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Thursday
May122011

Another Obstetrician's Lament

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By Gustavo San Roman, MD


This obstetrician’s lament is that somehow in the debate of home birth versus hospital based birth both sides have forgotten that labor is a physical process.  At the beginning of time, the physical nature of labor was very evident, because if labor did not result in a vaginal birth then the lives of both the mother and her baby would be lost.  The inherent risk that this physical process would not result in a vaginal birth was determined solely by the physical characteristics of the mother and her baby.  The concept of having other humans assist a woman during labor arose from an effort to decrease each woman’s inherent risk.  These assistants needed to be part experienced coach and part skilled extractor of babies that get stuck in the birth canal.  Unfortunately, even with these helpful assistants, some women and their babies could not be saved.  This gave rise to the concept of a cesarean delivery.

About 100 years ago a paper was published comparing women who had a cesarean delivery versus a woman who was run over by a wagon and another who was gored by a bull.  The women who delivered their babies via abdominal trauma had better outcomes than the women who had a cesarean delivery.  However, with the discovery of aseptic technique, antibiotics and advanced surgical training a cesarean delivery has become a reasonable alternative when labor does not result in a vaginal birth or when it is safer for the mother or baby. 

However, safer is a relative term.  Perhaps in the hands of an assistant (now called an obstetrical care provider) who has never performed a vaginal breech birth it is safer for a woman to have a cesarean delivery.  If your hospital does not have an anesthesiologist who is in house, perhaps it is safer to perform a scheduled cesarean delivery rather than inducing labor for an attempted VBAC.  These are questions that should be answered long before labor begins.  If a woman does not like the answers provided by her obstetrical care provider then the woman can seek out another provider with better answers if she wants to avoid a cesarean delivery.  However, at no time should we forget that labor is a physical process and that the physical characteristics of the mother and her baby will determine each woman’s inherent risk for cesarean delivery.

Asking an obstetrical care provider about their experience and skill with breech presentation and VBAC are easy questions to ask.  The more important and more difficult question is; “Will the obstetrical care provider’s experience and skill increase or decrease a woman’s inherent risk for cesarean delivery?”  Unfortunately, obstetrical care providers cannot answer this question unless they are using a method to measure their results that accounts for the inherent risk of the women that they deliver.  Therefore, it is important to understand that an obstetrical care provider’s high or low cesarean delivery rate may not reflect the experience or skill of the obstetrical care provider.  This is because a high or low cesarean delivery rate may be more a reflection of the inherent risk of the obstetrical care provider’s patient population than the experience or skill of the provider.

In an ideal world we would have obstetrical care providers (obstetricians, family practitioners or midwives) that analyze their own results with a method that can determine the best way to decrease the inherent risk of laboring women without compromising safety.  Those providers (home or hospital based) that find the labor management strategies that are best at decreasing a woman’s inherent risk would then promote these strategies to all of the other obstetrical care providers.  If these strategies are applied in or near a hospital setting then this should end the debate because the best of both home and hospital based births could be combined and the worst of each would be eliminated. However, for this ideal world to become a reality we would need to see to it that women or babies who suffered unavoidable injuries at birth receive help from all of the members of our society and not just from the pockets of obstetrical care providers.  In this ideal world everybody would know that labor is a physical process and women would obtain their best physical condition before considering taking on such a physical process.  I will work tirelessly to make this ideal world the new reality so that my lament may be no more.

 

This post is featured as one of a series of posts by OB-GYNs in response to the May 2011 article, An Obstetrician’s Lament, by Dr. Annette Fineberg.


 

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Reader Comments (21)

While this is not a paid post, Dr. San Roman's company, Birthrisk.com, is an advertiser on this site. We have no material interest to declare, but I thought I'd disclose that he advertises here before anyone gets their knickers in a twist.

May 12, 2011 | Registered CommenterJill

I wanted to like this, really I did. But this lament is written as if there is no such thing as Cochrane Reviews. We already DO have evidence about what obstetrical practices are helpful, harmful, or unlikely to be either. We already DO know that choice of care provider and that provider's preferred practices have the most influence about what kind of birth a woman will have. I get the point about comparing apples to apples--most birth care studies I've read do exactly that.

Oh, and P.S. If your hospital can't handle VBAC emergencies, it has no business advertising maternity services, period. If a hospital cannot handle uterine rupture during a VBAC, then its staff certainly is not equipped to handle prolapsed cord, placental abruption, amniotic fluid embolism, or uterine ruptures not associated with VBAC. This is a pet peeve of mine.

May 12, 2011 | Unregistered CommenterMelissa

Melissa, I share that same pet peeve. If you can not handle one type of emergency, how do you handle the others, particularly those not related to VBAC?

May 12, 2011 | Unregistered CommenterTori

Yeah, I'm not impressed atall. Everything Melissa said, and he lost me at inherent risk. Risk in birth in NOT inherent, tis ACQUIRED, reflecting the conditions of the woman's life/community, and the capabilities of the practitioner. Historically the risky practitioners were/are the untrained and the over-trained. In the 1920's a quarter of a million--250,000--women died from obstetrical care. US OB's were known for their "orgy of interventions"
Birth is a physical process that a good diet and emotional support, preferably through out the conception, pregnancy and birth, has historically produced both good experiences and outcomes for the majority of women.
I also found his tone to be patronizing. This more of an ad than a response.

May 12, 2011 | Unregistered CommenterD'Anne

D'Anne, I find it bizarre and illogical to pretend that maternal characteristics are completely irrelevant.

We're almost in the 2020's. We can extrapolate a lot from history but can we really still sit around complaining about puerperal sepsis in the 1920's because nobody knew to wash their hands at the time?

May 12, 2011 | Registered CommenterJill

My problem with this response is this: The reasoning that ob/gyn's are limited in the options they offer women because of their lack of training is a cop out. If they don't have the training and experience to offer breech delivery and VBAC then why? Who's responsible for that and how is that lack of training being addressed. I already know from talking to new obs that they are not taught to do breech deliveries. There's no excuse for obstetricians not being taught the skills they need to provide safe and viable options for women. It's absolutely inexcusable. Furthermore, this idea that if you don't like your provider's options you can just go to another provider is shortsighted and unrealistic. Obstetrics is not a heavily populated field of medicine. Many towns have only one ob/gyn or none at all. I lived in an area where the only maternity hospital nearby was 40 miles away and the choices for ob/gyns were severely limited and there were NO midwives. For some areas, they have to go even further and only have one option unless they relocate for their pregnancy which isn't economically feasible. Women shouldn't be faced with not being able to find safe, viable delivery options. And if ob/gyns aren't getting those skills then someone needs to be asking some serious questions and finding a way to fix that not bemoaning their lack of experience.

May 12, 2011 | Unregistered CommenterMaryJane

I think the post was a good summary of the problems if you were addressing the obstetrical community. I appreciate the efforts to make evidence-based labor management protocols and the attempt to provide a glimpse into individual practice patterns.

May 12, 2011 | Unregistered CommenterSteph G.

Melissa, thank you for your comment, I welcome any and all criticism. I have been helping women to deliver their babies for almost twenty five years and I am trying to put my experience to good use. Yes, there are things like the Cochrane Reviews and this is one of their recent reviews:

“Induction of labour for improving birth outcomes for women at or beyond term (Review)” which comes to the conclusion that “Labour induction at 41 completed weeks should be offered to low risk women. The message from this review is that such a policy is associated with fewer deaths although the absolute risk is small. There does not seem to be any increased risk of assisted vaginal or abdominal delivery.” – Cochrane 2009.

I personally disagree that labor induction at 41 weeks does not increase the risk of assisted vaginal or abdominal delivery based on my analysis of over 284,000 women who labored in New York State and my review of the relevant literature. Obstetrical care providers who use things like Cochrane Reviews to help them establish management plans will most likely be offering induction to their patients at 41 completed weeks as a result of this review and many of their patients will jump at the opportunity to end their pregnancies. However, if obstetrical care providers had a better method of analyzing their own results they may be able determine if induction of labor at 41 weeks increased the risk of assisted vaginal or abdominal delivery in their own patients.

The concept of inherent risk is not one that is meant to be demeaning. Perhaps I can give a better explanation of inherent risk using the following question. If a home birth midwife has 100 tall young first time mothers having smaller babies this year and next year she has 100 shorter older first time mothers having bigger babies, will the number of women requiring transfer to the hospital for dystocia be the same each year? I believe that the answer to this question is no and there are many studies that have confirmed that these physical characteristics affect an individual woman’s risk (inherent risk) for cesarean delivery.

Most of the evidence on what obstetrical practices are helpful, harmful, or unlikely to be either do not take inherent risk into account. For example, patients ask; how much will an epidural increase my risk for cesarean delivery? Do we just “assume” that the risk of the epidural is the same for my shorter older first time mother having the bigger baby as it was in the published study that used taller, younger first time mothers having smaller babies? I don’t believe that we can make this assumption. Furthermore, making this kind of assumption can lead good obstetrical care providers to make recommendations that put their patients on a path that will more likely end in cesarean delivery.

I will work tirelessly to help find and promote the labor management strategies that can decrease inherent risk for cesarean delivery. If you know of an obstetrical care provider that has found those strategies and has the data to prove it, please have them contact me so that I can help them to promote their labor management strategies.

Dr. San Roman, I wanted to ask if you were concerned about your risk management strategies adding fuel to the fire, as it were, with regard to inherent risk? Wouldn't there be a chance that doctors would use a woman's inherent risks against her when advising how to manage labor. For example, "if you are overweight then your chances of VBAC are lower so we should just schedule a c-section". Do you see this as a possibility?

May 12, 2011 | Unregistered CommenterSteph G.

Hi Steph – You bring up an excellent point. My software uses eight physical characteristics to find similar women and the case mix is limited to women who labor with a singleton, term, vertex pregnancy without a history of a prior cesarean delivery. Therefore, my software cannot be used to discourage VBACs or women whose only risk factor is that they are overweight. In fact, since I use eight characteristics, the risk of being overweight may be totally negated if the woman is younger, taller and having a smaller baby.

My software can be used by the 65-70% of pregnant women who do fit the case mix. With over 285,000 deliveries in the database we find that over 90% of women will have a Cesarean Rate History of under 35% and that only 1% will have a Cesarean Rate History of over 65%. This means that doctors will have very few patients to “advise” towards scheduled cesareans. However, obstetrical care providers will have valuable information to help encourage 90% of their patients against a cesarean delivery. Lastly, my Birthrisk Cesarean Birth Measure can be used to reveal those obstetrical care providers who significantly increase their patient’s inherent risk and I will bet that we will find that these are the providers that you are referring to in your comment.

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