OpEdFailure to Progress: What's Wrong with Hospital Obstetrics?By Katharine M. Hikel, MDVermont Woman respected the wishes of the practitioners interviewed for this OpEd column to preserve their confidentiality by withholding their names.
The “aggressive management” of labor with drugs and surgery is now the norm in America. This dependence on technology has undermined society’s confidence in women’s innate abilities to manage birth naturally — and has also provoked questions about the safety of interventions for both women and children. In a statement to the FDA in 2003 on “Improving the Outcome of Pregnancy Through Science,” Doris Haire, CNM, President of the American Foundation for Maternal and Child Health, said: “In light of the soaring rate of autistic (500% in some states) and otherwise neurologically impaired children during the last ten years, it behooves the FDA to question whether cervical ripeners, uterine stimulants and the various pain relieving drugs administered to laboring women permanently alter the brain chemistry of the fetus and newborn sufficiently to interfere with the normal dendritic arborization [nerve development] within the infant’s brain.” For women, pelvic floor disorders — incontinence and organ prolapse, severe enough to require surgery — are nearing the half-million mark annually. The effects of drugs used in labor — epidural analgesia, and Pitocin — on the muscles of the birth canal, as well as the high rate of traumatic episiotomy in some hospital deliveries, are raising questions about the commonplace use of these interventions in obstetrical practice. Aggressive management of labor is costing us a fortune. We spend more on birth-related care than does any other country, yet our rate of maternal and fetal deaths remains among the highest in industrialized nations. Malpractice premiums for OB doctors are skyrocketing faster than in any other field of medicine – $100,000 to $250,000 per year for beginning practitioners; still, the main reform called for within the specialty is tort reform – to limit awards for damages. “The medical world has over-medicalized birth; there is little justification for a cesarean section rate of 30 percent and an induction rate of 30 percent,” said a local OB/GYN who’s been in the field for thirty years. “Yet, the broader U.S. public feels entitled to the ‘perfect baby,’ and when this doesn’t happen, someone is to blame and has to pay for this loss of expectation. So the medico-legal climate has just ruined OB from my point of view.” A Vermont-trained OB doctor practicing in New York agreed, saying, “I cannot practice the kind of medicine I was trained to do.” These physicians are part of an unhappy chorus of practitioners who feel that their ability to care for patients is restricted by the fear of legal action, pushing them toward aggressive management of delivery, and more and earlier interventions. I’m Ready For My Epidural Now Most OB interventions – especially those directed at relieving pain in childbirth – were invented in the spirit of “First Do No Harm.” In many cases, however, harm was done. In the early days of anesthesia, starting at the turn of the century, women were sold on heavy doses of inhaled gases, scopolamine (“twilight sleep”) and morphine-type sedatives that led to long, highly-drugged labors. These often resulted in what one Vermont OB practitioner and educator described as “traumatic instrument deliveries,” where the use of forceps caused injury, often permanent, to mother and child. Surgical (cesarean) births were even riskier then, up until around the 1960s, because the anesthesia of today was not available. To obstetricians of that era – who rarely saw a truly natural childbirth – a nice clean C-section is a modern-day blessing, and an epidural, with the patient moving, talking, and sipping drinks, seems like a benign way to provide relief to a laboring woman. And many women love their epidurals; as one mother put it, “I want that epidural the minute I walk through the door!” But this love affair with pain medication obscures significant data on complications from anesthesia in labor. A 1992 study in the Canadian Journal of Anesthesia indicated that a general overall rate of complications associated with epidurals was 23 percent. And according to the Lamaze Institute for Normal Birth, “Studies show that epidurals are associated with a lower rate of spontaneous vaginal delivery, a higher rate of instrument delivery (vacuum or forceps), and longer labors, particularly for women having their first baby. [...] Evidence exists that the use of epidurals, especially for first-time mothers, may increase the rate of cesarean births.” Epidurals also interfere with naturally-occurring hormones that help both mother and baby manage the process of labor and birth. Birth activist Sarah J. Buckley, MD, writes in Mothering magazine that epidurals block beta-endorphin, catecholamines, and oxytocin, thus disturbing the natural progression of labor. The most common drugs in epidurals are fentanyl, a synthetic-morphine type drug, and bupivacaine, a cocaine derivative. Oxytocin, nicknamed “the hormone of love”, is the pituitary hormone that causes the contractions of labor. Epidurals block its normal rise and release during labor and obliterate the maternal oxytocin peak that occurs at birth. This peak brings on the final pushing contractions, as well as the rush or high that many mothers experience at the moment of birth and when looking at their babies for the first time. Buckley says, “It helps mothers and babies fall in love.” Beta-endorphin is a pain-relieving stress hormone that also builds up in a natural labor. It is associated with what Buckley calls “the altered state of consciousness that is normal in labor”: “Being ‘on another planet,’ as some describe it, helps the mother-to-be to work instinctively with her body and her baby, often using movement and sounds. Epidurals reduce the laboring woman’s release of beta-endorphin. Perhaps the widespread use of epidurals reflects our difficulty with supporting women in this altered state, and our cultural preference for laboring women to be quiet and acquiescent.” But very high CA levels indicate stress – as when a laboring woman feels hungry, cold, fearful, or unsafe; and high CA levels inhibit labor. According to Buckley, “This response makes evolutionary sense: if the mother senses danger, her hormones will slow or stop labor and give her time to flee to find a safer place to give birth. Epidurals reduce the laboring woman’s release of CA, which may be helpful if high levels are inhibiting her labor. However, a reduction in the final CA surge may contribute to the difficulty that women laboring with an epidural can experience in pushing out their babies, and to the increased risk of instrumental delivery (forceps and vacuum) that accompanies the use of an epidural.” Epidural drugs affect the baby as well as the mother. The U.S. Food and Drug Administration currently requires the manufacturer of bupivacaine to provide information about the drug for providers. The label reads, in part: Local anesthetics rapidly cross the placenta, and when used for epidural, caudal or pudendal block anesthesia, can cause varying degrees of maternal, fetal and neonatal toxicity [...] Adverse reactions in the parturient [birthing woman], fetus and neonate involve alteration of the central nervous system, peripheral vascular tone and cardiac function. In her statement to the FDA, Doris Haire said, “I am concerned that as the number of children with learning disability, autism, dyslexia, attention deficit, and hyperactivity continue to mount to a frightening number, the FDA does not appear to be making a strong endeavor to see if obstetric related drugs contribute to these problems [...] Uterine stimulants which foreshorten the oxygen-replenishing intervals between contractions, by making the contractions too long, too strong, or too close together, increase the likelihood that fetal brain cells will die.” Time Passages Another problem with hospital birth is time. A normal labor – starting with the rupture of membranes, or breaking of waters – can go on for a day or more, starting and stopping, especially in the early stages. Midwife Elizabeth Davis, in her book Heart and Hands: A Guide to Midwifery, describes a baby born at home, healthy and with no complications, 40 hours after the mother’s water broke; and offers that as an example of a normal labor. Breaking the bag of water often seems to be a small, benign intervention. But statistics show that when membranes are ruptured early in labor, the rate of cesarean birth increases. The Lamaze Institute reports that, “because prolonged rupture of the membranes is associated with increased risk of infection in both mother and baby, in a very real sense the clock starts ticking once a woman’s water breaks. Breaking the bag of water may shorten labor, but there are tradeoffs.” If labor does not progress after the rupturing of membranes, the next step is the administration of Pitocin to speed up labor. Pitocin is a synthetic form of the hormone oxytocin, administered intraveneously to laboring women to force contractions; it supplements the natural oxytocin that is released in the brain during normal labor. But Pitocin administered by IV does not reach the brain, so it doesn’t stimulate the release of pain-killing natural endorphins as oxytocin does. The result is contractions that feel harsher and more painful. And they are. Normal contractions measure around 60 mmHg (millimeters of mercury, the same measurement that describes blood pressure). Pitocin-augmented contractions can reach levels of 90 mmHg, and are stronger and longer, with a sharper build-up to peak. The use of Pitocin increases the risk of uterine rupture, especially in vaginal birth after cesarean (VBAC). It also increases stress on the baby, so that women receiving Pitocin need continual fetal monitoring. And when the baby’s systems are depressed with opiate drugs, and its blood supply is interrupted during long, hard Pitocin-augmented contractions, fetal distress is more likely; and surgical intervention becomes necessary. As one local practitioner said, “Shorter labors have better outcomes”; the longer the baby spends in the epidural-Pitocin environment, the greater are its chances of experiencing distress. And because Pitocin increases pain, the women who are given it usually need an epidural. So Pitocin goes hand in hand with both epidurals and surgery. Down On The Pelvic Floor Another side effect of aggressive management of labor is the increase in pelvic floor dysfunction, which includes urinary stress incontinence and other problems such as “dropping” of the bladder or uterus, or difficult-to-repair tears between the rectum and vagina, usually associated with episiotomy (the ‘cut’ made to widen the vagina at the time of birth). The increased need for pelvic floor repair has made urogynecology the fastest-growing subspecialty in medicine. In May, 2005, the American Journal of Obstetrics and Gynecology ran an article called “The Hidden Epidemic of Pelvic Floor Dysfunction.” The abstract read: “Each year, pelvic floor dysfunction affects between 300,000 and 400,000 American women so severely that they require surgery. Approximately 30 percent of the operations performed are re-operations. The high prevalence of this problem indicates the need for preventive strategies, and the common occurrence of re-operation indicates the need for treatment improvement.” While some degree of pelvic floor disorder may occur in women who have never given birth, the aggressive management of childbirth contributes to the problem in different ways. First, an epidural relaxes the pelvic floor muscles, which, in natural labor, tighten during contractions, keeping the pelvic organs in place and helping the baby maneuver down the birth passage. Lax pelvic floor muscles prevent the baby from staying in the most favorable position for birth – thus slowing the progress of labor. Pitocin-augmented contractions also increase the pressure on the pelvic floor, whose muscles, without their natural resistance, are liable to strain. “One in ten women has problems with pelvic floor dysfunction and the fact that no one really knows how to prevent them is a major problem,” says Dr. John O. L. DeLancey, M.D., the article’s author and professor of obstetrics and gynecology at the University of Michigan. “Childbirth is by far the most common cause of these problems and people suggest cesareans, but with only 1 out of 10 patients having the problem, that means 9 out of 10 will have unnecessary cesarean. We don’t yet know what injury at birth is responsible for these problems.” America’s 30 percent cesarean rate is startling from a global perspective. The International Cesarean Awareness Network reports that countries with cesarean rates under 10 percent have the lowest perinatal mortality rates in the world. And the World Health Organization says, “There is no justification in any specific region to have more than 10-15 percent cesarean section births.” Yet our cesarean delivery rate continues to climb, in part because obstetrics is a surgical, not a medical, specialty. One local OB educator estimated that residents need fifty to a hundred cases or more to achieve competence in performing cesareans. The demand for practice cases at OB training centers is directly at odds with the goal of preventing unnecessary cesareans. The Midwifery Model In contrast to the aggressive management approach of obstetrics, there is a kinder, gentler approach to childbirth – the midwifery model, which says that women possess all the knowledge and power they need to give birth, including inborn mechanisms for coping with pain — and that these processes should be encouraged, not impeded. Historically, obstetricians have been wary of, even opposed to, this woman-centered model. In many states, including New York, giving birth at home with an independent midwife is now illegal. In the mid-1980s, OB practitioners in Vermont blocked the creation of an independent birthing center on the midwifery model. In 2001, Fletcher Allen obstetricians appeared before the State Legislature to restrict the licensure of independent midwives, and aggressively restricted women’s choices around home birth. A local midwife was told by a hospital OB practitioner: “If you screw up once, we will nail you.” Women who give birth in Vermont have few options – stay at home with limited backup, or go to a hospital where aggressive labor management practices prevail. While hospital birthing centers are improving – especially those with midwifery services – teaching centers are still in the grip of the old model and the demands of obstetrical training. Fewer medical students are choosing OB as a specialty; the numbers of medical school graduates who specialize in OB has declined every year since 1993. Nationwide, the number of unfilled positions has increased, so there are fewer resident physicians to handle the work. Under new national guidelines, residents work 80 hours per week – down from 120, but still twice the standard work week. There is little continuity of care or connection with patients, and the pressure to “do cases” and conform to aggressive management practices during the four-year training period is still enormous. Some OB practitioners are adopting the midwifery model, however. A young, hospital-trained obstetrician currently practicing in Vermont incorporates the midwifery model into her practice: “We try to teach women that they already have everything they need to give birth; they have it from their mothers, their grandmothers, their great-grandmothers—it’s in their mitochondrial DNA!” Training for the traditional midwife consists of an apprenticeship in which the trainee is partnered with a senior midwife whom she assists, taking on more responsibility as her skills grow. An independent midwife may take as much time as she needs to achieve competency; there is no set number of months or deliveries she must attend. Her practice is grounded in a knowing relationship with her clients, rather than in statistics. The OB practitioner who incorporates the midwifery model into her practice said, “OB training needs to be more of an apprenticeship. The residents never get to really know the patients – there’s no connection; it’s just work, and when you sign out, you are done.” Practitioners in both midwifery and obstetrics, and many consumers, recognize a need to merge the wisdom of the midwifery model with the skills of surgery, and for the two disciplines to become cooperative instead of competitive. Hospital birthing programs need to become more supportive of women’s choices in childbirth, including choice of provider, from family practitioners to independent midwives, especially as obstetricians become scarcer. There is also a need for OB training programs to take into account the real needs of doctors-in-training. “No provider should work more than 35 hours a week; it’s just not healthy,” said the obstetrician who supports the midwifery model. Another practitioner suggested that OB residents form partnership groups in which they would be responsible for the continued care of small groups of patients, instead of being shifted to different departments in the hospital month by month. They could, early on, learn the value of connecting with their clients and each other, and learn all the processes of natural pregnancy and birth. “There’s more than enough work to go around!” said the midwifery-friendly OB. “It doesn’t have to be ‘us’ versus ‘them’.” She also said that patients must assume more responsibility for their decisions, and must be fully cognizant of the real risks and benefits of medical options such as epidurals and Pitocin, and of natural processes in general – which may include death. She, and other practitioners, feel that childbirth education for everyone should begin early, and openly; and that new models for care should be encouraged to evolve. “We are all in this because we love it, and that’s a good place to start.” Katharine M. Hikel is a non-practicing physician living in Hinesburg. |
The main problem with giving birth today is the specialty of OB as now practiced. From its origins in the manly realms of medieval Europe, obstetrics has increasingly promoted a culture of childbirth that interferes with women’s natural processes rather than working with them.