comment?

I don't support elective inductions or cesareans in total and treat them on a case by case basis. Whenever my patients show me that they are well informed & have good reason, I honor their wishes as it is well within their rights to do what they wish. However, I don't make a blanket rule to not consider elective inductions/cesareans as I believe you're doing your patients a disservice.

 

[chrisisinnocent]

Thats what I thought too, and then I found this:

http://www.ncbi.nlm.nih.gov/sites/entrez



Its an extremely large data set, and indeed it shows more women on the ob/gyn side had pregnancy and perinatal complications.

HOWEVER, it also showed that the ENTERING patient baseline was equivocal in terms of risk factors. In fact, the midwives did BETTER than ob/gyns for women with zero prenatal care.

This study excluded women who were transferred from midwife to ob/gyn care, so its not biased by the transfer effect of sicker women going to the ob/gyn service.

Can you link to the actual article rather than the front page of Pubmed?

 

[Global Disrobal]

Here is the link to the article he is citing:

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

MacDorman MF, Singh GK. Midwifery care, social and medical risk factors, and birth outcomes in the USA. J Epidemiol Community Health. 1998 May;52(5):310-7.

 

[luvOB]

10 years ago??? come on! hasn't obesity and diabetes increased since 1998??? why are you citing a paper from a decade ago?😴 there are too many confounding factors! many of the "granola ladies" are vegan, do yoga and live less stressful lifestyles... they tend to be the ones with the birthing plans and go to midwives. Not your CEO who smokes, drinks and lacks sleep nor the low income, fast-food eating, non-exercising morbidly obese ladies. Sorry for generalizing but it's true that those with more health problems pre-pregnancy are more likely to go to a MD because they are so used to going to doctors for everything else. Healthier women are more likely to believe they will have an absolutely normal pregnancy and opt for a more natural birth.

 

[MacGyver]

10 years ago??? come on! hasn't obesity and diabetes increased since 1998??? why are you citing a paper from a decade ago?😴 there are too many confounding factors! many of the "granola ladies" are vegan, do yoga and live less stressful lifestyles... they tend to be the ones with the birthing plans and go to midwives. Not your CEO who smokes, drinks and lacks sleep nor the low income, fast-food eating, non-exercising morbidly obese ladies. Sorry for generalizing but it's true that those with more health problems pre-pregnancy are more likely to go to a MD because they are so used to going to doctors for everything else. Healthier women are more likely to believe they will have an absolutely normal pregnancy and opt for a more natural birth.

Maternal age, maternal weight, and smoking status was matched between midwives and OBs, so that does not explain the discrepancy in outcomes.