This VBAC story is from Dr Daniels' blog. She is an ob-gyn physician why had an unintended VBAC, which dramatically changed her perspective on the obstetrical profession and the unintentional role it plays in making normal childbirth for healthy women more difficult, less satisfactory, unnecessarily medicalized and unproductively expensive. She had a lot of very insightful things to say about the difference btw medicalized care and physiological management.
Here is one that is a "Pearl of Great Price":
"We should continue to make efforts to reduce medically unnecessary inductions for mom and baby’s well-being, we should attempt to humanize cesareans for moms who need to have them, we should properly evaluate and assess each VBAC individually to decrease risk, and we should place natural labor and birth back into the realm of the norm, with the interventions and surgeries reserved for the truly high-risk."
If you reading time is limited, drop down to read the last few paragraphs.
original source: www.drpoppy.com/wordpress/?p=116
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March 19th, 2010
As I type, I look over at my one-week old baby zonked out in his cradle swing and am in awe at how awesome his arrival was. Instead of having my third c-section as scheduled, I went into labor on my own (first time in 5 tries) and delivered him (precipitously in fact), one hour before I was to arrive at the hospital for my surgery. I find this wonderful and quite ironic in light of the recent NIH VBAC conference in Bethesda, MD; I had just downloaded the consensus statement and was digesting it while awaiting my baby’s arrival (more on that later).
In order to tell the story of how I ended up with a surprise VBAC, I have to start at the beginning of my long and adventurous reproductive journey. My first pregnancy ended in the first trimester with a miscarriage and heavy bleeding requiring a D&C to stop it. I was a OB/Gyn resident at the time and was surrounded by high risk OB patients every day. I trained in downtown Philadelphia where an addicted mom with no prenatal care could deliver on one end of the hall, while a high risk IVFer from the Main Line might be delivering on the other end. Although we worked side by side with midwives, we only became involved if their patients developed complications or needed a C-section. Needless to say, like most OB residents, my experience with normal, low-risk physiological birth was minimal.
Being pregnant in this environment and then losing the baby certainly colored my perspective. Like any mom who loses a first baby, I was troubled with the worry that I wouldn’t be able to have another baby, so that when I did become pregnant again, I embraced the “we have to be very careful and be supervised very closely with this one” approach. I worked up until term, 36 hr shifts, 100 hr work-weeks, having to turn sideways at the operating table at the end, and then it was decided that I should be induced at 39 weeks due to gestational hypertension. There were no signs of pre-eclampsia and the pressures were not sky-high, but at the time, I fell into the “you’re term, what’s the need to take a chance” mentality and was scheduled for an induction.
I went in at night for prostaglandin gel due to an unripe cervix (should have known better) followed by Pitocin the next morning. I labored all day, getting the obligatory epidural that a Pitocin induction necessitates, finally getting to complete around 8 pm. I pushed for 2 1/2 hrs, I used the bar, the sheet, everything the hospital approach has to offer…but the baby was OP and would not rotate with “all” of our maneuvers and so I received a C-section for “arrest of descent.” Happy as I was with my new son, everyone who has labored and then had surgery, knows the pain that you are in for. I wasn’t disappointed in the C-section because at that time, I was still fully entrenched in the “at least I have a healthy baby” mindset.
Despite that experience, I always wanted to have a vaginal birth and since most university hospitals were still doing them regularly (’03), I chose a new doctor whose obstetrical/surgical skills I trusted who would support by desire for VBAC. My pressures started acting up again so I was slated for induction, although this time my cervix was riper and I went right in for Pitocin. They did one of the most inhumane things which was to artifically rupture my membranes on Pitocin in the active phase of labor. Needless to say, an epidural was imperative but I almost couldn’t sit for it due to the pain. This time I pushed for 3 hours, hard pushing, hands and knees at one point (I must have learned something from the midwives), and ended up with a vacuum extraction and a fractured coccyx, from a 7#14oz baby. He had jaundice and a cephalohematoma but hey, I got my VBAC. He today is honored to say, “I broke mom’s butt when I was born.”
Baby number 3 was an easier pregnancy although this time I added on gestational diabetes so that plus the usual spike in blood pressures brought us back to induction. Although he was my smallest baby, 7#, he still was delivered by vacuum although my butt remained intact. With baby number 4, I figured another VBAC was practically guaranteed so I didn’t resist the induction assuming the last birth meant smoother sailing now. This time they decided to start the Pitocin the night before, but instead of staying at a low dose overnight, the nurse kept coming in and increasing the dosage. I knew I wasn’t progressing because I was not in active labor, so I questioned her about the dose, reminding her that I did have a scarred uterus. She responded that everything looked fine but she would stop until morning.
Morning arrived with the usual course of epidural, AROM and increasing Pitocin. When it came time to push, within 20 minutes, I knew something was wrong. Despite the epidural, I could tell he wasn’t coming down with my pushing and by the frazzled looks of everyone in the room, I knew the heart tones were dropping. I looked at my husband and told him we needed to stop. By the time they got down to the uterus in the OR, it became clear that if we wouldn’t have stopped, I would have had a uterine rupture. As it was, I had what is called a uterine window, they were able to see the baby’s hair through a very thin lower uterine segment.
Finally, I made the connection between the induction and the narrow avoidance of catastrophe. So with baby number five, I knew I did not want another induction. Interestingly, this pregnancy was also my healthiest. I had made a concentrated effort before becoming pregnant to address my diet and treat my vitamin deficiencies, so I had no blood sugar or blood pressure problems, kept my weight gain to 15 pounds and did not have any obstetric problems other than being an advanced maternal age grandmultipara with a history of 2 c-sections! Knowing that I had never gone into spontaneous labor, I felt the safest route was to do a scheduled repeat C-section at 40 weeks.
I did put it into God’s hands and had been in prayer that I was open to the baby coming forth in whatever way he was supposed to…and so I went into spontaneous labor at 2 am, the morning of surgery, got to the hospital at 4:30 and was 9 cm dilated. The staff asked me what I wanted to do and I said, “I’m going to have him!” They also offered me an epidural (too late for that) and IV pain meds (I certainly didn’t want a narced up baby), so unmedicated it was, and he was born at 5:13 AM, a beautiful, alert 7#11oz baby boy who latched right on and has been peaceful ever since. Not having to recover from an extensive surgery was a gift for which I continue to be amazed and grateful.
Reflecting back over my journey, I see how much the field of obstetrics has managed to contribute and sometimes outright cause complications, all the while assuming they are just keeping everyone safer. And I see how much fear has overtaken the natural birthing process. I’ve said before that shows like Deliver Me, A Baby Story, and Birth Day should be renamed “Fear Factor” because they play on a woman’s often natural concerns about the birth by portraying the whole process as highly dramatic, with a woman strapped down and hooked up, by a doctor gowned and gloved like an alien visitor and often highlighting very anxious family members. Sure a woman has fear, fear that something is going to happen to her or the baby, fear of pain, fear of failure, that she just won’t be able to “do it.” Add in snarky, cynical nurses and doctors who ridicule anyone who seems to want to be in charge of her birth (after all we’re the experts)…limited labor support or assistance in the form of doulas or labor coaches except in certain areas…restricted mobility, food and drink…and almost endless interventions and you have potential for trouble.
We have cultivated an environment that this is normal, and somehow now some women even find value in being “risky.” My mentor, Dr. Lauren Plante, a maternal-fetal medicine specialist who had two midwife-attended home births, wrote about this in an essay entitled “Mommy, what did you do in the industrial revolution?” Meditations on the rising cesarean rate: “Although the inherent literal meaning of the high-risk pregnancy is one that entails a higher risk of a poor outcome (for mother or baby), the sub-text seems to be that high-risk equals high-value…is it the Disneyfication of a primal human endeavor, longing for the synthetic and dramatized in preference to the authentic?” In other words, do we have more regard for the Main-Liner’s IVF-achieved pregnancy who has an elective c-section over the addicted mother’s unmedicated spontaneous birth?
All of the repeat C-sections and almost extinction of VBAC, have not really prevented poor outcomes as revealed by the NIH VBAC conference. Women who have a trial of labor after a previous cesarean have a lower risk of maternal mortality compared to those who have a repeat cesarean. Although there is a higher risk of uterine rupture with trial of labor, spontaneous labor versus induction has the lowest risk. And there have been no reports of maternal mortality due to uterine rupture (we were constantly told…mother and baby could die with VBAC). Repeat C-sections are also associated with an increased risk of abnormal placental position and growth in subsequent pregnancies, which also increases risk of cesarean hysterectomy. Although there is an increased risk of perinatal mortality with trial of labor, the risk is small and not that different from a laboring woman with her first pregnancy. Issues related to medical liability are a big concern for many practitioners, a fact that could be alleviated or helped by tort reform and hospitals assuming some malpractice costs up front.
In our local hospital, although the hospital allows VBACs, there is at least one doctor who simply doesn’t want to take any risk and personally won’t do VBACs. This approach is unfortunate since the overall finding of the NIH conference is that trial of labor is a safe option for many women and that women should be fully informed so that they may make the best decision for them. ACOG certainly needs to revise its mandate that anesthesia and c-section should be available immediately so that more rural hospitals can still offer VBAC to their patients without feeling they are not within standard of care.
Can you imagine if I had been in a VBAC-banned hospital and been forced to have surgery at 9 cm dilated? Can you imagine how that would have increased my potential for morbidity and even mortality? Should everyone have a VBAC? No, but every woman should still have the opportunity to discuss her personal issues and whether it could be an option for her, and she should be not be forced to have surgery against her will due to a medically-unsubstantiated VBAC ban. We should continue to make efforts to reduce medically unnecessary inductions for mom and baby’s well-being, we should attempt to humanize cesareans for moms who need to have them, we should properly evaluate and assess each VBAC individually to decrease risk, and we should place natural labor and birth back into the realm of the norm, with the interventions and surgeries reserved for the truly high-risk.
Check out Dr Daniel's blog www.drpoppy.com/
Monday, June 07, 2010
Monday, March 22, 2010
MaternityCare_2.0 ~ Mother-Baby-Father-Friendly Care for Normal Childbirth that all Americans can be proud of!
Today’s blog is the final installment about an ABC article reporting on the increase in maternal mortality in the US (published by ABC on March 4th, 2010, excerpts embedded in the March 8th of this blog (Normal-Birth.blogspot.com).
We know that what has been happening is the US is wrong - the false idea that Cesarean surgery makes birth safer. Now we need to figure out how to correct this problem -- how do we transform our maternity care system? And in particular, how do we end the mindless medicalization of normal birth - the overuse and misuse of induction of labor and elective Cesarean - in healthy women and replace it with evidence-based, cost-effective maternity care. This is the best way to (a) reduce preventable maternal mortality and (b) to provide an effective and efficient system that is highly rated by childbearing families as "satisfying" and highly rated by health care officials as affordable and accessable.
The science-based model of maternity care for normal childbirth protects and preserves maternal-fetal wellbeing, while providing access to appropriate obstetrical intervention for those women or babies with complications or if medical interventions are requested by the mother. This serves the needs of healthy families far better than our expensive and inflexible high-tech model, which costs two to ten times more than it needs to.
Billions of health care dollars can be saved every year by lowering the direct cost of maternity care and reducing post-operative, delayed and downstream complications associated with Cesarean surgery.
MaternityCare_2.0 is a big first step on our national path to a safe, effective, affordable, accessible healthcare system that we Americans can to proud of -- HealthCare_2.0
Adopting evidence-based standards for normal childbirth will require legal and legislative changes that move us away from the mistaken idea that it is "substandard" for a physician to provide physiologic (i.e. non-medical) care, since childbirth is legally defined as a surgical procedure by the medical profession. We also need regulations to end the perverse incentives that pay for doing things *to* the mother (often risky, invasive or painful procedures) but don’t compensate a physician for spending time *with* the mother. Under the current surgical billing code for normal birth, medical providers are paid per procedure. This makes more interventions more profitable.
What we need is a new, non-surgical billing code for physiologically-managed childbirth that allows birth attendants to be protected from outmoded policies and inappropriate litigation, while at the same time being fairly compensated for their time and rewarded for preventing complications. This will also reduce long-term problems that burden the family and are expensive to the healthcare system.
Maternity Care 2.0 – a science-based model for the 21st Century:
For an essentially healthy population, the most efficacious form of maternity care is always the method that provides “maximal results with minimal interventions”. This is defined as a *beneficial ratio of interventions to outcomes* for each childbearing woman.
The ideal maternity care system *seeks out the point of balance* where the skillful use of physiological management and adroit use of necessary medical interventions provides the *best outcome* with the *fewest number* of medical/surgical procedures and *least expense* to the health care system.
This is the right way, the only way to eliminate preventable maternal mortality and morbidity and eliminate unnecessary suffering of the children, fathers and families left behind.
Faith Gibson - former L&D nurse, California licensed professional midwife, ratifier of the Coalition for Improving Maternity Services (CIMS) “Mother Friendly Childbirth Initiative”
www.collegeofmidwives.org
www.normalbirth.org
Today’s blog is the final installment about an ABC article reporting on the increase in maternal mortality in the US (published by ABC on March 4th, 2010, excerpts embedded in the March 8th of this blog (Normal-Birth.blogspot.com).
We know that what has been happening is the US is wrong - the false idea that Cesarean surgery makes birth safer. Now we need to figure out how to correct this problem -- how do we transform our maternity care system? And in particular, how do we end the mindless medicalization of normal birth - the overuse and misuse of induction of labor and elective Cesarean - in healthy women and replace it with evidence-based, cost-effective maternity care. This is the best way to (a) reduce preventable maternal mortality and (b) to provide an effective and efficient system that is highly rated by childbearing families as "satisfying" and highly rated by health care officials as affordable and accessable.
The science-based model of maternity care for normal childbirth protects and preserves maternal-fetal wellbeing, while providing access to appropriate obstetrical intervention for those women or babies with complications or if medical interventions are requested by the mother. This serves the needs of healthy families far better than our expensive and inflexible high-tech model, which costs two to ten times more than it needs to.
Billions of health care dollars can be saved every year by lowering the direct cost of maternity care and reducing post-operative, delayed and downstream complications associated with Cesarean surgery.
MaternityCare_2.0 is a big first step on our national path to a safe, effective, affordable, accessible healthcare system that we Americans can to proud of -- HealthCare_2.0
Adopting evidence-based standards for normal childbirth will require legal and legislative changes that move us away from the mistaken idea that it is "substandard" for a physician to provide physiologic (i.e. non-medical) care, since childbirth is legally defined as a surgical procedure by the medical profession. We also need regulations to end the perverse incentives that pay for doing things *to* the mother (often risky, invasive or painful procedures) but don’t compensate a physician for spending time *with* the mother. Under the current surgical billing code for normal birth, medical providers are paid per procedure. This makes more interventions more profitable.
What we need is a new, non-surgical billing code for physiologically-managed childbirth that allows birth attendants to be protected from outmoded policies and inappropriate litigation, while at the same time being fairly compensated for their time and rewarded for preventing complications. This will also reduce long-term problems that burden the family and are expensive to the healthcare system.
Maternity Care 2.0 – a science-based model for the 21st Century:
For an essentially healthy population, the most efficacious form of maternity care is always the method that provides “maximal results with minimal interventions”. This is defined as a *beneficial ratio of interventions to outcomes* for each childbearing woman.
The ideal maternity care system *seeks out the point of balance* where the skillful use of physiological management and adroit use of necessary medical interventions provides the *best outcome* with the *fewest number* of medical/surgical procedures and *least expense* to the health care system.
This is the right way, the only way to eliminate preventable maternal mortality and morbidity and eliminate unnecessary suffering of the children, fathers and families left behind.
Faith Gibson - former L&D nurse, California licensed professional midwife, ratifier of the Coalition for Improving Maternity Services (CIMS) “Mother Friendly Childbirth Initiative”
www.collegeofmidwives.org
www.normalbirth.org
Wednesday, March 10, 2010
The antidote to the routine medicalization of normal labor and overuse of induction of labor and elective Cesarean surgery
Today’s blog continues the commentary on the ABC article increasing maternal mortality (published March 4th, 2010, excerpts embedded in the March 8th Normal-Birth blog).
The only good reason for a risky medical or surgical procedure is a serious health problem that makes the potentially life-threatening complications of surgery less of a danger than the disease being treated. In the absence of a potentially life-threatening condition, potentially life-saving medical interventions are themselves life-threatening.
The lives of mothers and babies are depending on us to replace the well-meaning but ill-advised ‘pre-emptive’ use of technology and routine interventions with a genuinely evidence-based and cost-effective mother-baby-father-friendly model of maternity care.
There is no getting around these very grim facts: Cesarean surgery, as the route of delivery, is associated with 33 serious complications – a number 8 times greater that the risks of vaginal birth. Not only is the risk of maternal death 2 to 5 times greater during or after operative delivery, but for every post-Cesarean maternal death there are a 100 new mothers who suffer a serious complication, such as emergency hysterectomy, secondary infertility or stillbirth in a subsequent pregnancy.
To access the research, go to: www.motherfriendly.org/pdf/TheRisksofCesareanSectionFebruary2010.pdf
The only answer or antidote to routine medicalization, with its emphasis on elective procedures such as induction and scheduled Cesareans, is a return to the time-tested principles of physiological management. Medical dictionaries define “physiological” as: “…in accord with or characteristic of the normal functioning of a living organism”.
Physiologic care provides a reliable method for working with the normal process of biology and has long been used by those countries with the best maternal-infant outcomes. The scientific literature identifies physiological management for normal birth as the safest and most economical type of maternity care for a healthy woman with a normal pregnancy. It is the scientific or evidence-based standard of care.
Physiologic care during labor and birth is associated with the lowest rate of preventable maternal and perinatal mortality and is protective of the mother's pelvic floor. It has the best psychological outcomes and the highest rate of breastfed babies. Dependence on physiological principles results in the fewest number of medical interventions, lowest rates of anesthetic use, obstetrical complications, episiotomy, instrumental deliveries, Cesarean surgery, post-operative Cesarean complications and delayed or downstream complications of Cesareans in future pregnancies.
Physiological management takes into account the positive influence of gravity on the stimulation of labor, dilatation of the cervix and decent of the baby through the bony pelvis. Maternal mobility not only helps this normal process move along without the need to use artificial hormones to speed up labor, but also diminishes the mother’s perception of pain, perhaps by stimulating endorphins.
Effective labor support always addresses the mother’s pain, her fears and privacy needs so that labor can progress spontaneously, reducing or eliminating the need for medical interventions such as artificial hormones (Pitocin) to speed up labor, pain medication, anesthesia and operative delivery.
Healthy, mentally-competent women have a natural right to have control over the manner and circumstance of normal labor and birth. Just as we acknowledge a woman’s right to choose obstetrical intervention, epidural or an elective Cesarean, so women have an even more compelling right to choose normal care based on the principles of physiological management and the healthcare system has a matching responsibility to provide access to physiologic care. It is society twin obligation to provide maternity care based on ‘best practices’ as determined by the scientific evidence, as well as seeing that women desiring or requiring obstetrical interventions do so with informed consent that also fully reflects the scientific literature.
What we need now is to reboot our maternity care system so that all categories of birth attendants (obstetricians, family physicians and midwives) are taught the body of knowledge and specific skills for effectively addressing the physical and biological needs and emotional stresses that healthy women typically face during labor. In addition, hospitals must become truly “mother-friendly” by providing evidenced-based care in a low-tech environment that is appropriate to normal childbirth.
This model of normal childbirth includes continuity of care, the full-time presence of the primary birth attendant though out active labor and the supportive presence of family members or other companions chosen by the laboring women. It acknowledges the mother’s on-going need for social and emotional support and physical privacy, which includes control over her environment and the people present. This means that laboring women are free to move about and choose their own positions and activities.
The strategies of physiologically-based care include patience with nature, the right use of gravity and proven methods to help mothers cope with the pain and stress of labor, such as one-on-one support, therapeutic touch, movement and access to hot showers or deepwater tubs.
Women who walk and move about at will and make use of traditional coping strategies to keep pain within manageable levels usually have greatly reduced rate of drugs and other interventions. However, mother-friendly care also provides ‘no-fault, no-blame’ use of pain medication or epidural analgesia when other methods don’t provide the needed relief.
Patience, maternal mobility and the right use of gravity are also critically important during the pushing stage. Even mothers who’ve had epidural analgesia benefit by pushing and delivering on their side, so they are not bearing weight on their sacrum (reducing blood supply to the placenta and O2 to the baby) or fighting against gravity as they try to push an 8# baby uphill and around the normal 60-degree angle of the pelvic outlet (the Curve of Carus).
This science-based model of maternity care for normal childbirth protects and preserves maternal-fetal wellbeing, while providing access to appropriate obstetrical intervention for those women or babies with complications or if medical interventions are requested by the mother. This serves the needs of healthy families far better than our expensive and inflexible high-tech model, which costs two to ten times more than it needs to.
Billions of health care dollars can be saved every year by lowering the direct cost of maternity care and reducing post-operative, delayed and downstream complications associated with Cesarean surgery.
MaternityCare_2.0 is a big first step on our national path to a safe, effective, affordable, accessible healthcare system that we Americans can to proud of -- HealthCare_2.0
Come back tomorrow for the last installment of this 3-part series on the irrational enthusiasm of the “system” to unnecessarily medicalized and complicate normal birth and the deleterious consequences to maternal health and the economics of our national healthcare system.
Today’s blog continues the commentary on the ABC article increasing maternal mortality (published March 4th, 2010, excerpts embedded in the March 8th Normal-Birth blog).
The only good reason for a risky medical or surgical procedure is a serious health problem that makes the potentially life-threatening complications of surgery less of a danger than the disease being treated. In the absence of a potentially life-threatening condition, potentially life-saving medical interventions are themselves life-threatening.
The lives of mothers and babies are depending on us to replace the well-meaning but ill-advised ‘pre-emptive’ use of technology and routine interventions with a genuinely evidence-based and cost-effective mother-baby-father-friendly model of maternity care.
There is no getting around these very grim facts: Cesarean surgery, as the route of delivery, is associated with 33 serious complications – a number 8 times greater that the risks of vaginal birth. Not only is the risk of maternal death 2 to 5 times greater during or after operative delivery, but for every post-Cesarean maternal death there are a 100 new mothers who suffer a serious complication, such as emergency hysterectomy, secondary infertility or stillbirth in a subsequent pregnancy.
To access the research, go to: www.motherfriendly.org/pdf/TheRisksofCesareanSectionFebruary2010.pdf
The only answer or antidote to routine medicalization, with its emphasis on elective procedures such as induction and scheduled Cesareans, is a return to the time-tested principles of physiological management. Medical dictionaries define “physiological” as: “…in accord with or characteristic of the normal functioning of a living organism”.
Physiologic care provides a reliable method for working with the normal process of biology and has long been used by those countries with the best maternal-infant outcomes. The scientific literature identifies physiological management for normal birth as the safest and most economical type of maternity care for a healthy woman with a normal pregnancy. It is the scientific or evidence-based standard of care.
Physiologic care during labor and birth is associated with the lowest rate of preventable maternal and perinatal mortality and is protective of the mother's pelvic floor. It has the best psychological outcomes and the highest rate of breastfed babies. Dependence on physiological principles results in the fewest number of medical interventions, lowest rates of anesthetic use, obstetrical complications, episiotomy, instrumental deliveries, Cesarean surgery, post-operative Cesarean complications and delayed or downstream complications of Cesareans in future pregnancies.
Physiological management takes into account the positive influence of gravity on the stimulation of labor, dilatation of the cervix and decent of the baby through the bony pelvis. Maternal mobility not only helps this normal process move along without the need to use artificial hormones to speed up labor, but also diminishes the mother’s perception of pain, perhaps by stimulating endorphins.
Effective labor support always addresses the mother’s pain, her fears and privacy needs so that labor can progress spontaneously, reducing or eliminating the need for medical interventions such as artificial hormones (Pitocin) to speed up labor, pain medication, anesthesia and operative delivery.
Healthy, mentally-competent women have a natural right to have control over the manner and circumstance of normal labor and birth. Just as we acknowledge a woman’s right to choose obstetrical intervention, epidural or an elective Cesarean, so women have an even more compelling right to choose normal care based on the principles of physiological management and the healthcare system has a matching responsibility to provide access to physiologic care. It is society twin obligation to provide maternity care based on ‘best practices’ as determined by the scientific evidence, as well as seeing that women desiring or requiring obstetrical interventions do so with informed consent that also fully reflects the scientific literature.
What we need now is to reboot our maternity care system so that all categories of birth attendants (obstetricians, family physicians and midwives) are taught the body of knowledge and specific skills for effectively addressing the physical and biological needs and emotional stresses that healthy women typically face during labor. In addition, hospitals must become truly “mother-friendly” by providing evidenced-based care in a low-tech environment that is appropriate to normal childbirth.
This model of normal childbirth includes continuity of care, the full-time presence of the primary birth attendant though out active labor and the supportive presence of family members or other companions chosen by the laboring women. It acknowledges the mother’s on-going need for social and emotional support and physical privacy, which includes control over her environment and the people present. This means that laboring women are free to move about and choose their own positions and activities.
The strategies of physiologically-based care include patience with nature, the right use of gravity and proven methods to help mothers cope with the pain and stress of labor, such as one-on-one support, therapeutic touch, movement and access to hot showers or deepwater tubs.
Women who walk and move about at will and make use of traditional coping strategies to keep pain within manageable levels usually have greatly reduced rate of drugs and other interventions. However, mother-friendly care also provides ‘no-fault, no-blame’ use of pain medication or epidural analgesia when other methods don’t provide the needed relief.
Patience, maternal mobility and the right use of gravity are also critically important during the pushing stage. Even mothers who’ve had epidural analgesia benefit by pushing and delivering on their side, so they are not bearing weight on their sacrum (reducing blood supply to the placenta and O2 to the baby) or fighting against gravity as they try to push an 8# baby uphill and around the normal 60-degree angle of the pelvic outlet (the Curve of Carus).
This science-based model of maternity care for normal childbirth protects and preserves maternal-fetal wellbeing, while providing access to appropriate obstetrical intervention for those women or babies with complications or if medical interventions are requested by the mother. This serves the needs of healthy families far better than our expensive and inflexible high-tech model, which costs two to ten times more than it needs to.
Billions of health care dollars can be saved every year by lowering the direct cost of maternity care and reducing post-operative, delayed and downstream complications associated with Cesarean surgery.
MaternityCare_2.0 is a big first step on our national path to a safe, effective, affordable, accessible healthcare system that we Americans can to proud of -- HealthCare_2.0
Come back tomorrow for the last installment of this 3-part series on the irrational enthusiasm of the “system” to unnecessarily medicalized and complicate normal birth and the deleterious consequences to maternal health and the economics of our national healthcare system.
Monday, March 08, 2010
On March 4th (2010), ABC News ran a story proclaiming: “Maternal Mortality Rates Rising in California -- New Study Shows More Women are Dying After Childbirth, but Most Deaths are Preventable”
It’s good that the media picked up this long-neglected story, but unfortunately the article draws the wrong conclusions, while failing to identify the real issue. According to this article, the increase in maternal deaths is being brought on mothers themselves – more women are dying because so many pregnant women are obese and so many women are foolishly demanding risky surgical deliveries. According to this theory, the obstetrical profession is just the helpless victim of the poor judgment of childbearing women who are forcing doctors to perform dangerous procedures.
ABC’s fact-checkers also misunderstood the crucial statistics on so-called ‘maternal choice’ Cesareans – they were wrong by a factor of *30*. Worse yet, the article only mentions the connection between fatalities due to surgical delivery and the sky-rocketing rate of elective Cesarean deliveries in a headline. However, the article itself never acknowledges the overuse of C-sections based on “physician preference” and hospital policies.
Many healthy women with normal twin, breech or VBAC pregnancies being required by their OBs or by hospital policy to have so-called "elective" C-sections, when in fact, the mother did not choose or prefer a surgical delivery. In other instances, obstetricians are doing C-sections for reasons not justified by the medical science – older or overweight mother, a post-date pregnancy, slow progress, a fetal monitor tracing that is other than perfect, or in a misguided attempt to prevent shoulder dystocia in what the provider fears may be a big baby.
When the article does suggest a remedy, it’s to recommend that every hospital have several $4,600 dollar medical devises to prevent blood clots, which are used AFTER the C-section is performed – never a whisper to suggest that the best way to prevent unnecessary maternal deaths from post-operative complications is to prevent medically unnecessary Cesarean surgeries.
Here is the jest of the ABC article [emphasis mine], followed by additional comments:
“According to the World Health Organization, the U.S. ranks behind more than 40 other countries when it comes to maternal death rates, with 11 deaths per 100,000 pregnancies when measured in 2005. More women die in the U.S. after giving birth than die in countries including Poland, Croatia, Italy and Canada, to name a few.
A new report out of California found the number of women who died in the state after giving birth has nearly tripled over the past decade, from 5.6 deaths per 100,000 to *16.9 per 100,000* in 2006. The report was commissioned by the California Department of Health but has not yet been publicly released. ABC News first learned of its existence from a watchdog group called "California Watch." www.californiawatch.org
Death after childbirth is still rare, but experts say many of those deaths could have been prevented. "We've been able to double-check the data so we can truly say there is a rise," said Dr. Elliott Main, chairman of the California Maternal Quality Care Collaborative, which worked on the report.
The Joint Commission, the leading accreditation and certification group in the United States for hospitals, issued an alert Jan. 26, 2010 stating that "current trends and evidence suggest that maternal mortality rates may be increasing in the United States."
"As many as half of maternal deaths are preventable," said Dr. Mark Chassin, president of the Joint Commission. "The rate of maternal death today is not acceptable in the United States. We need to work much harder than we have been to reduce it."
In some cases, the chances of maternal mortality rise simply because important warning signs are missed. [New father] Jim Scythes knows first-hand how important those warning signs are and how tragic the consequences of missing them can be.
"I just think it's unbelievable that in our country today people still die of childbirth," said Jim Scythe. "I had no idea that anything like that could've happened when we went to the hospital that Friday morning."
It was March of 2007. Jim's wife Valerie had a scheduled cesarean section that seemed to go well. Their daughter Isabella was born. But by the next day, Jim started to notice clues that all was not well. He says his wife's legs felt hard to the touch. "She sat in her bed for 30 hours after her surgery and then got herself up and collapsed," Scythe said. A blood clot in Valerie's leg had moved to her brain and caused a stroke. She later died.
Doctors Say Obesity & C-Sections May be Increasing Risk:
Doctors say it's hard to pinpoint exactly why the numbers are rising. Experts have cited the *growing number of obese mothers* as a big factor -- 20 percent of all pregnant women in the U.S. are now obese at the start of their pregnancy, according to the Centers for Disease Control. These women are more likely to have underlying health conditions, including diabetes or asthma, which can lead to pregnancy-related complications.”
The *popularity of scheduled C-sections* has also been cited by public health experts as a possible cause for rising maternal mortality rates. The *latest data from the CDC shows that 31 percent of the mothers now choose to have C-sections, up 50 percent since 1996*. Studies have repeatedly shown a higher rate of mortality in mothers who have a C-section delivery, especially those who have multiple C-sections.
"If the risks of a Cesarean birth are small, they're magnified greatly when you add many more Cesarean births each year," said Main, adding that "not that many women actually choose to have an elective C-section at the beginning, but it's easy to fall into a pattern of care that ends up resulting in a C-section."
While no one can know for certain in Valerie Scythes' case, simple devices called compression boots could have helped. The boots are worn around the calves and keep blood pumping to hopefully prevent clots.
Mt. Sinai Hospital in New York is at the cutting edge of preventing maternal mortality, trying to turn the trend around in the United States. For women who have a C-section at Mt. Sinai, inflatable boots are standard practice, but providing the extra treatment can be expensive.
While the compression boots cost only $14, the machine that inflates them costs $4,600. Dupree admits that the costs and lack of awareness of the technology might be keeping some hospitals from using compression boots, but a good portion of what Mt. Sinai does costs nothing at all.
Doctors and nurses at Mt. Sinai work constantly at improving communication and training to make sure that staff members ask patients the right questions and that patients are empowered to speak up when something doesn't feel right.
For more on maternal mortality and pregnancy complications, visit the CDC's page on the topic by clicking here.
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Here is my reply as posted on the ABC blog:
This overuse and misuse of Cesarean surgery is not the result of women 'demanding' C-sections.
Post-operative maternal mortality is not primarily a consequence of the mother’s age or weight.
ABC's facts are just wrong -- 31% of childbearing women do NOT choose an elective C-section -- 31% is the *total* C-section rate in the US, not the rate of so-called "maternal choice" Cesareans.
The real number for women who elect to have a medically unnecessary or ‘elective’ C-section is less than 1%. Research done by Childbirth Connection's "Listening to Mothers Survey" 2006 found only 1 new mother out of 1,600 who requested a C-section (www.childbirthconnection.org).
Sociologist Raymond DeVries, professor of bio-ethics at the U. of Mich School of Medicine, has done extensive research on this issue with similar results, as has Gene Declercq, PhD and professor in the department of Maternal-Child health at Boston University. A powerpoint PDF document with this data can be downloaded at:
www.motherfriendly.org/pdf/2008_CIMS_Gene_Declercq.pdf
Additional scientific information on the risks of Cesarean is also available @ www.motherfriendly.org.
The way to eliminate preventable post-operative complications and death after elective reproductive surgery is not by spending more money for more expensive equipment like the special $14 compression boots that require a $4,600 machine. This suggestion sounds like an info-mercial for the medical equipment lobby and the hospitals buying such expensive products.
On a practical level, no new post-op patient should ever be just "sitting in bed for 30 hours". Good nursing care requires that post-op patients get up and walk around within a few hours of surgery and continue to move about on a regular schedule to prevent pneumonia and deep vein blood clots associated with surgery. This is a time-tested and inexpensive method to prevent DVTs. For women with unusual risk-factors, the use of compression boots may well be warranted, but this technology is not a replacement for using common-sense when it come to elective use of major abdominal surgery.
The only good reason for a risky medical or surgical procedure is a serious health problem that makes the potentially life-threatening complications of surgery less of a danger than the disease being treated. In the absence of a potentially life-threatening condition, potentially life-saving medical interventions are themselves life-threatening.
There is no getting around the facts: Cesarean surgery, as the route of delivery, is associated with 33 serious complications – a number 8 times greater that the risks of vaginal birth. Not only is the risk of maternal death 3 to 5 times greater during or after operative delivery, but for every post-Cesarean maternal death there are a 100 new mothers who suffer a serious complication, such as emergency hysterectomy, secondary infertility or stillbirth in a subsequent pregnancy.
The lives of mothers and babies are depending on us to replace the well-meaning but ill-advised ‘pre-emptive’ use of technology and routine interventions with a genuinely evidence-based and cost-effective mother-baby-father-friendly model of maternity care.
Tomorrow I’ll comment on the unnecessary medicalization of normal birth, with its emphasis on elective procedures such as induction and scheduled Cesarean, and identify the only antidote to routine medicalization. Stay tuned….
It’s good that the media picked up this long-neglected story, but unfortunately the article draws the wrong conclusions, while failing to identify the real issue. According to this article, the increase in maternal deaths is being brought on mothers themselves – more women are dying because so many pregnant women are obese and so many women are foolishly demanding risky surgical deliveries. According to this theory, the obstetrical profession is just the helpless victim of the poor judgment of childbearing women who are forcing doctors to perform dangerous procedures.
ABC’s fact-checkers also misunderstood the crucial statistics on so-called ‘maternal choice’ Cesareans – they were wrong by a factor of *30*. Worse yet, the article only mentions the connection between fatalities due to surgical delivery and the sky-rocketing rate of elective Cesarean deliveries in a headline. However, the article itself never acknowledges the overuse of C-sections based on “physician preference” and hospital policies.
Many healthy women with normal twin, breech or VBAC pregnancies being required by their OBs or by hospital policy to have so-called "elective" C-sections, when in fact, the mother did not choose or prefer a surgical delivery. In other instances, obstetricians are doing C-sections for reasons not justified by the medical science – older or overweight mother, a post-date pregnancy, slow progress, a fetal monitor tracing that is other than perfect, or in a misguided attempt to prevent shoulder dystocia in what the provider fears may be a big baby.
When the article does suggest a remedy, it’s to recommend that every hospital have several $4,600 dollar medical devises to prevent blood clots, which are used AFTER the C-section is performed – never a whisper to suggest that the best way to prevent unnecessary maternal deaths from post-operative complications is to prevent medically unnecessary Cesarean surgeries.
Here is the jest of the ABC article [emphasis mine], followed by additional comments:
“According to the World Health Organization, the U.S. ranks behind more than 40 other countries when it comes to maternal death rates, with 11 deaths per 100,000 pregnancies when measured in 2005. More women die in the U.S. after giving birth than die in countries including Poland, Croatia, Italy and Canada, to name a few.
A new report out of California found the number of women who died in the state after giving birth has nearly tripled over the past decade, from 5.6 deaths per 100,000 to *16.9 per 100,000* in 2006. The report was commissioned by the California Department of Health but has not yet been publicly released. ABC News first learned of its existence from a watchdog group called "California Watch." www.californiawatch.org
Death after childbirth is still rare, but experts say many of those deaths could have been prevented. "We've been able to double-check the data so we can truly say there is a rise," said Dr. Elliott Main, chairman of the California Maternal Quality Care Collaborative, which worked on the report.
The Joint Commission, the leading accreditation and certification group in the United States for hospitals, issued an alert Jan. 26, 2010 stating that "current trends and evidence suggest that maternal mortality rates may be increasing in the United States."
"As many as half of maternal deaths are preventable," said Dr. Mark Chassin, president of the Joint Commission. "The rate of maternal death today is not acceptable in the United States. We need to work much harder than we have been to reduce it."
In some cases, the chances of maternal mortality rise simply because important warning signs are missed. [New father] Jim Scythes knows first-hand how important those warning signs are and how tragic the consequences of missing them can be.
"I just think it's unbelievable that in our country today people still die of childbirth," said Jim Scythe. "I had no idea that anything like that could've happened when we went to the hospital that Friday morning."
It was March of 2007. Jim's wife Valerie had a scheduled cesarean section that seemed to go well. Their daughter Isabella was born. But by the next day, Jim started to notice clues that all was not well. He says his wife's legs felt hard to the touch. "She sat in her bed for 30 hours after her surgery and then got herself up and collapsed," Scythe said. A blood clot in Valerie's leg had moved to her brain and caused a stroke. She later died.
Doctors Say Obesity & C-Sections May be Increasing Risk:
Doctors say it's hard to pinpoint exactly why the numbers are rising. Experts have cited the *growing number of obese mothers* as a big factor -- 20 percent of all pregnant women in the U.S. are now obese at the start of their pregnancy, according to the Centers for Disease Control. These women are more likely to have underlying health conditions, including diabetes or asthma, which can lead to pregnancy-related complications.”
The *popularity of scheduled C-sections* has also been cited by public health experts as a possible cause for rising maternal mortality rates. The *latest data from the CDC shows that 31 percent of the mothers now choose to have C-sections, up 50 percent since 1996*. Studies have repeatedly shown a higher rate of mortality in mothers who have a C-section delivery, especially those who have multiple C-sections.
"If the risks of a Cesarean birth are small, they're magnified greatly when you add many more Cesarean births each year," said Main, adding that "not that many women actually choose to have an elective C-section at the beginning, but it's easy to fall into a pattern of care that ends up resulting in a C-section."
While no one can know for certain in Valerie Scythes' case, simple devices called compression boots could have helped. The boots are worn around the calves and keep blood pumping to hopefully prevent clots.
Mt. Sinai Hospital in New York is at the cutting edge of preventing maternal mortality, trying to turn the trend around in the United States. For women who have a C-section at Mt. Sinai, inflatable boots are standard practice, but providing the extra treatment can be expensive.
While the compression boots cost only $14, the machine that inflates them costs $4,600. Dupree admits that the costs and lack of awareness of the technology might be keeping some hospitals from using compression boots, but a good portion of what Mt. Sinai does costs nothing at all.
Doctors and nurses at Mt. Sinai work constantly at improving communication and training to make sure that staff members ask patients the right questions and that patients are empowered to speak up when something doesn't feel right.
For more on maternal mortality and pregnancy complications, visit the CDC's page on the topic by clicking here.
@@@@@@@@@@@@@@@@@@@@@@@@
Here is my reply as posted on the ABC blog:
This overuse and misuse of Cesarean surgery is not the result of women 'demanding' C-sections.
Post-operative maternal mortality is not primarily a consequence of the mother’s age or weight.
ABC's facts are just wrong -- 31% of childbearing women do NOT choose an elective C-section -- 31% is the *total* C-section rate in the US, not the rate of so-called "maternal choice" Cesareans.
The real number for women who elect to have a medically unnecessary or ‘elective’ C-section is less than 1%. Research done by Childbirth Connection's "Listening to Mothers Survey" 2006 found only 1 new mother out of 1,600 who requested a C-section (www.childbirthconnection.org).
Sociologist Raymond DeVries, professor of bio-ethics at the U. of Mich School of Medicine, has done extensive research on this issue with similar results, as has Gene Declercq, PhD and professor in the department of Maternal-Child health at Boston University. A powerpoint PDF document with this data can be downloaded at:
www.motherfriendly.org/pdf/2008_CIMS_Gene_Declercq.pdf
Additional scientific information on the risks of Cesarean is also available @ www.motherfriendly.org.
The way to eliminate preventable post-operative complications and death after elective reproductive surgery is not by spending more money for more expensive equipment like the special $14 compression boots that require a $4,600 machine. This suggestion sounds like an info-mercial for the medical equipment lobby and the hospitals buying such expensive products.
On a practical level, no new post-op patient should ever be just "sitting in bed for 30 hours". Good nursing care requires that post-op patients get up and walk around within a few hours of surgery and continue to move about on a regular schedule to prevent pneumonia and deep vein blood clots associated with surgery. This is a time-tested and inexpensive method to prevent DVTs. For women with unusual risk-factors, the use of compression boots may well be warranted, but this technology is not a replacement for using common-sense when it come to elective use of major abdominal surgery.
The only good reason for a risky medical or surgical procedure is a serious health problem that makes the potentially life-threatening complications of surgery less of a danger than the disease being treated. In the absence of a potentially life-threatening condition, potentially life-saving medical interventions are themselves life-threatening.
There is no getting around the facts: Cesarean surgery, as the route of delivery, is associated with 33 serious complications – a number 8 times greater that the risks of vaginal birth. Not only is the risk of maternal death 3 to 5 times greater during or after operative delivery, but for every post-Cesarean maternal death there are a 100 new mothers who suffer a serious complication, such as emergency hysterectomy, secondary infertility or stillbirth in a subsequent pregnancy.
The lives of mothers and babies are depending on us to replace the well-meaning but ill-advised ‘pre-emptive’ use of technology and routine interventions with a genuinely evidence-based and cost-effective mother-baby-father-friendly model of maternity care.
Tomorrow I’ll comment on the unnecessary medicalization of normal birth, with its emphasis on elective procedures such as induction and scheduled Cesarean, and identify the only antidote to routine medicalization. Stay tuned….
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