A reader’s comment on my last post questioned my statements:
“I am incredulous at how ignorant this article sounds. No wonder MD’s often get frustrated with the way midwives practice. Please go read some NEJM or JAMA articles before you go asking the sky, “Where’s the evidence??” Or better yet, go to medical school.”
Well, yes, MDs do get frustrated with midwives–sometimes understandably so–and midwives get frustrated with MDs, because none of us are immune to blindly following the herd and participating in practices that are not evidence-based. My concern is with any practitioner, MD or midwife, who ignores evidence because “I’ve always done it this way and never had a problem. . .”
Following is a sampling of the current evidence regarding ten procedures commonly used in modern obstetrics despite a lack of evidence to support their use. Please note: many of these procedures are beneficial in specific situations. It is their routine use without medical indication that I am addressing.
1. Inductions/elective c-sections for suspected macrosomia (big baby): The Cochrane Database reports “no evidence of improved outcomes following induction of labour for non-diabetic women who are thought to be carrying large babies. Babies who are very large (macrosomic – over 4500 g) can sometimes have difficult and, occasionally, traumatic births. One suggestion to try to reduce this trauma and to reduce operative births has been to induce labour before the baby grows too big. However, the estimation of the baby’s weight in utero is difficult and not very accurate. Clinical estimations are based on feeling the uterus and measuring the height of the fundus of the uterus, and both are subject to considerable variation. Ultrasound scanning is also not accurate.”
- Cochrane Database of Systematic Reviews. Induction of labor for suspected fetal macrosomia. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD000938/pdf_fs.html
- Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol.2006 Sep;195(3):657-72. Epub 2006 Apr 21.
2. Pitocin to speed labor: I am referring here to the routine use of pitocin to speed up a normal labor. Unfortunately, this happens more frequently than one might think. Doctors and midwives have lives outside the hospital, and the temptation to speed labor in order to get home sooner is difficult to resist when you’re tired and anxious to get home. Evidence shows: “Early amniotomy and high doses of oxytocin may both increase the risk of fetal heart rate anomalies, but are both useful for avoiding prolonged labour.”
- Verspyck E, Sentilhes L. Abnormal fetal heart rate patterns associated with different labour managements and intrauterine resuscitation techniques. J Gynecol Obstet Biol Reprod (Paris).2008 Feb;37 Suppl 1:S56-64. Epub 2008 Jan 9.
- Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E. A guide to effective care in pregnancy and childbirth. 2000et al. New York: Oxford University Press.
- Fraser W, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour. The Cochrane Database of Systematic Reviews. 1999;4:CD000015.F.
- Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol. 2009; 200(1):35.e1–6.
3. Amniotomy to speed labor: The Cochrane Library reports: “Evidence does not support the routine breaking the waters for women in spontaneous labour. The aim of breaking the waters (also known as artificial rupture of the membranes, ARM, or amniotomy), is to speed up and strengthen contractions, and thus shorten the length of labour. The membranes are punctured with a crochet-like long-handled hook during a vaginal examination, and the amniotic fluid floods out. Rupturing the membranes is thought to release chemicals and hormones that stimulate contractions. Amniotomy has been standard practice in recent years in many countries around the world. In some centres it is advocated and performed routinely in all women, and in many centres it is used for women whose labours have become prolonged. However, there is little evidence that a shorter labour has benefits for the mother or the baby. There are a number of potential important but rare risks associated with amniotomy, including problems with the umbilical cord or the baby’s heart rate. The review of studies assessed the use of amniotomy routinely in all labours that started spontaneously. It also assessed the use of amniotomy in labours that started spontaneously but had become prolonged. There were 14 studies identified, involving 4893 women, none of which assessed whether amniotomy increased women’s pain in labour. The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”
- The Cochrane Library. Amniotomy for shortening spontaneous labor. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD006167/frame.html
4. Continuous electronic fetal monitoring: The American Congress of Obstetricians and Gynecologists (2005) recommends that healthy women with no complications may be monitored with intermittent auscultation or with EFM. Intermittent auscultation instead of EFM may safely reduce the cesarean rate.
- American College of Obstetricians and Gynecologists [ACOG]. (2005). ACOG practice bulletin #70: Intrapartum fetal heart rate monitoring. Obstetrics and Gynecology, 106(6), 1453–1460.
- Gourounti, K., & Sandall, J. (2007). Admission cardiotocographyversus intermittent auscultation of fetal heart rate: Effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumentaldelivery—A systematic review. InternationalJournal of Nursing Studies, 44(6), 1029–1035.
5. Requirement of “immediate” emergency services for women attempting a VBAC. The recent NICHD consensus statement speaks: “Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.”
- Consensus Development Conference Panel Final Statement on VBAC. http://consensus.nih.gov/2010/vbacstatement.htm
6. Routine Episiotomy: None of the following studies found a benefit to routine episiotomy. Current recommendations are to use episiotomy when there are indications of fetal distress and birth does not appear to be imminent.
- Dannecker, C., Hillemanns, P., Strauss, A., Hasbargen, U., Hepp, H., & Anthuber, C. (2004). Episiotomy and perineal tears presumed to be imminent: Randomized controlled trial.Acta Obstetricia et Gynecologica Scandinavica, 83(4), 364–368.
- Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., & Lohr, K. N. (2005). Outcomes of routine episiotomy: A systematic review. Journal of the American Medical Association, 293(17), 2141–2148.
- Klein, M., Gauthier, R., Robbins, J., Kaczorowski, J., Jorgensen, S., Franco, E., et al. (1994). Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American Journal of Obstetrics and Gynecology, 171(3), 591–598.
7. Routine ultrasound to estimate fetal size:“Fetal weight estimation is inaccurate, with poor sensitivity for prediction of fetal compromise.” (Dudley 2005). “Prediction of fetal macrosomia remains an inaccurate task even with modern ultrasound equipment” (Henrickson2oo8). ”Considerable error in fetal weight estimations. . .may limit the accuracy and clinical utility of these measurements” (Landon 2000).
- Dudley NJ. A systematic review of the ultrasound estimation of fetal weight. Ultrasound Obstet Gynecol. 2005 Jan;25(1):80-9.
- Henrickson T. The macrosomic fetus: a challenge in current obstetrics. Acta Obstet Gynecol Scand. 2008;87(2):134-45.
- Landon MB. Prenatal diagnosis of macrosomia in pregnancy complicated by diabetes mellitus. J Matern Fetal Med. 2000 Jan-Feb;9(1):52-4.
8. Immediate cord clamping: “Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy” (Hutton & Hassan 2007).
- Hutton, E. K., & Hassan, E. S. (2007). Late vs early clamping of the umbilical cord in full-term neonates: Systematic review and meta-analysis of controlled trials. JAMA, 297(11), 1241-1252.
9. Directed (purple) pushing: The following studies concluded that allowing the mother to push spontaneously (when, how long, and how hard to push are left up to the mother rather than directing her how to push), is superior to directed pushing. Directed pushing is not recommended as there is greater risk of perineal trauma, fetal distress, and it does not significantly shorten the pushing phase of labor.
- A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194(1), 10–13
- Mayberry, L. J., Wood, S. H., Strange, L. B., Lee, L., Heisler, D. R., & Nielsen-Smith, K. (2000). Second-stage management: Promotion of evidence-based practice and a collaborative approach to patient care. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).
- Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.
- Schaffer, J., Bloom, S., Casey, B., McIntire, D., Nihira, M., & Leveno, K. (2006). A randomized trial of the effects of coached vs. uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. American Journal of Obstetrics and Gynecology, 192(5), 1692–1696.
10. Supine Pushing: This, along with routine amniotomy and continuous fetal monitoring, is used in the vast majority of hospital births. The following studies concluded that supine pushing is not beneficial and can even be harmful to the mother, by working against gravity, decreasing blood pressure which can lead to fetal intolerance of labor, increased episiotomy, increased use of vacuum/forceps, and increased pain for the mother.
- Gupta, J. K., Hofmeyr, G. J., & Smyth, R. (2004). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD002006.
- Johnson, N., Johnson, V., & Gupta, J. (1991). Maternal positions during labor. Obstetrical and Gynecological Survey, 46(7), 428–434.
- Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.
I think it’s sad that you even had to defend your last post with this more recent one. Most of them sound like common sense to me! But maybe they wouldn’t have sounded so reasonable a year ago; I don’t know. I know that I would never totally disregard someone else’s research if I hadn’t done my own, like the person who left that “ignorant” comment.
Unfortunately, there is such a mindset among most providers of obstetric healthcare that none of these are really important issues. The evidence may say that routinely breaking the water carries risks, but modern obstetrics is so used to seeing the risks of these procedures occur, and perceiving them as the normal risks of labor, they can’t see that they cause many of the labor complications that occur.
This is so sad. There’s a real lack of exposure among OB’s and L & D nurses in many hospitals about what a “normal” un-interfered with birth looks like. Many of these “birth professionals” have no idea, or see it so seldom they forget how calm and “easy” things can go when the mother is not rushed or stressed by someone else’s time table. Like you pointed out in a previous post, to change our modern obstetric practices would cost too many people – ob/gyns, anesthesiologists, and hospitals – too much money. And ACOG has a powerful lobby group in D.C. However, if the consumer demand for those hospital births and OB care goes down because more people want midwifery/birth center/homebirth care, perhaps things might change a bit. Perhaps education and exposure to “normal births” is part of the answer. I love your blogs and your info. SO helpful and informative. Thank you.
okay, WOW to what u just said (birth sense) prior to Laura’s post. just that wording alone… that they see the risks so often that they now consider it normal…
and Laura.. as i was reading your post it occurred to me that us placing our ‘vote’ by choosing midwifery etc, would cause things to change a bit, that that very reason is why homebirth is becoming illegal more and more? that they DO see us choosing that and they are trying to remove that option from us??? scary.
In no way in defense of what “normal” medical practices in OB have become, as a Mother/Baby nurse in a hospital, I see time and time again that many of our new and future moms have no, or little, interest in doing what is best for themselves or their babies. While many fall prey to blindly believing what society (doctors, nurses, family, friends, TV, movies, etc.) tells them, a good many of them want what is fast, easy and pain-free. We have become a society of people who don’t want to have to wait for, work for, or be inconvenienced or uncomfortable in what we want. Just look at the obesity rate in this country. But that’s another story! I am frequently blown away by the new mother who has a newborn that is ready, willing, and eager to breastfeed who decides not to just because she “doesn’t like it”. Or the mom who was just induced because she “was tired of being pregnant”. The list goes on and on. I know most of these moms have been led to believe that these decisions are completely safe and acceptable and even “normal”. And, even if we can/do manage to change medical procedure policies, we have a long road ahead of us in convincing a lot of the rest of our society what is best. While I dream of a world where women desire and demand a midwife/homebirth experience,whether in the hospital or at home, I’m afraid at this point we are far from it.
You’ve hit the nail on the head. If there was a widespread, educated, consumer demand for normal & natural labor and delivery services, hospital practices would change dramatically. I sympathize with the well-intended CNM who has a client come in with no real intention of natural birth. However, I think it would be fantastic if more medical professionals, like yourself, were vocal on these topics to help better educate the masses on the risks these procedures pose to themselves and their babies. Thanks for your comment. I think it added a great perspective to the post!
i totally hear you rebecca. as a doula i have seen it all. and there are plenty of mom’s who want a normal birth that we need to give way to them……..
quick, easy, convenient…..i really believe it’s about education. ‘When we know better, we do better’.
I’ve seen first hand how consumer demand can change practices. When I was in nursing school, I used to ask my gyn if he would take me in to practice when I became a midwife. “No way!” was always his response. “Then I’ll set up shop across the street” I always responded.
At that time only the university hospital used midwives. But because all the hospitals were relatively close together (called Pill Hill), when one hospital got new equipment (birthing balls, chairs, bed bars, LDRPs) or changed policies (midwife privileges, dads rooming in, sibs rooming in) within 6-12 months all of Pill Hill had to implement them. Then all the outlying hospitals, or folks would just go into town.
Last time I was home, I noticed my old ob-gyn (who was in an outlying suburb) had had a group of midwives working with he & his partner for yrs.
OB practices changed in that town (and at relative lightning speed driven by consumer demand.
Great job on this! Just wanted to point out that the section on directed pushing is an incomplete sentence. “The following studies concluded that allowing the mother to push spontaneously” was what?
I see you fixed it
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Yes on all of these. I see them all the time as a doula.
I was at a VBA2C birth this week (waiting for moms approval to post her story on my blog) and I heard the nurses talking at their stations – “That mom needs pitocin, she isn’t going fast enough” Because she was VBAC pitocin wasn’t allowed and yes the progress was slow, but she did progress and had her VBA2C. It was awesome!
Every single one of these is practiced in hospitals near me. I’ve even had doctors still give episiotomy’s without even asking or informing my client(and yes,for NO medical reason). I try my best to inform women of the risks and benefits. Unfortunately,until something is done about hospitals/MD’s thinking of themselves and looking at women as potential lawsuits..these practices will still go on.
All the reasons above plus more are why I decided to have my 2nd baby and any future children at home with the guidance of loving midwives. Hospital-based births do not give the mother the power of choice and decision making, only what is convenient for them. I have heard so many stories of mothers having hospital births with unecessary medical interference. Shame on OBGYN’s for making mothers feel that they are not able to make the best decisions for their baby and bodies! We as women and mothers are the best judges of what we need to birth our children. Women have been birthing on their own at home for centuries! Thank you for this great read! I highly recommend Ina May Gaskin’s books! It’s time we stand up to medical intervention and demand our requests be followed!
The great thing about working in a UK unit with a strong midwifery voice, 2 consultant midwives and 2 interdisciplinary midwife Practice Educators is that I read this and think ‘I thought we had this stuff all sorted out years ago’ – none of this stuff is supported by evidence. Then I read this and realise it’s STILL going on in parts of the world – in clinical terms, this type of care should be out with the dinosaurs. PS I’m a 24/7 caseloader and we have a high rate (on the National Health Service) of home birth
Any intelligent fool can make things bigger and more complex… It takes a touch of genius – and a lot of courage to move in the opposite direction.
Albert Einstein
I love this Einstein quote. If I were still with my former Ob-gyn’s office I’d give them a copy of it (maybe at the appointment when they give me the hand-out about their preference for “active labor management”)
I am hoping my new place is better, but since they do free ultrasounds for everybody at 8 weeks “just for fun”, I’m guessing not. They’re supposedly the best in town though-I guess I’ll see!
Thank you so much for conferming my feelings as mother. It was very educating.
What a list! It’s amazing to me that #10 is still routine; I remember reading about the problems with the supine position, and the alternatives such as crouching, decades ago. Why is it taking so long for this and the other practices to change? Grrrrr.
We had our babies with a midwife at home here in Korea. We wanted to avoid every thing on this list. We are so grateful we did after hearing several terrible stories of my friends having little say in what happened to them while birthing their babies in the hospital.
What about Cicumcision? Ob/gyn’s do preform a lot of them and they are not even the babies doctor! Thoughts on this?
This is so great. Recently I wrote an article (http://blog.christianitytoday.com/women/2012/09/are-pregnant-women-who-have-bi.html) about how choices in birth are more than just a plain old consumer preference–and really a matter of justice, because it’s about doing what’s healthiest and best–and have been attacked soundly for it. Keep up the great work.
Processing things I’ve done as a mifwide is really important to me so that I can keep learning and growing both in my practice and as an advocate for women’s rights around childbirth. Owning our decisions as practitioners is the only way to reflect and improve. Discovering and revealing inadequacy’s in ourselves is never easy. Thanks wildmama, love your work.
As a doula I instill in my parent clients that that they need to start parenting the child long before they bring them home from the hospital and that involves making decision in pregnancy and birth. As a majority of people would agree, we do the best we can with the information we have. Today the information is massive, all we have to do is look or ask. Thanks for being such a wonderful source of information.
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