Childbirth management has been disputed turf since the invention of forceps by the barber-surgeons of the Middle Ages. Modern-day childbirth practices are governed by organizations that have long been run mostly by men — the American Board of Obstetrics and Gynecology (ABOG), founded in 1930, and the American College of Obstetrics and Gynecologists (ACOG), founded in 1950. These organizations control who practices hospital obstetrics, and how they do it. ACOG and ABOG also influence laws governing childbirth outside the hospital — often in opposition to women insisting on choice in the matter, so that, even now, it is illegal to choose a home birth with a midwife in many U.S. states, including New York.

Society and fashion, however, also influence how women give birth. Women’s preferences have shaped the practice of obstetrics, even within its academic-based hospital culture, in everything from pain control to the design of delivery rooms.

A new birthing center at the Fletcher Allen Health Center in Burlington opens this month. Dr. Mark Phillippe, chairman of OB-GYN at Fletcher Allen, shared his thoughts about the changes in obstetrics, and what the future looks like.

The Old Way

Dr. Phillippe was trained at the Boston Lying-In Hospital in the mid-seventies. “Natural childbirth was not the norm,” he says. “Most women came in, they labored, they often got fairly strong sedative medications, so they slept through most of the labor. Women were given high doses of narcotics, or scopolamine. Women in that era, in the sixties and seventies, were less participatory in their deliveries. There was also a fairly high operative delivery rate, with forceps.”

The cesarian delivery rate was low, less than ten percent; but very long labors were common, as were aggressive forceps deliveries. Dr. Phillippe says that avoiding c-sections was justifiable then, as antibiotics and anaesthetic techniques weren’t as reliable as they are now, and the procedure was riskier.

“Now,” he says, “cesarian section is still a major procedure, but the morbidity is very low, and the infectious complications are significantly lower; and so it’s an approach that we use much more readily.”

“Pit” and the Pendulum

In the late seventies and early eighties, the concept of natural childbirth became much more prevalent. Dr. Phillippe says that women preferred minimal anesthesia; they were awake, alert, and participated much more in their labor and delivery than women in the previous era.

“With that came the option of epidural anesthesia, and graduated epidurals, where there’s adequate pain control, but the woman still had enough motor control so that she could push, and help expel the fetus effectively.”

Pain control in labor always involves trade-offs. In the narcotics era, the use of opiates went hand-in-hand with prolonged labor and the need for often-traumatic forceps deliveries. In the epidural era, labor is commonly augmented with pitocin, a drug that stimulates uterine contraction. Vacuum-assisted delivery is more prevalent; and, as the rate of forceps deliveries declined, the c-section rate rose.

Dr. Phillippe says there is a broad natural range for the length of labors — hours to days. In the sixties and seventies, labor was often allowed to go on for two to three days. Today, both doctors’ and patients’ expectations have changed.

“Women in general want to come in, they want to labor for some reasonable period of time, they want to have a baby, and resume their lives. They don’t want to labor for two or three days. Some want to come in and pop the baby out in a couple of hours, and be done with it,” he says.

Pitocin is the drug that allows the acceleration of labor in hospital births. Pitocin is a synthetic form of the pituitary hormone oxytocin that naturally stimulates the uterus to contract. The hormone peaks late in labor, around the pushing stage; but, in hospital births, the drug may be administered much sooner, by intravenous drip. Dr. Phillippe says, “We use pitocin fairly liberally, to enhance the effectiveness of labor and to identify which patients are slowing down because of dysfunctional contractions, versus those who are slowing down because the baby’s not going to fit through the pelvic cavity. So, at this point in time, probably forty to fifty percent of women will receive pitocin before delivery, either as part of an induction, to start labor, or to augment the effectiveness of labor once it’s ongoing.”

Rumblings from the Street

The push for short, efficient labors is being questioned by a growing chorus of women who protest what they say is the overuse of pitocin. One objection is that the drug causes harder, more painful contractions, and thus the use of more anesthesia, and even cesarians. A 1995 report from Atlanta Maternal-Fetal medicine said, “The incidence of cesarian section among patients undergoing induction of labor has uniformly been higher than that of patients who labor spontaneously.”

Pitocin causes uterine muscle fibers to contract all at once, unlike natural contractions that start at the top of the uterus, then work downward, building up, peaking, then relaxing in force and sensation. Women complain that pitocin contractions are unnaturally harsh, and that practitioners rarely turn down, or stop a drip once it’s started, even during the natural deceleration phase in late labor, when a woman’s body often slows down her contractions as if to rest for the pushing stage.

Dr. Phillippe says that one reason for cesarian section is “fetal intolerance of labor.” Squeezing a baby, its cord, and its placenta with more force than nature intended may itself provoke signs of fetal distress, such as hypoxia — low oxygen — or an altered heartbeat. Delivery by cesarian section, to avoid the possibility of injury related to birth hypoxia, addresses a problem that the use of pitocin may have caused in the first place.

Current academic research supports the use of pitocin-augmented labor. Dr. Phillippe says, “As is true in all of medicine, but particularly in obstetrics and gynecology, we’ve gone much more into looking at whether the intervention is effective and produces the outcome that we want, with very few side effects or complications. That has really been a major trend in obstetrics and gynecology in the last twenty years. A lot more evidence is in place to justify what we do.”

The myriad of consumer complaints about the drug may eventually change the way it is used in hospitals, though not without some effort. There is a move to include more narrative-based evidence, such as patient reports, into clinical practice. Women’s feedback around the use of pitocin and other interventions may eventually affect their use in hospital births.

Always Cesarian — No More

Another change that Dr. Phillippe has seen is the trend toward vaginal birth after c-section (VBAC). “Through the eighties and nineties,” he says, “there was a big push to attempt vaginal deliveries after previous cesarian section, and that seemed to make a lot of sense; and there was evidence suggesting that for women who delivered vaginally after cesarian section, their risk was lower, their morbidity was lower, the infant outcomes were comparable, and that this was a good thing.”

A recent posting on the ACOG Web site cites a 60 to 80 percent success rate for VBAC (www.childbirth.org/section/VBAC1.html). Dr. Phillippe says that obstetricians are also getting better at identifying, earlier in labor, those women who won’t be successful with a VBAC. “Some indications are identifiable beforehand — if the baby isn’t lined up with the birth canal, if it’s breech, or transverse, or angled to the side, what’s called oblique; if the woman doesn’t want to undergo a vaginal birth. A lot of the repeats are by patient preference.”

Some obstetricians are wary of VBAC. In 2001, when the licensure of independent midwives for home births was before the Vermont legislature, several Fletcher Allen obstetricians spoke out against allowing VBAC at home, citing the risk of uterine rupture. A 2002 report on VBAC in American Family Physician cites a study showing that pitocin had been used in a majority of cases of uterine rupture. Other research shows a greater risk of uterine rupture with prostaglandin induction — starting labor by dilating the cervix — in hospitals. Dr. Phillippe says that risk of rupture is why prostaglandins are not used to induce labor in women with previous cesarians at FAHC. He says that most ruptures of previous c-section scars occur spontaneously during labor.

Make Yourself at Home

Women’s preferences have helped to shape the new birthing center at Fletcher Allen. “The concept of family involvement, particularly the husband, and significant others, and labor coaches — the whole entourage — obviously requires larger space,” Dr. Phillippe says. “Patients are now more interested in a space that has a more homey ambiance to it.”

“There are seven LDR, or Labor-Delivery-Recovery rooms,” says Dr. Phillippe, “where women can labor, deliver, and recover, without moving to another place. All the rooms have soaking tubs. Waterproof, wireless transducers allow monitoring while a woman walks around, or soaks in the tub.

“The 2,200 babies born at the Fletcher Allen each year will arrive in a setting with ‘all the creature comforts,’” he says.

Who’s in the House

Fletcher-Allen is a teaching hospital, with twelve residents in its OB-GYN program. Dr. Phillippe spoke candidly about current issues in training resident, particularly the limits for residents’ work hours.

“About a year ago,” he says, “the eighty-hour-per-week rule was instituted, so that at most, a resident will only be in the hospital for about eighty hours. Before that, a resident was often in the hospital for up to a hundred and twenty hours per week. If you take a third of that time away, you need to make sure that you are teaching the same quality and quantity of information.” Programs were not expected to increase their numbers of residents to accommodate this change in the work schedule.

Obstetrics is considered a surgical specialty; this raises the question of whether academic obstetrics programs are rather more concerned with teaching surgical interventions like c-sections than in preventing them. The American Board of Obstetrics and Gynecology provides minimal standards for the number of procedures performed by residents as guidelines in certifying OB specialists, Dr. Phillippe explains. “To become competent in cesarian section, it’s in the fifty to one-hundred range; likewise with all the other major operative procedures. Over the four years, the expectation is significant numbers, initially as an assistant, and then, as the more functionally operating surgeon, with the attending physician directly supervising.” The c-section rate at Fletcher Allen is 22 to 23 percent. In the U.S. overall, the cesarian rate is around 25 percent; that includes Puerto Rico, where the rate approaches 50 percent, and the procedure is largely elective.

Another challenge is that fewer people are going into obstetrics and gynecology. In the nationwide residency match for 2004, there were sixty OB-GYN positions that went unfilled. Dr. Phillippe says, “The decreasing number of residents is a big concern, both for the American College of OB-GYN, and for specialists in the field.”

A declining number of men go into the field, partly due to patient preference, Dr. Phillippe says. “Medical students on our rotation may end up sitting in the hallway because patients don’t want a male in the room. Then it’s difficult for that student to say, ‘Oh, gee, let me go into obstetrics and gynecology, so I can spend four years as a resident sitting in a hallway.’ That is a real issue.”

Another factor is that huge malpractice premiums — $100,000 to $250,000 per year — discourage doctors from the specialty. ACOG actively supports President Bush’s efforts to limit malpractice awards, cap lawyers’ contingency fees, and shorten the statute of limitations. ACOG advocates tort reform in a campaign called “Who Will Deliver My Baby?” that focuses on the dwindling numbers of specialists. In Vermont, the statute of limitations for obstetrics cases now extends throughout childhood to the age of 21.

Long and sometimes unpredictable work hours are another reason doctors are choosing other specialties. Expanding the work force is a concern for Dr. Phillippe, who says, “We rely more on other providers — we utilize more certified nurse-midwives in labor and delivery; the faculty play a more direct role; and we are identifying more providers who can do more of the work than before.” The nurse-midwifery program at Fletcher-Allen, with seven midwives on staff, is the largest in northern New England. The question “Who will deliver my baby?” even in hospitals may increasingly be answered by, “A midwife.”

Labor Intensive — The Evolution of Childbearing