Obstetrics Case

[periopdoc]

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Death rates rose when women started having babies in hospitals. Maternal mortality did not begin to fall until the late 1930’s when antibiotics to treat infection were introduced and more stringent controls were placed on obstetric training and practices. Many factors contributed to reduced death rates including better living conditions, good nutrition, child spacing, and the development of blood transfusions, but moving birth into the hospital and under doctor control was not one of them’.
Goer, Henci, “The Thinking Woman’s Guide to a Better Birth”(New York: Perigee Books, 1999),202.

First, I would recommend that when you want to try to use data to make an argument to physicians (whether on an internet forum or in your future life on the labor deck), you should refrain from directly quoting activist sources like Henci Goer. Feel free to take a look at her arguments, then look at her sources, then present the real data from those primary sources. Quoting an editorialized piece like Goers book makes you look sophomoric and unprofessional. Don't forget, Goer makes a good living off of her books and international speaking engagements by attacking the medical establishment. That makes her motives at least as questionable as the motives of the very establishment which she is attacking. btw kudos for including a reference, I was halfway through that paragraph and thinking of jumping on you for plagiarizing Goer when I noticed the reference.

20th century maternal mortality rates were highest during 1900-1930, a convenient time frame to pick when you want to make an argument against the medical establishment. During this time frame, obstetrics was the bastard stepchild of American medicine and was generally shunned by physicians. Care was provided by poorly trained/ untrained medical practitioners. Following the 1933 White House Conference on Child Health Protection, Fetal, Newborn, and Maternal Mortality and Morbidity, institutional practice guidelines and guidelines defining physician qualifications needed for hospital delivery privileges were developed.

It was in this time frame that the shift to institutionalized births took place. During 1938-1948, the proportion of infants born in hospitals increased from 55% to 90% and maternal mortality decreased by 71%. Changes in infant, childhood, and maternal mortality over the decade of 1939-1948: a graphic analysis. Washington, DC: Children's Bureau, Social Security Administration, 1950

Medical advances developed and advanced by PHYSICIANS (including the use of antibiotics, oxytocin to induce labor, and safe blood transfusion and better management of hypertensive conditions during pregnancy) were responsible for this decrease in mortality.

When you read the arguments of the "natural birth" crowd, you see that they typically are arguing against historical obstetric practice. I will leave it to the reader to consider whether this is mere ignorance or purposefully misleading. Meanwhile, obstetrics has made huge paradigm changes and has improved our practice.

Now, we have to ask ourselves where are we presently, 60 years later

Per WHO/ USAID

The most common direct causes of maternal death include severe bleeding, infection, consequences of unsafe abortions, hypertensive disorders, and obstructed labor. For every one woman who dies due to pregnancy or childbirth, another 30 experience a short or long term disability including anemia, infertility, and hormonal damage from severe bleeding. Women surviving infection during labor face pelvic inflammatory disease, chronic pelvic pain, reproductive organ damage, and infertility. Obstructed or prolonged labor leads to incontinence, fistula, genital prolapse, uterine rupture, and nerve damage. Pregnancy-induced hypertension can be a precursor to chronic hypertension, kidney failure, or nervous system problems.

Note that nowhere on that list do you find "unnecessary" c-section or its sequelae as a major cause of maternal morbidity.

I would like to recommend a book to you because I honestly think you would find it to be a fascinating. It is an unbiased history of obstetric and midwifery practice as well as the history of maternal morbidity and mortality. Death in childbirth: an international study of maternal care and maternal mortality, 1800-1950 by Irvine Loudon.

Studies have shown that for healthy women home birth with a trained midwife (or doctor) is just as safe (if not safer*) than hospital births. There is no point in arguing that point - it has been very well established. *mortality rates are the same, morbidity rates are lower in a home birth

I will argue it because there is a point in arguing it. It has not been shown in any of the studies I have read, and in all likelihood it never will be shown. The existing studies are extremely biased and underpowered. If you have data to prove this point, present it.

There is actual hard data to support that when c-section rates fall below 15% for all comers, maternal and perinatal morbidity and mortality is increased.

Birth is inherently risky, and anyone who says otherwise is kidding themselves.

Something we can all agree on.

...The feelings of failure are less pronounced when a women feels that she really tried all she could. And, please don't deny that many women feel like failures when they have c-sections.

And which group is propagating the attitude that these women have failed when they needed a c-section? Hint it isn't ACOG members.

I am sure there is more to say but lets just, for now, agree to disagree.

Oh you aren't getting out of it that easily. This is not politics or religion where two "right" answers can exist. This is medicine and patient outcomes are at stake. If you want to survive an OB residency, you had best give up that agree to disagree attitude quickly.

For starters, EFM over intermittent doppler which has not shown any benefit to infant mortality but has shown a large increase in cesearan rates. I believe 9 studies have shown this correlation.

Great. Did ANY of those studies show an INCREASE in morbidity and mortality secondary to the higher c-section rate? I would contend that the earlier you get the evidence of a bad baby, the earlier you get that baby out, the less morbidity and mortality you will experience even if you have a higher number of "unnecessary" c-sections.

The crux of the problem is that we will never know how many c-sections are "unnecessary" because there is no way to retrospectively look back and say exactly which babies would have successfully delivered vaginally if we had not done the c-section. Compare that to appendectomies where we can look at the appendix after it is out and say definitively whether it needed to come out or not. Even then we accept a certain percentage of unnecessary appendectomies, although that percentage is getting smaller as CT scans get better. Thank god we never had the natural appendicitis crowd trying to save our patients from the psychological trauma of undergoing unnecessary appendectomy.

Modern medicine should not be versus natural medicine. I am sure that you are a wonderful attending with many years experience, but how many homebirths have you attended? How many fully naturally unmonitered births?

Modern medicine absolutely must hold up a standard against any movement, that is primarily philosophically motivated. Medicine is data driven, not "experience" driven. It does not matter how many glorious home births you or I have experienced. What matters is the statistically most probable outcome for our patient. Until "natural" medicine gives up its philosophical experience driven thrust, and takes an impartial look at patient safety and outcomes, modern medicine must raise a standard against it.

I hope that I can be convinced from my beliefs enough to practice the way I need to in order to get through a residency.

You feel that I don't have evidence on my side of the debate - and I feel very strongly that I do

Beliefs are a dangerous way to practice medicine. If you have data on your side you need to present it. Believe me, I will listen. As a person with a long-term interest in this subject I am very familiar with the data on both sides. I can also tell you that I have left you some openings to present data against my argument, but so far you have not taken the opportunity to do so. Come on you are almost a doctor... start acting like it.

 

[periopdoc]

Ok, now that we have officially hijacked this thread, sorry Lonestar, I want to add a verbatim quote of a discussion from one of my favorite bloggers Amy Tutuer. This is a hilarious rebuttal of a comment left on her blog and well worth the read.

"I never hear hospital birthers rave about the empowerment, beauty and spirituality of their births the way I hear it from those who've birthed at home."

Of course not, they don't feel the need to impress other people in the social subgroup of "natural" childbirth advocates. It's all a bunch of baloney. Women have given birth for hundreds of thousands of years, but it's only in the last 75 years that a small group of people told women that they should find it "empowering". Now, people who want to impress other "natural" childbirth advocates find it "empowering", too. What a coincidence!

Why is "empowering" childbirth restricted to white, Western, well educated and relatively well off women who have lived within the last 75 years? Because it is a made up social construct that has nothing to do with birth in nature.

"Those mothers who give their children the gift of a drug-free entry into the world deserve specific praise for that accomplishment."

It's not an accomplishment. Any woman can do it, if she chooses to do so. 99% of mothers who have ever lived have done so (or died trying) and the majority of women who give birth each and every day do so (or die trying). Only a group of elitist white, Western, well educated and relatively well off women would think to praise themselves for doing something that virtually everyone else has done, and which anyone can do. Congratulating yourself for having an unmedicated vaginal delivery is like congratulating yourself for digesting your food. It happens without any input from you.

This is my truth."

Sorry, I don't believe there is such a thing as "your truth". You have the right to your own opinions, but you don't have the right to your own facts, and the FACT is that homebirth has an excess risk of preventable neonatal death. The FACT is that childbirth is inherently dangerous, and the FACT is that "natural" childbirth was made up by a bunch of men to convince women to stay home and reproduce.

-pod

p.s Does anyone else think that it is funny to see a GYN thread started by someone named "Lonestar?"

 

[TopDocChick]

I will argue it because there is a point in arguing it. It has not been shown in any of the studies I have read, and in all likelihood it never will be shown. The existing studies are extremely biased and underpowered. If you have data to prove this point, present it.

There is actual hard data to support that when c-section rates fall below 15% for all comers, maternal and perinatal morbidity and mortality is increased.

Just one example of the studies I am quoting,
From: Murphy, Patricia Aikins CNM, DrPH, FACNM Planned home birth with a regulated midwife is as safe as hospital birth for low-risk women.

Background: The choice to give birth at home with a regulated midwife in attendance became available to expectant women in British Columbia in 1998. The purpose of this study was to evaluate the safety of home birth by comparing perinatal outcomes for planned home births attended by regulated midwives with those for planned hospital births.
Methods: We compared the outcomes of 862 planned home births attended by midwives with those of planned hospital births attended by either midwives (n = 571) or physicians (n = 743). Comparison subjects who were similar in their obstetric risk status were selected from hospitals in which the midwives who were conducting the home births had hospital privileges. Our study population included all home births that occurred between Jan. 1, 1998, and Dec. 31, 1999.
Results: Women who gave birth at home attended by a midwife had fewer procedures during labour compared with women who gave birth in hospital attended by a physician. After adjustment for maternal age, lone parent status, income quintile, use of any versus no substances and parity, women in the home birth group were less likely to have epidural analgesia (odds ratio 0.20, 95% confidence interval [CI] 0.14–0.27), be induced, have their labours augmented with oxytocin or prostaglandins, or have an episiotomy. Comparison of home births with hospital births attended by a midwife showed very similar and equally significant differences. The adjusted odds ratio for cesarean section in the home birth group compared with physician-attended hospital births was 0.3 (95% CI 0.22–0.43). Rates of perinatal mortality, 5-minute Apgar scores, meconium aspiration syndrome or need for transfer to a different hospital for specialized newborn care were very similar for the home birth group and for births in hospital attended by a physician. The adjusted odds ratio for Apgar scores lower than 7 at 5 minutes in the home birth group compared with physician-attended hospital births was 0.84 (95% CI 0.32–2.19).
Interpretation: There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted.


Please send me your data regarding c-section rates correlation to morbidity.

And which group is propagating the attitude that these women have failed when they needed a c-section? Hint it isn't ACOG members.

Why are you making belittling childbirth? To many women, even without the natural movement, this is a huge time in their lives. The beginning of life, motherhood - some women even have religious feelings towards it. It is not an "attitude" that is propogated by one certain group. Are you suggesting that we desensitize women to childbirth completely? It is in their medical interests to see it as simply a procedure?

Oh you aren't getting out of it that easily. This is not politics or religion where two "right" answers can exist. This is medicine and patient outcomes are at stake. If you want to survive an OB residency, you had best give up that agree to disagree attitude quickly.

Because physicians never disagree and evidence never changes. Please, if we knew all the answers, why do people continue to do studies?


I'll get back to the rest of your statements, but I am jetting off to do a carpool (which I am already late too due to this discussion). See you later 🙂

 

[isoman2000]

Check them I do, not do not want to cause a fight but I limit my clinical threads to facts or proven practice, and once I have said that I am not going on ad on, soooo I would appreciate if comments like southpaws (who has not ever given a clinical answer) would be held in check.

Oh chr**t forget it not worth the trouble of arguing.

 

[Planktonmd]

Check them I do, not do not want to cause a fight but I limit my clinical threads to facts or proven practice, and once I have said that I am not going on ad on, soooo I would appreciate if comments like southpaws (who has not ever given a clinical answer) would be held in check.

Oh chr**t forget it not worth the trouble of arguing.

😕

I am really having trouble understanding what you are trying to say, could you please help me out and repeat it in English if possible???

 

[isoman2000]

Nahh not really worth fighting over, I am never going to change any minds here, I will always be in many eyes a stupid dangerous nurse here, in the rest of the world I will be a comptent caring provider.

 

[Bertelman]

Nahh not really worth fighting over, I am never going to change any minds here, I will always be in many eyes a stupid dangerous nurse here, in the rest of the world I will be a comptent caring provider.

You'll be considered the latter here once you demonstrate an acceptable level of competence. We may always keep you at arm's length, but you do the same with the physicians you work with. The antagonistic relationship works both ways.

 

[Noyac]

Nahh not really worth fighting over, I am never going to change any minds here, I will always be in many eyes a stupid dangerous nurse here, in the rest of the world I will be a comptent caring provider.

No, stupid and dangerous comes from those that don't know their limitations. You don't have to be a nurse to be stupid and dangerous.

 

[periopdoc]

Ok, SDNers, I admit it. I have not been telling the whole truth about the data on this home-birth thing. In fact, I have been baiting TDC to see if she would step up to the plate, act like a physician, and bring us the good data that actually does exist on this subject.

Instead, we get a citation of a 3-paragraph COMMENTARY, by a CNM activist, on the Janssen article from British Columbia. TDC at least give credit to the actual author of data when you decide to cite it.

The abstract you quote is accurately cited as follows.

Janssen et al Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. Rather than crafting a critique of this article, I will let the authors response to the letters speak for itself.

We would like to address the misconception that we were trying to create comparison groups in our study that were equal in obstetrical risk status. Although we tried to ensure that comparison groups met eligibility criteria for home birth, women who choose home birth differ from those who select hospital birth in both measurable and unmeasurable ways. This selection bias is unavoidable. The purpose of our study was not to determine which method of care was better, home vs. hospital, but rather to assess whether, at the 2-year interval, home birth was safe enough to continue to be offered as a choice for women in the context of ongoing evaluation

Put another way, this was not an adequate study to compare the safety of home birth to the safety of hospital birth. It was a preliminary study to determine if it is ethical to study the issue. Despite this fact, home-birth advocates have trumpeted it as one of their primary arguments for the safety of home birth. It is interesting how these same individuals usually ignore the fact that 2 babies died in the home birth group that very likely would have been saved in a hospital setting. No babies died in the hospital group. The home birth group had 5 babies that required > 24h of ventilator support (including one of the deaths). The hospital group had no babies that required prolonged ventilator support.

Tuteur made an interesting observation on this

If the C-section rate in the homebirth group had matched that of the physician group, possibly 110 additional women would have had C-sections of which 108 would have been unnecessary in hindsight.

So here's my question: was it worth it to avoid 108 potentially unnecessary C-sections if 2 babies died as a result? How many unnecessary C-section would be acceptable to save the life of a baby?

Now, let us briefly look at the intrapartum death rates in the major studies of home-birth to date.

- Murphy & Fullerton 2/1221 = 16/10,000
- Johnson & Daviss 5/5418 = 9.2/10,000
- Janssen 1/860 = 12/10,000
- Northern Region 5/2888 = 17/10,000

Compare those rates to a typical hospitalized intrapartum death rate of 2-3 per 10,000 for all comers and the difference is stark. If you could compile intrapartum death rates solely for the low-risk hospitalized births you should expect an even lower rate, and a more dramatic difference.


The most recent and in some ways most compelling data can be easily compiled from the CDC Linked Birth / Infant Death Records, 2003-2004



Thanks again to Dr. Tuteur for that tabulation. See her website for why the specific limits are set like they are. The CNM numbers here are combined hospital and home based CNMs. Out of hospital deaths for CNMs = 10/ 16,188 for a rate of 0.62/ 1000, an equivalent death rate to MD's despite a lower overall population risk. I will admit that because the numerator is less than 20, it does not meet the NCHS standard for precision and reliability. (DEM stands for direct entry midwife meaning non-certified midwife homebirths).

Note once again that the MD rate includes all comers with a higher baseline risk PLUS all of the patients that were transferred to physician care from home-birth, birthing center, and hospital based CNM settings prior to delivery/ death. If we were somehow able to look at this data on an intention to treat basis, the numbers would be even worse for homebirths.

Please send me your data regarding c-section rates correlation to morbidity.

I have already provided that. See Post # 53 above.

Why are you making belittling childbirth? To many women, even without the natural movement, this is a huge time in their lives. The beginning of life, motherhood - some women even have religious feelings towards it. It is not an "attitude" that is propogated by one certain group. Are you suggesting that we desensitize women to childbirth completely? It is in their medical interests to see it as simply a procedure?

I am not belittling the childbirth experience. However, I am a physician and you will soon be one. Our interaction is on a different level. I would never take the same tone with a patient that I have taken with you. You and I are professionals who should be able to divorce ourselves from the emotional aspect of these experiences when called upon to discover what will bring about the best chance of achieving our primary goal, healthy mothers and healthy babies. Once we have discovered that, we can introduce it into the emotional paradigm of our expectant mothers to guide them toward an optimal outcome within their paradigm. When I was in OB, my mothers loved me and I delivered a lot of babies "naturally." Those mothers especially loved my post-delivery pudendal block skills. 😍

The rise of "natural childbirth" as an "experience" was a social construct that closely followed the increased safety brought about by the medicalization of birth in the early 20th century. Freed from the fears of death and disability, mothers were now presented with an entirely different perspective by individuals like Grantly Dick-Read. Much of this new philosophy was/is profoundly racist, claiming that "primitive" peoples do not feel pain like modern civilized humans (sound familiar? hint see justifications for slavery). These same arguments persist today. For an interesting read on the birth "experience" of early American women, read Brought to Bed: Childbearing in America 1750-1950." by Judith Walzer Leavitt. Let me summarize it for you. Early on, women were not looking for an "experience," they were pretty much just hoping against hope for the survival of themselves and their babies.

Because physicians never disagree and evidence never changes. Please, if we knew all the answers, why do people continue to do studies?

No, because we vehemently disagree. That is what drives us to seek out new evidence to support our separate positions and eventually find the evidence that brings us to some semblance of the real truth. If we "agree too disagree" we lose the impetus to seek new data to prove the other person wrong. It is precisely our refusal to agree to disagree that makes physicians so successful at improving patient outcomes.

pod

 

[proman]

Strong work! I've always thought physicians should communicate with passion and data. FYI maternal mortality ratio in the US is 11:100,000, tied for 8th according to the WHO.

 

[Farmer Jane]

Excellent work!

I just have to answer this, as a former L&D nurse and as a women who will *hopefully* be having a baby within the next few years:

So here's my question: was it worth it to avoid 108 potentially unnecessary C-sections if 2 babies died as a result? How many unnecessary C-section would be acceptable to save the life of a baby?

Other women may feel differently, and certainly it would be great to eliminate unnecessary C-sections, but if my receiving an unnecessary C-section contributes to the decreased chances that my baby will be one of the stillbirths, sign me up.

 

[Bertelman]

Vajayjays aside, this thread underscores the beauty of our forum.

Search far and wide, it will be hard to find as many quality discussions on any other SDN or non-SDN medical forum.

As much as I groan every time a newbie comes along and passionately argues an indefensible point, I always learn something from the discussion.

 

[dhb]

Strong work!

Chackmate 👍

 

[Consigliere]

Well gents, I think that's the last we'll be hearing from top"doc"chick.

Peace out, girl!

 

[TopDocChick]

Well gents, I think that's the last we'll be hearing from top"doc"chick.

Peace out, girl!

Not so fast. I'm thinking about things... Whether it makes sense to subjegate 108 women to surgery for 2 babies. I don't know. I mean, I am all for saving lives but we don't force people to donate kidneys in order to save other people. Anyway - I'm still thinking because perio is right, I don't have the experience and statistical knowledge to challenge him well. Heck, I don't even know how to get appropriate journal articles to prove myself or disprove his points. I am a newbie.

But, I still think labor is managed in a horrible way in the hospitals and that there is much need for improvement which includes respect and space for healthy women with healthy pregnancies to labor naturally and avoid being one of those 108. Many of you have agreed with me theoretically but with lawsuits say it is not realistic. Midwives get sued less, so why not let midwives take over the cases of healthy women with healthy pregnancies and let them refer to the physician if the need arises?

I have not defined my usage of midwives and there are so many types. The only type i am referring to are CNMs who have a nursing degree and a 3 year masters in midwifery and certification in neonatal rescusitation. These are well trained professionals, better trained than the OB nurses on the L&D floor. Picture the woman who stays at home as long as she can and comes to the hospital when she feels like her contractions are close enough. She spends all that time at home without a professional and then gets checked into the hospital and checked by a nurse who has 5 other patients, some monitors and maybe a resident. Her doc isn't usually called until the very end. Contrast that with a well trained professional midwife who shows up at her home, with a lot of equipment including oxygen, amniohooks, pitocin, IV antibiotics, Saline... so much stuff. She shows up early on and is focused just on one patient. She is constantly monitoring the labor and listening for decels of the baby, taking moms blood pressure, follows the rythm of the contractions. If there is any trouble looming, they get in the car and head straight for the hospital. This woman is being cared for at home by a midwife who knows how to deliver a baby. If there is a cord prolapse at home from teh water breaking, this woman alone would not kow what to do on her own, but a midwife would call an ambulance right away and keep the cord from compression of the baby. How many midwives have actually saved babies from a cord prolapse DOA? I don't know, doubt they have studied it.

The midwives of today are not the midwives of 100 years ago when women died in labor. They have so many more tools at there disposal. They are trained medically and have far less c-section rates than physicans without an increase in infant or maternal mortality.

 

[smq123]

Not so fast. I'm thinking about things... Whether it makes sense to subjegate 108 women to surgery for 2 babies. I don't know. I mean, I am all for saving lives but we don't force people to donate kidneys in order to save other people.

😕 Donating a kidney is hardly the same thing as having a c-section.

But, I still think labor is managed in a horrible way in the hospitals and that there is much need for improvement which includes respect and space for healthy women with healthy pregnancies to labor naturally and avoid being one of those 108. Many of you have agreed with me theoretically but with lawsuits say it is not realistic. Midwives get sued less, so why not let midwives take over the cases of healthy women with healthy pregnancies and let them refer to the physician if the need arises?

Contrast that with a well trained professional midwife who shows up at her home, with a lot of equipment including oxygen, amniohooks, pitocin, IV antibiotics, Saline... so much stuff. She shows up early on and is focused just on one patient. She is constantly monitoring the labor and listening for decels of the baby, taking moms blood pressure, follows the rythm of the contractions. If there is any trouble looming, they get in the car and head straight for the hospital.

OH MY GOD. Your idealism is nice, but painful.

CNMs are sued less....although the number of CNMs that are sued is NOT zero. If the number of women cared for by CNMs increases, what do you think is going to happen? Maybe, just maybe, the number of CNMs who get named in lawsuits will go UP???

I mean, THINK about it. What if, as you suggested, all healthy and low-risk pregnancies go to CNMs - I would bet that there would be a huge uprise in the number of midwives who get sued. Can't you picture it? "As a nurse midwife, are you or are you not trained to recognize the early signs of fetal distress? And, therefore, why did it take you 4 weeks to refer your patient to an obstetrician for management? And why did it take you 45 minutes to call an ambulance for your patient who was laboring at home?" etc, etc.

Midwives don't get sued less because natural birth is "intrinsically better," or because their practice methods are always safer. They get sued less because they have fewer patients, and they have smaller salaries. If we do what you suggest, I would bet that either a) the number of lawsuits against CNMs would skyrocket, or b) midwives would start doing more c-sections and start practicing more CYA medicine....and we'd be right back to where we started.

But, I still think labor is managed in a horrible way in the hospitals and that there is much need for improvement which includes respect and space for healthy women with healthy pregnancies to labor naturally and avoid being one of those 108.

😱

Natural birthing advocates amaze me. They tend to be extremely well-educated, middle-to-upper class women (and almost all are caucasian). They make up such a small and exclusive part of the population....and yet they assume that ALL women, of all socioeconomic classes and ethnicities think just like they do.

Maybe you delivered in a small, cozy hospital located somewhere in the suburbs. Where a LOT of OB/gyns do their training though....these tend to be low-income, inner city hospital where most of the patients are either black, Hispanic, or immigrants that don't speak English.

The patients at these places are 16 year olds who do NOT want to "labor naturally." They want an epidural the second they walk through the door, and God help you if the anesthesiologist is busy or late.

Or the patients at these places are Mexican immigrants who live in a small, 2 bedroom apartment with three other (illegal) couples and their children. Oddly, they'd have MORE space and privacy in the hospital than they would at home! And yet you'd want them to deliver in their "own home"?

Or the patients at these places are women who "didn't want this damn baby in the FIRST PLACE!," and are ready to put the child up for adoption. They don't want to "labor naturally," they're not excited to feel "labor pains," they don't want to deliver vaginally because they don't want vaginal tears, and, in all honesty, they'd rather just deliver the baby under general anesthesia.

Or, my personal favorite, the women who will tell you that they WANTED an abortion, but they didn't realize that they were pregnant until it was too late. They're totally healthy, and fine, but this child was totally unwelcome and they would rather put this whole delivery experience behind them ASAP.

I could go on, and on, and on. The point is, delivering a baby is not always a joyful, celebratory, overwhelmingly-happy experience for everyone. You, and other natural-birth advocates, may like to delude themselves into thinking that all women think like they do, but - and this may be news for you - they do not. There are SO many women out there who are bitter and angry over the fact that they are pregnant, and do NOT want anything to do with natural birth. Heck, I've had patients who WANT a c-section, just so they could get the baby out of their lives as soon as possible. 🙁

 

[Farmer Jane]

In three years as an obstetric nurse--NRP certified the entire time--I never had five laboring patients. Never. The most I ever had was two, and that was on a very bad night. We also use more than "monitors" to care for our patients, TYVM. 🙄

I know many CNMs and very few have done homebirths. Most prefer the hospital where they can call for help if needed. Newsflash: when cord prolapse occurs that baby is in trouble. Minimizing cord compression is at best a stopgap until an emergency c-section. Outside of rare, extremely lucky circumstances, a baby with a prolapsed cord at home will die.

 

[TopDocChick]

😱

Natural birthing advocates amaze me. They tend to be extremely well-educated, middle-to-upper class women (and almost all are caucasian). They make up such a small and exclusive part of the population....and yet they assume that ALL women, of all socioeconomic classes and ethnicities think just like they do.

Maybe you delivered in a small, cozy hospital located somewhere in the suburbs. Where a LOT of OB/gyns do their training though....these tend to be low-income, inner city hospital where most of the patients are either black, Hispanic, or immigrants that don't speak English.

The patients at these places are 16 year olds who do NOT want to "labor naturally." They want an epidural the second they walk through the door, and God help you if the anesthesiologist is busy or late.

Or the patients at these places are Mexican immigrants who live in a small, 2 bedroom apartment with three other (illegal) couples and their children. Oddly, they'd have MORE space and privacy in the hospital than they would at home! And yet you'd want them to deliver in their "own home"?

Or the patients at these places are women who "didn't want this damn baby in the FIRST PLACE!," and are ready to put the child up for adoption. They don't want to "labor naturally," they're not excited to feel "labor pains," they don't want to deliver vaginally because they don't want vaginal tears, and, in all honesty, they'd rather just deliver the baby under general anesthesia.

Or, my personal favorite, the women who will tell you that they WANTED an abortion, but they didn't realize that they were pregnant until it was too late. They're totally healthy, and fine, but this child was totally unwelcome and they would rather put this whole delivery experience behind them ASAP.

I could go on, and on, and on. The point is, delivering a baby is not always a joyful, celebratory, overwhelmingly-happy experience for everyone. You, and other natural-birth advocates, may like to delude themselves into thinking that all women think like they do, but - and this may be news for you - they do not. There are SO many women out there who are bitter and angry over the fact that they are pregnant, and do NOT want anything to do with natural birth. Heck, I've had patients who WANT a c-section, just so they could get the baby out of their lives as soon as possible. 🙁

So, what your saying is that the well-educated, middle-to-upper class women should be treated like the women who "didn't want this damn baby in the FIRST PLACE! Maybe because you can't treat one differently than the other or you'll get sued for that? No wonder the well-educated etc etc are turning towards other alternatives to birth attendants and places. I know that I wouldn't want a doctor who is so used to the climate of birth you are describing assuming that I want the baby TORN out of me ASAP. But with so many of them, and just a small group of me, is MY birth being treated statistically better for my socioeconomic group? Is the fact that it doesn't bother me in the least bit to labor 26 hours, and have done it and had healthy babies, going to change the way a doctor will treat my next birth if I labor over 12 hours? No! because you will treat that birth like a statistic of the general population, assuming that it is healthier for the general masses to get the baby out quickly so it is healthier for me. All I have been saying here is to even out your view points. I have many colleagues who would never want to labor without an epidural. I respect them, I don't judge them. I am defending people like myself who DO NOT WANT ANY INTERVENTIONS including EFM, routine checks, etc etc. WE ARE NOT RESPECTED BY YOU! If you truly wanted to make birth safer for EVERYONE you would accpet my small group just like you accept the group who plans their ceseareans months in advance in order to encourage them back into the hospitals so that the 2 babies that die in 110 would have a better chance of surviving, but that still only 16% of them would end in c-section instead of the prevalent 30% hospital statistic currently.

When you are treating the population that wants the birth to end quickly, can't take the pain, pleas please remove this thing NOW you are more than willing to help them along and treat them with every medical method you know. When you are treating the population that says, please - I trust my body to do this, my mother had her babies naturally and I have had 2 others safely this way, you STILL make them do the supposedly safe routine interventions that can lead to things spiraling out of control. Do you not see that you are holding by a double standard?

 

[huktonfonix]

Alright, now this is just getting silly. topdocchick, the issue some of my colleagues seemed to have earlier were that you were saying that DATA showed natural childbirth was safer as opposed to physician guided birth. This has not been shown to be true based on DATA shown throughout this thread. NOW youre saying that it should be a womans choice if she wishes to give birth naturally, and thats fine. It still is a womans choice how she wants to give birth and noone on this board is trying to say otherwise. If a woman is having an uncomplicated pregnancy AND she understands the risks and benefits of both methods of delivery then she should be able to do as she pleases. SMQs point wasn't that everybody should be delivered in hospitals, but that not everyone should be "forced" to deliver naturally or feel guilty for not doing so. In other words now it has become a discussion of both sides not wanting their beliefs (not DATA at this point) forced on the other. Now its more of a argument over philosophies rather than science which is fine too.

 

[militarymd]

Not so fast. I'm thinking about things... Whether it makes sense to subjegate 108 women to surgery for 2 babies. I don't know. I mean, I am all for saving lives but we don't force people to donate kidneys in order to save other people. Anyway - I'm still thinking because perio is right, I don't have the experience and statistical knowledge to challenge him well. Heck, I don't even know how to get appropriate journal articles to prove myself or disprove his points. I am a newbie.

But, I still think labor is managed in a horrible way in the hospitals and that there is much need for improvement which includes respect and space for healthy women with healthy pregnancies to labor naturally and avoid being one of those 108. Many of you have agreed with me theoretically but with lawsuits say it is not realistic. Midwives get sued less, so why not let midwives take over the cases of healthy women with healthy pregnancies and let them refer to the physician if the need arises?

I have not defined my usage of midwives and .....

I love that statement....I don't know the data....I don't know HOW to obtain the data.....but don't let the data confuse or contradict what I "think"

 

[Noyac]

TDC, you come across, to me at least, as a passionate person with a lot of beliefs and very little understanding due to your unwillingness to objectively look at the data. YOu seem, like many midwives, afraid of what you might find if you did actually look at the data.
I'm really starting to doubt that you are even a med student. Most med students are capable of this. They learn to keep their feelings out of the discussion or at least base their arguments on data and not "feelings". If you keep this up you will most definitely be dangerous as a physician. Feelings can get in the way of good medicine.

 

[dhb]

Feelings can get in the way of good medicine.

[YOUTUBE]http://www.youtube.com/watch?v=ivUzfuuJNQI[/YOUTUBE]

-"David we need to talk"
- F**K
😆

 

[TopDocChick]

TDC, you come across, to me at least, as a passionate person with a lot of beliefs and very little understanding due to your unwillingness to objectively look at the data. YOu seem, like many midwives, afraid of what you might find if you did actually look at the data.
I'm really starting to doubt that you are even a med student. Most med students are capable of this. They learn to keep their feelings out of the discussion or at least base their arguments on data and not "feelings". If you keep this up you will most definitely be dangerous as a physician. Feelings can get in the way of good medicine.

http://www.yin-yang.com/vbfree/docs/schlenzka.htm

Olsen O. Meta-analysis of the safety of home birth. Birth 1997;24(1):4-11.


No more editorial comments by me, way too emotional I suppose

 

[TopDocChick]

[FONT=verdana,arial,helvetica,sans-serif][SIZE=-1]Kenneth C Johnson and Betty-Anne Daviss
Outcomes of planned home births with certified professional midwives: large prospective study in North America
BMJ, Jun 2005; 330: 1416.

(This is the one I have been looking for - thought it was UMD that did the study, but I see it was canada so I was searching in the wrong place)
[/SIZE].

 

[Southpaw]

I'm really starting to doubt that you are even a med student. Most med students are capable of this. They learn to keep their feelings out of the discussion or at least base their arguments on data and not "feelings". If you keep this up you will most definitely be dangerous as a physician. Feelings can get in the way of good medicine.

I was starting to think the same thing, b/c it definitely is not the mindset of a medical student to simply repeat over and over again "this is way it is b/c that's what I've experienced!" That's the mindset of a ummm, well, nevermind.

TDC, if you're a med student you KNOW how to find objective data. You've gotta be kidding me. And rather than continually state your thoughts and post random studies with which you don't explain or defend statistically, it's probably best to go back to POD's post and refute some of his claims if you can. As it stands he laid down some serious thought-provoking statistics that you've yet to address other than saying 'huh, maybe it's worth two babies lives to save 108 women a scar...". Seriously? Come on....

 

[Southpaw]

BTW TDC, from what I can tell this debate centers around low-risk births at home vs. hospital. That last study you posted, which you said you've been looking for, has NO COMPARISON of home vs. hospital. It simply lists some statistics from home births. It does nothing to compare mortality of similarly low risk births in the hospital or potentially decreased morbidity from hospital births. It's not really helpful for this discussion as far as I can tell.

 

[TopDocChick]

BTW TDC, from what I can tell this debate centers around low-risk births at home vs. hospital. That last study you posted, which you said you've been looking for, has NO COMPARISON of home vs. hospital. It simply lists some statistics from home births. It does nothing to compare mortality of similarly low risk births in the hospital or potentially decreased morbidity from hospital births. It's not really helpful for this discussion as far as I can tell.

Homebirths are inherently low intervention. I am simply using these studies to show that lower intervention does not harm the mother. I agree that birth in a hospital setting is theoretically better for the cases where a problem may arise but the point I am trying to get across is to allow the "crazy natural folk" to refuse certain routine procedures without being scoffed at or looked down upon. To get back to the OP, to allow a women to labor for over 10 hours if everyone is healthy and she wants to with the type of careful monitoring done at homebirths. This study shows the outcomes of thousands of homebirths, which are inherently low intervention, and shows that the women and baby came out with similar mortality rates to hospital births of the same risk women.

 

[Consigliere]

IF you are a med student (which I seriously doubt) then I fear for the future of medicine. On a positive note, though, you are an extreme minority and your impact will be minimal AT BEST.

 

[smq123]

WE ARE NOT RESPECTED BY YOU! If you truly wanted to make birth safer for EVERYONE you would accpet my small group just like you accept the group who plans their ceseareans months in advance in order to encourage them back into the hospitals so that the 2 babies that die in 110 would have a better chance of surviving, but that still only 16% of them would end in c-section instead of the prevalent 30% hospital statistic currently.

😕😕😕

<sigh> If English is not your native language, and that is why you're having such difficulty understanding some of these posts, then I apologize.

The idea that women can come into hospitals demanding "natural birthing techniques," and that those demands will automatically be met, is a little naive.

However, natural birthing advocates like to claim that this is "evidence" of "disrespect" from the medical community. 🙄🙄🙄 These people have either the biggest agendas in the world, or they just enjoy feeling wronged.

It is HARDLY disrespect to refuse to do something that either violates hospital policy or is flagrantly not in the standard of care. It is also NOT disrespectful to refuse to do techniques that you are not equipped to perform safely.

For instance, if you come into a standard L&D requesting to use a "birthing ball," or to deliver while squatting....they're probably going to say no. Why? Is it because they "disrespect" your beliefs? 🙄 No, it's because they don't have the equipment necessary to safely deliver you in that manner. If you tried to deliver while squatting in a regular L&D, you'll blow out your perineum. It would be irresponsible for the OB to agree to deliver you while you are squatting, if she knows that you may suffer severe, irreparable physical damage from that.

Similarly, it is not "disrespect" to refuse to do things that violate hospital policy. I know that you're either an MS-1 or an "MS-0" (as they like to say in pre-allo), but hospital policy is one of those immovable forces that no one likes to follow, but everyone has to. For instance, if you come in for a cholecystectomy, and you tell the nurse that you don't want an IV, do you think she's going to listen? No, because hospital policy (as well as standard medical treatment) dictates that you need IV access. If she refuses, she's going to lose her job.

It's the same thing on L&D. Unless you really seem uncomfortable, and the baby really looks fine, you will probably have to be on continuous EFM. If something goes wrong, and you sue the hospital, God help that poor nurse that agreed to take you off. She will lose her job and be named in a lawsuit, in the best case scenario. Worst case - she may have trouble finding work as an OB nurse.

When you are treating the population that wants the birth to end quickly, can't take the pain, pleas please remove this thing NOW you are more than willing to help them along and treat them with every medical method you know. When you are treating the population that says, please - I trust my body to do this, my mother had her babies naturally and I have had 2 others safely this way, you STILL make them do the supposedly safe routine interventions that can lead to things spiraling out of control. Do you not see that you are holding by a double standard?

🙄 You are really not understanding what I am trying to say.

What YOU were saying was that "all women should be encouraged to engage in natural birth." My point was that, as an OB/gyn, I am NOT going to encourage all women to engage in natural birth. If they want to, great!! I'll refer them to a doula, show them the nearest holistic birthing center - whatever. But, it is just as unfair to demand that all women engage in YOUR beliefs and adhere to YOUR standards, as it is the reverse.

 

[periopdoc]

You know, every morning I go to work telling myself that I am done with this thread. I am still considering whether to bother responding to todays random assortment of "evidence."

Like most of you, I started getting the idea over the last couple of days that TDC may not be a medical student. A little brief sleuthing this morning bore this out. It appears that she was accepted into Indiana U SOM for fall 2008 but deferred her slot to fall 2009.


Posted 1/18/2008, Indiana University School of Medicine Admissions Process

If I get in this year, Ill be an over the hill 29 year old first year.

Posted 1/24/2008, Indiana University School of Medicine Admissions Process

I'm In I'm In!!!!!!!!!!!

Posted 10/15/08, Indiana University School of Medicine Class of 2013 started by TDC

Just thought I'd start this one up so we can meet each other. I was accepted last year and deferred...
Looking forward to hearing from future hoosiers! 🙂

So, like many of us suspected, we have a pre-med student passing herself off as a med student. On the one hand I am tempted to cut her a little more slack since she has an excuse for not knowing how to find and interpret evidence. On the other hand, she has had ample opportunity to step up to the plate and say, "hey folks I am not a medical student yet, just accepted into medical school so give me some leeway."

hmmm

Oh, will everyone please refrain from using the 108 c-section number as if it were some sort of fact? It is a made up, rhetorical number that would happen IF you applied the hospitalized patient c-section rate to the home birth c-section rate to the patients in that study. That would never be accurate since the home birth population would (hopefully) belong to the low-risk subset of the hospitalized population, and would therefore have a lower c-section rate than that for the total hospitalized population. It was made up for dramatic effect, but I fear that people are using it as if it is actual data. Thanks

- pod

 

[periopdoc]

[FONT=verdana,arial,helvetica,sans-serif][SIZE=-1]Kenneth C Johnson and Betty-Anne Daviss
Outcomes of planned home births with certified professional midwives: large prospective study in North America
BMJ, Jun 2005; 330: 1416.

(This is the one I have been looking for - thought it was UMD that did the study, but I see it was canada so I was searching in the wrong place)
[/SIZE].

Wow, thanks for bringing up a novel study... Oh wait a minute, that is the Johnson-Daviss study that I mentioned in Post # 109.

But since you mentioned it, why don't we take a closer look at this particular study.

This study was designed as a prospective cohort study comparing 2 things
1 - The medical intervention rates for the planned home births of 5418 women compared to medical intervention rates for all 3,360,868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics. (Interventions defined as EFM, AROM, IV, Epidural, IOL, Episiotomy, Forceps, Vacuum, C-section etc)

2 - Intrapartum and neonatal death rates for these 5418 women were compared with those in other North American studies of at least 500 low risk hospital births. The dates of these studies ranged from 1969-1999.


Unfortunately several problems pop up immediately.

IN RE Comparison #1 did they choose an appropriate comparison group?

Table 1 shows several problems with cohort similarity.

In each of these areas, the hospital cohort is at significantly higher risk than the home-birth cohort. Other aspects of table one were similar between cohorts to my eye.


IN RE Comparison #1 did they choose an appropriate comparison group?
Why did they choose all women presenting in vertex at term delivering in hospital as the control? This would include women with previous medical issues, congenital deformities, and other known fetal problems. They should have controlled for those risks since that data exists and would have been easy to utilize.


Using the data derived from this questionable control group, the authors demonstrate a c-section rate difference of 3.7% for home-birth and 19-24% for hospital birth. If we look instead at the appropriate control group low risk hospitalized white women in 2000, we get a c-section rate of 4.7%... Not so different from the home birth rate.


IN RE Comparison #2, why did they choose a different cohort for mortality statistics than for instrumentation statistics when the mortality data for the instrumentation control cohort is easily available?

IN RE Comparison #2 why did they compare home births in 2000 to hospitalized births ranging from 1969-1999 when the data for the 2000 hospitalized births was easily available. Has obstetric practice not changed since 1969-1999?

Since the proper control group data exists, we can run the numbers to determine the actual safety comparison. The authors discovered a death rate of 2/ 1000 for home births. If we look at the CDCs Wonder data from 2000 for singleton, term, white deliveries at the hospital, the death rate was 0.72/1000. When you use the appropriate control group, home birth was associated with a > 2-fold increase in neonatal mortality. I have seen a reanalysis of the home birth data that suggest the actual death rate was 2.7/1000 giving almost a 4x increase in death for home-births. And this is with highly trained CNMs. There was no data included on lay/ direct entry midwives.


Since I don't have time or energy to comment on the Schlenzka study (look at the time I posted this), I will just include a quote from the Johnson-Daviss study on Schlenzka's study that should suffice to put it to rest.

When the author compared 3385 planned home births with 806,402 low risk hospital births, he consistently found a non-significantly lower perinatal mortality in the home birth group.

Homebirths are inherently low intervention. I am simply using these studies to show that lower intervention does not harm the mother. I agree that birth in a hospital setting is theoretically better for the cases where a problem may arise but the point I am trying to get across is to allow the "crazy natural folk" to refuse certain routine procedures without being scoffed at or looked down upon.

This study shows the outcomes of thousands of homebirths, which are inherently low intervention, and shows that the women and baby came out with similar mortality rates to hospital births of the same risk women.

You continue to claim improved safety and superiority of low intervention, home delivery for low risk women despite the fact that I have now repeatedly shown that there is no data to support this claim, and in fact the data supports the opposite conclusion. I do think that it is crazy to desire a more risky setting to birth someone that is so precious, but I also believe in patient autonomy. However, a patient cannot have true autonomy without also having the correct information upon which to make an informed decision. If the home-birth movement would just step back, look at their OWN data and say, "Ok it is riskier, but if the patient is willing to accept the risk for an experience we will help," I would not have a problem with it.

Actually on second thought, I would still have a problem with it... It is child abuse.

- pod

 

[Consigliere]

Fantastic retort! Which is exactly what I'd expect from a physician, not a nurse midwife in training masquerading as a pre-med student.

 

[jwk]

IF you are a med student (which I seriously doubt) then I fear for the future of medicine. On a positive note, though, you are an extreme minority and your impact will be minimal AT BEST.

If you are a med student, maybe you should make the jump now and start thinking like a doctor - and if you want to be a midwife, change now and do that. Because really, that's what it seems like you want to practice - midwifery, not medicine.

 

[fval28]

It is so sad, I agree. I just wonder, how is it that the nurse midwives rarely get sued when comparing a similar patient population? (women with no risk factors, etc).

CNM's don't do csections- also I would bet dollars to donuts that the bedside handholding and labor-coaching that is part of a CNM's practice goes a long way toward building a relationship with their patient that makes it a very awkward environment for a lawsuit.

 

[BlondeDocteur]

But, I still think labor is managed in a horrible way in the hospitals and that there is much need for improvement which includes respect and space for healthy women with healthy pregnancies to labor naturally...

Picture the woman who stays at home as long as she can and comes to the hospital when she feels like her contractions are close enough. She spends all that time at home without a professional and then gets checked into the hospital and checked by a nurse who has 5 other patients, some monitors and maybe a resident. Her doc isn't usually called until the very end. Contrast that with a well trained professional midwife who shows up at her home, with a lot of equipment including oxygen, amniohooks, pitocin, IV antibiotics, Saline... so much stuff. She shows up early on and is focused just on one patient. She is constantly monitoring the labor and listening for decels of the baby, taking moms blood pressure, follows the rythm of the contractions. If there is any trouble looming, they get in the car and head straight for the hospital. This woman is being cared for at home by a midwife who knows how to deliver a baby. If there is a cord prolapse at home from teh water breaking, this woman alone would not kow what to do on her own, but a midwife would call an ambulance right away and keep the cord from compression of the baby. How many midwives have actually saved babies from a cord prolapse DOA? I don't know, doubt they have studied it.

I find it interesting that the OP's model of "natural childbirth" is so damn... medical.

TDC, what has been repeatedly demonstrated is that the patients who choose home birth, as well as the people who write homebirth/natural birthing books, are a monolithic privileged population who have been able through their social influence and education to cherry pick from the hard-won medical knowledge of obstetrics accumulated throughout the years. Do you think Victorian midwives spoke of "cord prolapse" or AROM'd with amniohooks or-- most laughably-- had EFM equipment and could reliably interpret heart strips? Therefore their model (and YOUR model) of "natural birth" is a completely artifical one, all the more so because *every* woman choosing a home birth psychologically has the enormous safety net of "hospital transfer" that can "fix" anything that goes awry. How many ardent died-in-the-wool natural birther Manhattanite women laboring in their birthing pools in their Williamsburg lofts would choose an unmonitored home birth in the Alaksan bush, 600 miles from the nearest hospital? It suddenly becomes a lot more scary when doctors are truly taken out of the picture.

I might be one of the few people on this board who has actual experience with "natural birth"-- not the carefully packaged artificial construct you outlined, but actual natural birth. I've delivered babies, or been present for their birthing, in the most piss poor countries on this planet. Women laboring in the dirt, baby's umbilical cord packed full of cowdung, the whole nine yards. It's a degrading, terrifying experience, full of guttural screams, blood, and death. I've delivered twins on a gravel road surrounded by traffic and an open sewer-- naturally. Of course, most women make it through, and they love and welcome their children. But I highly doubt they would find much kinship with the glowing terms natural birthers use to describe their experience in those dark huts. Offer any of them a reliable Western hospital, a guarantee both they and their baby would survive the experience, and analgesia, and see how quickly they take it.

I think for most of us-- which will most certainly include you on your OB rotation in a couple of years, when your n of 3 births will be dramatically expanded-- have seen enough ****ty things on L&D, enough tragedy and drama and unexpected crisis, that we all look at home births and say "why?" Why on earth would you take the chance, with something so very, very precious as your own newborn child? Even if the day doesn't go as planned, even if you have a scar and it hurts to poop for the next week, at least you have almost 100% certainty of being discharged with a living, healthy baby.

 

[Geekchick921]

midwives are less sued because they have less money. the role of pain in labor is your opinion and has no factual basis. women do not, in fact, feel like they failed if they felt no pain and then move to c/s. and people who chose them are not MORE educated. every physician, lawyer, businessman, engineer, etc that i know had a physician help them deliver.

I'm going to necromance this thread because I can't get over how completely and utterly wrong this statement is. You have never heard of a woman that feels like they failed because they wound up with a C-section? I IMPLORE you to check out more message boards than SDN, because you can find scores of them easily.

And for what it's worth, hi, I'm Geekchick921. Now you've met one.

Also...

When time comes for you...and it will....you'll be doing those C-sections at 5 pm just like everyone else.

I guarantee you, IF I go the Ob route (if I go the medical school route at all anymore since my own birth experience has given me second thoughts), I will not be doing C-sections at 5PM just so I can get home in time for dinner.

 

[pgg]

I'm going to necromance this thread because I can't get over how completely and utterly wrong this statement is. You have never heard of a woman that feels like they failed because they wound up with a C-section? I IMPLORE you to check out more message boards than SDN, because you can find scores of them easily.

I think what he probably meant is that no rational and well adjusted woman feels like a failure because a c-section was deemed medically necessary. If they do feel that way, then they need to be gently and compassionately reassured that the c-section wasn't a product of their failure or inadequacy. I'm sorry to hear that you didn't get that kind of treatment.

And FWIW, I'd rather pour salt in my eyes while watching a Discovery Channel marathon of My Baby Story (or whatever it is) than go sift through forums full of laypeople talking about their birthing experiences.

I guarantee you, IF I go the Ob route (if I go the medical school route at all anymore since my own birth experience has given me second thoughts), I will not be doing C-sections at 5PM just so I can get home in time for dinner.

OK, if you say so, check in with us again when you get there. In the meantime, if you really are upset about your own birth experience, you owe it to yourself to seek better therapy than venting at a forum of medical students and doctors.

 

[Geekchick921]

I think what he probably meant is that no rational and well adjusted woman feels like a failure because a c-section was deemed medically necessary. If they do feel that way, then they need to be gently and compassionately reassured that the c-section wasn't a product of their failure or inadequacy. I'm sorry to hear that you didn't get that kind of treatment.

I spoke to my doctor about my feelings about my birth experience/C-section. We agreed that, while my C/S was necessary, the events leading up to it that caused it should not have happened (misdiagnosis that led to an induction that led to distress). Did it make me feel better? Slightly.

And also, at the risk of starting a debate, when the C-section rate in America is 2-3 times what the WHO recommends, and the attendings here are making cracks about doing C-sections at the end of shift so they can get home for dinner, it's pretty safe to say that there are plenty of women winding up with C-sections that aren't truly medically necessary. Many women feel the "woulda, coulda, shouldas" in regards to their labor & delivery when they look back on it, and the thought that "If I had done X or not agreed to Y, I wouldn't have had Z" is pretty prevalent in pretty much every other new mother I've spoken to, C-section or vaginal delivery, IRL or online.

OK, if you say so, check in with us again when you get there. In the meantime, if you really are upset about your own birth experience, you owe it to yourself to seek better therapy than venting at a forum of medical students and doctors.

I would hardly say I'm venting. What is so unrealistic about having a bad health care experience that you, as a practitioner, want to avoid your patients from having to go through as well?

 

[pgg]

when the C-section rate in America is 2-3 times what the WHO recommends

Oh boy.

the attendings here are making cracks about doing C-sections at the end of shift so they can get home for dinner,

First, you've got to recognize that in most cases, these are just cracks and nothing more. There's a lot of black humor and sarcasm in medicine. Much of it comes from dealing with patients like you. 🙂

Second, in the cases when they're not simply joking, you should realize that non-urgent c-sections are non-urgent and many may be safely performed within a window of time. Scheduling that non-urgent section for a time that is convenient for the obstetrician, anesthesiologist, and OR crew is not inappropriate in the least. Sometimes that means doing it now so you can have dinner later; sometimes that means eating dinner now and doing the section later.


I had more of a response typed in, but I think in the end I'd feel bad about arguing with you, given the fact that you're a patient who had a bad experience and not a med student or doctor who should know better. Hope you and your baby are well - good luck with AMCAS. 🙂

 

[Geekchick921]

First, you've got to recognize that in most cases, these are just cracks and nothing more. There's a lot of black humor and sarcasm in medicine. Much of it comes from dealing with patients like you. 🙂

Sarcasm recognition fail, in my case, then. I'm usually pretty good at picking up on the medical black humor, as I worked on a hospital floor for two years, but this is a sore spot for me as I've probably made obvious.

I had more of a response typed in, but I think in the end I'd feel bad about arguing with you, given the fact that you're a patient who had a bad experience and not a med student or doctor who should know better. Hope you and your baby are well - good luck with AMCAS. 🙂

I appreciate that. Thank you. We are both doing very well (sometimes I think she feels bad I had a C/S because she is a damn good baby :wink🙂. I try to look at it as an experience that will, ultimately, make me a better care provider from having "been there", even if it sucked.

 

[switching2gas]

We are talking about the OPs original case. I never said that c-sections are not justified ever - just that failure to progress is a stupid reason to perform one. As far as a women stuck in the pushing stage - I would certainly try to reposition her to help get the baby out - perhaps to squatting or on all fours - before cutting her open. I have seen two shoulder dystocias delivered vaginally simply by repositioning.

Umm, 99.9% of shoulder dystocias are delivered vaginally by repositioning. you almost never go to a Zavanelli (look it up.) First step in a shoulder is McRoberts, which is repositioning. So I'm not sure your infinite genius has gotten ahead of modern obstetrics the way you think.

 

[switching2gas]

Picture the woman who stays at home as long as she can and comes to the hospital when she feels like her contractions are close enough. She spends all that time at home without a professional and then gets checked into the hospital and checked by a nurse who has 5 other patients, some monitors and maybe a resident. Her doc isn't usually called until the very end. Contrast that with a well trained professional midwife who shows up at her home, with a lot of equipment including oxygen, amniohooks, pitocin, IV antibiotics, Saline... so much stuff. She shows up early on and is focused just on one patient. She is constantly monitoring the labor and listening for decels of the baby, taking moms blood pressure, follows the rythm of the contractions. If there is any trouble looming, they get in the car and head straight for the hospital.

Are you high? No L&D nurse in any reputable hospital is taking care of five laboring patients at once. 1-2 at most. And what do you think they are doing? Monitoring the baby's heart rate, mom's contractions, and mom's vitals, as well as being a support person. And guess what, that bag of goodies you are so excited about a midwife bringing to a homebirth is all available -- wait for it -- in the hospital, too.

This woman is being cared for at home by a midwife who knows how to deliver a baby. If there is a cord prolapse at home from teh water breaking, this woman alone would not kow what to do on her own, but a midwife would call an ambulance right away and keep the cord from compression of the baby. How many midwives have actually saved babies from a cord prolapse DOA? I don't know, doubt they have studied it.

This paragraph alone tells me how little you know about obstetrics. A cord prolapse is going to kill the baby in minutes. The only way to save a kid whose cord has prolapsed is to be IN A HOSPITAL, with the ability to do a stat cesarean section within 10 minutes. And a cord prolapse doesn't kill the kid from "compression of the baby," it kills the kid from compression of the cord, the blood supply. Talking about cord prolapse is a great example of why even "normal, healthy" labors can benefit from being in a hospital, not an ambulance-ride away, when second and minutes may be all you have in terms of getting the kid out.

You have a lot to learn, a long way to go.

 

[jwk]

You have a lot to learn, a long way to go.

A LITTLE knowledge is a dangerous thing.

 

[coprolalia]

I find it interesting that the OP's model of "natural childbirth" is so damn... medical.

TDC, what has been repeatedly demonstrated is that the patients who choose home birth, as well as the people who write homebirth/natural birthing books, are a monolithic privileged population who have been able through their social influence and education to cherry pick from the hard-won medical knowledge of obstetrics accumulated throughout the years. Do you think Victorian midwives spoke of "cord prolapse" or AROM'd with amniohooks or-- most laughably-- had EFM equipment and could reliably interpret heart strips? Therefore their model (and YOUR model) of "natural birth" is a completely artifical one, all the more so because *every* woman choosing a home birth psychologically has the enormous safety net of "hospital transfer" that can "fix" anything that goes awry. How many ardent died-in-the-wool natural birther Manhattanite women laboring in their birthing pools in their Williamsburg lofts would choose an unmonitored home birth in the Alaksan bush, 600 miles from the nearest hospital? It suddenly becomes a lot more scary when doctors are truly taken out of the picture.

I might be one of the few people on this board who has actual experience with "natural birth"-- not the carefully packaged artificial construct you outlined, but actual natural birth. I've delivered babies, or been present for their birthing, in the most piss poor countries on this planet. Women laboring in the dirt, baby's umbilical cord packed full of cowdung, the whole nine yards. It's a degrading, terrifying experience, full of guttural screams, blood, and death. I've delivered twins on a gravel road surrounded by traffic and an open sewer-- naturally. Of course, most women make it through, and they love and welcome their children. But I highly doubt they would find much kinship with the glowing terms natural birthers use to describe their experience in those dark huts. Offer any of them a reliable Western hospital, a guarantee both they and their baby would survive the experience, and analgesia, and see how quickly they take it.

I think for most of us-- which will most certainly include you on your OB rotation in a couple of years, when your n of 3 births will be dramatically expanded-- have seen enough ****ty things on L&D, enough tragedy and drama and unexpected crisis, that we all look at home births and say "why?" Why on earth would you take the chance, with something so very, very precious as your own newborn child? Even if the day doesn't go as planned, even if you have a scar and it hurts to poop for the next week, at least you have almost 100% certainty of being discharged with a living, healthy baby.

HOLY CRAP! I am in love. 😍

This is some of the best writing I've read on this forum - EVER.

This person should be posting on this forum a LOT.

-copro

 

[pgg]

HOLY CRAP! I am in love. 😍

This is some of the best writing I've read on this forum - EVER.

This person should be posting on this forum a LOT.

-copro

Yeah, this was a good thread. POD was in good form too. 🙂

 

[coprolalia]

Yeah, this was a good thread. POD was in good form too. 🙂

Agreed.

I'm so sick of dilettantes with their co-requisite lofty, naive, and hubristic opinions. Both POD and BlondeDocteur handed out the appropriate - and quite eloquent - smack-downs.

👍

And, Geekchick921, you have my permission to get over yourself. The problem is patients like you who want to harp on process instead of outcome, as if process is somehow pararmount (and all the touchy-feely bullsh*t that goes along with it that you feel you didn't get) despite the fact that it is over and done with already. Please don't turn into a clinician overly obsessed with this b.s., if as you say you even decide to continue in medicine. I hate friggin' drama queens like yourself, and if that's going to be your cause célèbre then you should've gone into nursing instead.

Doctors that are expert at showing compassion are, in no other uncertain terms, only one thing: great actors.

Get over yourself. The past is the past.

-copro

 

[pgg]

process instead of outcome

It's like the wedding day bridezillas, all caught up in the flower:candle ratio on the reception tables, totally distracted from what actually matters.

Maybe the Discovery Channel needs a show about momzillas for when a safe delivery and healthy mother & baby aren't enough.

 

[coprolalia]

It's like the wedding day bridezillas, all caught up in the flower:candle ratio on the reception tables, totally distracted from what actually matters.

Maybe the Discovery Channel needs a show about momzillas for when a safe delivery and healthy mother & baby aren't enough.

Yeah, I want someone to point out the place in the Constitution where it says that things will always go perfectly for everyone all the time.

We are turning, as a society, into such a pack of whiny little self-deserving babies, and I'm getting really sick of it.

-copro

 

[Geekchick921]

And, Geekchick921, you have my permission to get over yourself. The problem is patients like you who want to harp on process instead of outcome, as if process is somehow pararmount (and all the touchy-feely bullsh*t that goes along with it that you feel you didn't get) despite the fact that it is over and done with already. Please don't turn into a clinician overly obsessed with this b.s., if as you say you even decide to continue in medicine. I hate friggin' drama queens like yourself, and if that's going to be your cause célèbre then you should've gone into nursing instead.

Doctors that are expert at showing compassion are, in no other uncertain terms, only one thing: great actors.

Get over yourself. The past is the past.

-copro

Lovely. 👎

 

[coprolalia]

Lovely. 👎

Yeah, exactly.

This is why I hate whiners. You don't really have a cogent rebuttal, except that your feelings were hurt.

But, no doubt, you'll go find your gaggle of equally melodramatic girlfriends to rehash, over hours and hours, how this guy "coprolalia" on some forum was, gosh, such a complete jerk!

Like I said before, get over yourself.

-copro