On Becoming Babywise: A Flawed Parenting Philosophy?
(This article is from the Rick A. Ross Institute. I could not find an author's name.)
Baby care book could be dangerous (Child magazine, August 1998).
Babywise advice linked to dehydration, failure to thrive ("AAP News," April 1998).
A Tough Plan for Raising Children Draws Fire: Babywise Books Worry Pediatricians and Others (Washington Post, February 27, 1999).
These startling headlines refer to the top-selling and highly controversial childcare guides On Becoming Babywise and Babywise II, written by Gary Ezzo, a self-described Christian pastor, and endorsed by Robert Bucknam, a pediatrician. Chances are you've heard of these books; since it was published in 1995, On Becoming Babywise reportedly has sold more than 290,000 copies. Babywise is recommended for parents of babies up to 5 months old, and Babywise II addresses parents of children 5 to 15 months old. Soon to be released is On Becoming Childwise, a guide for toddlers through 8-year-olds.
Ezzo, who has no formal theological or medical training, is executive director of the for-profit organization Growing Families International (GFI). With his wife, Anne Marie, Ezzo runs church-based classes for parents who wish to give their children a rigid religious upbringing. Although few readers know it, the Babywise books are the secular versions of Ezzo's original parenting program, which includes guides such as "Preparation for Parenting" and "Growing Kids God's Way" (GKGW). The content of these guides is based on GFI's own unpublished self-conducted studies. The studies have not been subjected to peer review, which means there has been no independent, professional evaluation of the studies or their findings, the usual method of verifying the worth of scientific studies.
Despite the fact that Ezzo has a large and growing following — reportedly more than a million families in 93 countries, with his books translated into 17 languages — distress over his program is also growing. What are doctors, lactation specialists, and child development experts — some of whom are Christians — concerned about? Ezzo's self-designed, strictly regimented feeding program, called Parent-Directed Feeding (PDF), which has a parent put their newborn on a strict feeding / waking / sleeping schedule. Rather than feed a baby when he shows signs of hunger — a technique known as demand feeding — parents are instructed to feed by the clock. The goal? Ostensibly to establish routine in your baby's life from day one and stick to it no matter what.
A recent outcry from medical and child development experts persuaded Ezzo to revise his 1998 version of Babywise to say that babies should be fed when they're hungry. However, the book still instructs otherwise: Parents are told that if their baby doesn't eat at a scheduled feeding, he must wait until the next one.
Distress among doctors and childcare professionals
About six years ago, alarm bells went off when doctors began seeing more and more infants who were showing signs of failure to thrive, poor weight gain, and dehydration. When questioned about their feeding practices, many of the parents admitted they were following Ezzo's PDF program. And though they could see something was drastically wrong with their infants, the parents found it hard — sometimes impossible — to blame PDF. After all, they were following the advice of a Christian pastor and a pediatrician. How could such experts be wrong?
Members of the American Academy of Pediatrics (AAP), the highly respected body of primary care pediatricians, have found a great deal wrong. In fact, in April 1998, after receiving a letter signed by a hundred doctors, lactation specialists, and childcare professionals exposing a number of Ezzo's statements as unsubstantiated and false, the AAP issued a Media Alert. In it, the AAP directly contradicted Ezzo's advice on scheduled feedings, and instead advised parents that "newborns should be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing, or rooting. Crying is a late indicator of hunger. Newborns should be nursed approximately eight to 12 times every 24 hours until satiety."
The AAP is currently reviewing several parenting programs, including Gary Ezzo's, and within the next couple of years will publish guidelines to help parents evaluate the programs. For more information, visit the AAP Web site.
Doctors and Christians part company with Babywise
Matthew Aney, M.D., a Christian pediatrician and member of the AAP, worries that the advice in Babywise doesn't allow for individual differences among breastfeeding mothers and babies. He points out that while some parents may be able to follow the PDF method, Ezzo offers no alternative for those who can't. It's a one-size-fits-all prescription that can leave parents who "fail" the program feeling guilty and filled with doubt about their parenting skills. Aney found parents were often reluctant to admit they were following the PDF schedule, especially if they had a strong religious commitment to the program.
Aney points out at least 35 unsubstantiated medical "facts" in Babywise. Here are three examples:
"Demand-fed babies don't sleep through the night."
"A mother who takes her baby to her breast 12, 15, or 20 times a day will not produce any more milk than the mom who takes her baby to her breast six to seven times a day."
"Mothers following PDF have little or no problem with the letdown reflex compared to those who demand-feed."
Aney says that Ezzo simply throws out these statements without offering data to support them. He is also disturbed by Ezzo's questioning of recent research that shows that putting a baby to sleep on his back will reduce the chance of Sudden Infant Death Syndrome (SIDS). Ezzo says that the research is not conclusive, and that experts used questionable methods of gathering data. In fact, research conclusively shows that back sleeping has reduced the incidence of SIDS by about 30 percent.
BabyCenter's sleep expert Jodi Mindell says that while babies thrive on schedules and routine, she doesn't know of a single medical expert who supports using a PDF system. "Babies should be fed when they are hungry. Limiting a baby's feeding times is physically and emotionally dangerous," Mindell says.
James McKenna, director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame in Indiana, agrees. "The Ezzos appear to be the masters of the 'one-size-should-fit-all' school of childcare," he says. "Their simplistic, judgmental, and utterly self-serving program confuses personal and religious values with science, and strictly controlled infant care with successful parenting. The two are anything but compatible."
It's not just doctors and researchers who have parted company with Gary Ezzo and GFI. The board of elders of Grace Community Church in Sun Valley, California (the church where Ezzo first developed his parenting guides), issued a public statement ending all association with Ezzo and his GFI ministry. In their statement, they express concern about GFI's rigid feeding schedule and the organization's "blurring of the line between that which is truly Biblical and simple matters of preference." The elders worry that GFI's parents tend to isolate their children from those outside the GFI community. They also feel uncomfortable about Gary Ezzo's practice of responding "with exaggerated and even false accusations against his critics."
Another respected Christian organization that does not support the use of Ezzo's materials is Focus on the Family. The group has received numerous letters from parents, pastors, midwives, physicians, and lactation professionals reporting cases of failure to thrive in infants subjected to the PDF program. In a letter to Matthew Aney, one member of Focus expressed concern that parents who follow Ezzo's "controlled feeding proposals" could even wind up abusing their children.
The Child Abuse Prevention Council of Orange County, California, expressed similar fears. In a public document, council members reported their concerns about the risk of physical abuse to children when parents follow "Growing Kids God's Way." They note that "although the Ezzos advocate several alternatives to corporal punishment, they include the use of a strip of firm rubber to strike children." The council worries that condoning corporal punishment could lead some parents to abuse their children.
With so many people speaking out against it, what is the continuing appeal of Babywise?
"The appeal of Babywise is that everyone wants a good night's sleep, and everyone wants their kids to turn out well," says Kathleen Terner, a research associate at the Christian Research Institute who has spent several years investigating GFI and its programs. "Ezzo promises both if you follow his book faithfully. His information is very specific and is presented as foolproof. Sadly, many parents believe that if something is in print, then it has to be true."
In an article in the Christian Research Journal (Spring 1998) called "More than a Parenting Ministry: The Cultic Characteristics of Growing Families International," Terner, who is herself a Christian and a mother of a young child, and co-author Elliot Miller, acknowledge that GFI has some good things to contribute to the subject of Christian parenting, such as teaching children to be responsible, obedient, and respectful of others. But Terner feels the potential dangers of the program far outweigh the benefits. Jan Barger, an International Board Certified Lactation Consultant, agrees. "The overarching goal of Babywise is to shape children who are outwardly compliant, sleep a lot, and don't interfere with their parents' lives, rather than teaching parents how to develop happy, healthy, contented, intelligent babies."
So what's a parent to think?
"Do your homework before deciding what's best for your children," says Kathleen Terner. When it comes to choosing a childcare guide, check the author's credentials. Is he trained in medicine and child development? Does she back up her statements with medically proven facts? Who has endorsed the book? Get advice on choosing a guide from your pediatrician, lactation consultant, religious leader, or other parents. You also can contact the American Academy of Pediatrics or read the organization's own series of childcare books and brochures.
As a general rule of thumb, keep in mind that some babies don't need to be fed more than every three hours, but many need to be fed more often. Especially in the first few months, when your baby is growing rapidly, you should feed him when he shows signs of hunger. As he gets older, he will require less frequent feeding and will sleep for longer periods between meals. Above all, trust your baby to communicate his needs
Monday, January 25, 2010
Wednesday, August 26, 2009
Is vaginal birth after cesarean risky?
by Henci Goer
“A Risk Is Found in Natural Birth After Caesarean” New York Times
“Study: Labor Risky After a Caesarean.” Associated Press
From the above titles and the articles that followed them, readers would think that a new study published in the prestigious New England Journal of Medicine showed that planned repeat cesarean was safer than vaginal birth after cesarean (VBAC, pronounced “vee-back”). However, the study concluded nothing of the kind. Slanted by quotations from Dr. Michael Greene, an associate editor of the New England Journal who wrote an accompanying editorial, the newspaper, TV and radio reports were actually another salvo in the disinformation campaign to eliminate VBAC. Before we get to why obstetricians want to discredit VBAC, let’s look first at what the study really said.
What did the study really say?
Reuters Medical News was perhaps the sole major news outlet to get it right. They ran their piece under: “Prostaglandin-Induced Labor Linked to High Risk of Uterine Rupture after C-Section.” The researchers ascertained this by comparing the rate at which the uterine scar gave way in some 20,000 women in Washington State who had a second child after having the first by cesarean.
They found that the odds were:
1 in 625 with a planned repeat cesarean,
1 in 192 with starting labor on their own,
1 in 130 with an induction of labor but without using prostaglandin to
soften the cervix first,
1 in 41 with labor inductions that included prostaglandin.
While potentially serious, the scar giving way, though, is not the crucial issue in determining the safety of VBAC, but rather what happens to the mother and baby as a result. Even when uterine rupture occurred, only one-third of the women experienced a surgical complication during the emergency cesarean that would usually follow. As for irremediable harm, for a woman beginning labor spontaneously, the chance of ending up with a hysterectomy was 1 in 5,000 and of losing the baby was 1 in 3,300.
For women being induced without use of prostaglandin, the odds went up only slightly, but when labor induction included prostaglandin, they soared to 1 in 900 for hysterectomy and 1 in 770 for infant death.
In point of fact, this study had nothing to say about the merits of planned cesarean versus VBAC because it only considered uterine rupture. And while VBAC women have a slightly greater risk of this, cesarean section introduces a host of other complications that occur much less often with vaginal birth. To evaluate which is better, you have to compare outcomes between women having a planned repeat cesarean with women planning VBACs. Those studies exist. Among thirty studies comprising 56,300 VBACs, the rate of stillbirths and newborn deaths attributable to uterine rupture was 1 in 3,300, the same as in the Washington State women beginning labor spontaneously. Those odds did not differ significantly from the perinatal mortality rate in 29,900 women having planned cesareans. In other words, VBAC was no riskier for babies than planned cesarean.
By contrast, according to a Swiss study of 29,000 women with prior cesareans, women having planned cesareans for a subsequent birth were three times as likely to have hysterectomies as women planning VBACs: 1 in 220 versus 1 in 625. In addition, every time a woman elects a cesarean over a VBAC, she rolls dice that are loaded more and more heavily against her, especially if she desires more children.
Studies show that accumulating cesareans increase the risk of:
*infertility
*chronic pain and bowel problems
*the embryo implanting outside of the uterus (ectopic pregnancy)
*the placenta overlaying the cervix (placenta previa)
*the placenta detaching before the birth (placental abruption)
*the placenta growing into or through the muscular wall of the uterus
(placenta accreta or percreta).
The last three are life-threatening; placenta accreta particularly so. Planned repeat cesarean also puts babies at risk for breathing difficulties. One problem, persistent pulmonary hypertension, can be deadly.
Objective readers of the New England Journal study would conclude neither that VBAC was unduly risky nor even that VBAC women should never be induced.
3 things they would conclude are:
*The first cesarean should be avoided both because of the inherent risks of
major surgery and because it introduces risks into future pregnancies.
*Induction of labor should only be done when the risks of awaiting labor
outweigh the risks of inducing it -- a situation that occurs far less often
than the typical obstetrician thinks it does.
*When induction seems the most prudent course, don’t use prostaglandins.
Are OBs really objective about VBAC? Obstetric opposition to VBAC isn’t about safety. Obstetricians have been quite open about their motivation to condemn VBAC.
In 1996, a prominent obstetrician and the editor of an obstetric trade magazine proposed a prototype of what he called an “informed consent” form. It described the dreadful things that could go wrong with a VBAC but said nothing about the equally dreadful things that could go wrong with a repeat cesarean, let alone the dangers of accumulating scars for future pregnancies. Few women would be brave enough to attempt a VBAC after reading this form. This doctor frankly admitted that the form was intended to forestall lawsuits and that using it would “send your [cesarean] rate soaring.” Since then, malpractice insurance companies have widely adopted it and begun recommending that their obstetrician clients use this form or others like it. Many of them have.
The obstetricians’ professional trade organization, the American College of Obstetricians and Gynecologists , has been equally forthcoming about why it reversed its position on VBAC. Despite no change in the data, it issued new guidelines in 1998 that took a much more negative view of VBAC than the previous guidelines. A stated rationale for the about face was that “adverse events during trial of labor have led to malpractice suits.”
The desire to avoid malpractice suits doesn’t necessarily mean obstetricians don’t have a legitimate concern about VBAC. However, the logical discrepancies and inconsistencies that riddle obstetric arguments and pronouncements reveal that they aren’t, in fact, expressing genuine interest in promoting safe and effective care.
Let me cite some examples.
The new guidelines recommend that hospitals not permit VBAC unless they can perform immediate emergency cesareans. This has had a chilling effect on VBACs, because most community hospitals can’t do this, especially at night or on weekends. But the general hospital population has about the same potential for an emergency in labor as the potential for the scar giving way. If it isn’t safe for VBAC labors in hospitals that cannot perform an immediate cesarean, then it isn’t safe for any woman to labor there.
Leaving aside that cesareans impose other risks that balance out the risk of uterine rupture during a VBAC, commentators on the Washington State data deemed the 1 in 3,300 chance of losing the baby during a spontaneous VBAC labor was sufficient to mandate planned repeat cesarean. The odds of amniocentesis precipitating a miscarriage fall somewhere between 1 in 200 and 1 in 400, more than ten times the risk of the baby dying from a VBAC-related uterine rupture. Yet obstetricians aren’t lobbying for an end to amniocentesis on the grounds that it is too hazardous.
Another tip-off is a willingness to distort data. The 1998 VBAC guidelines cite a single study as the other rationale besides reducing liability for revising the guidelines. The sole study with this finding, it concluded that “major maternal complications” were twice as likely in women laboring compared with women having elective cesareans,. However, as a preeminent VBAC researcher points out, the authors coded wound infections and hemorrhage requiring transfusion as “minor complications,” both of which occurred more often in the planned cesarean group. If you make these major complications, as would normally be the case, the difference between the two groups disappears. Even without doing this, he adds, major complication rates were quite low--a bit less than one percent in the planned cesarean group, a bit more than one percent in the labor group.
Dr. Greene, the New England Journal editorialist obstetrician, provides another example of data distortion. He leaps from the limited finding that VBAC, at least barring prostaglandin use, slightly increases the risk of uterine rupture to the sweeping statement that VBAC is more dangerous than repeat cesarean. He treats a risk factor, uterine rupture, as the actual devastating outcome, stillbirth or newborn death. Both are such elementary errors of proper scientific approach for an assistant editor at a prominent medical journal that it strongly suggests he has an axe to grind.
To be fair, not every obstetrician who won’t do VBACs is willfully engaging in deception. Some are unconsciously suiting the facts to their beliefs. Some have been convinced by those they take as authorities that repeat cesarean is best. Some are glad to have an excuse to not do what they never wanted to do in the first place. Some have reluctantly bowed to pressure from their malpractice insurance company, hospital policy or colleagues. The result for you, though, is the same: the experts you trust to advise you on what is safest for you and your baby have abandoned that responsibility. With few exceptions, when obstetricians tell you planned repeat cesarean is the better option, they aren’t talking about your or your baby’s wellbeing; they are talking about their own.
Note: For those of you aware of the dangers of Cytotec (misoprostol), a prostaglandin implicated in high rates of uterine rupture in VBAC labors, the study states that Cytotec had only been introduced in 1996, the last year of the study. The study compares uterine rupture rates with induction involving prostaglandin in the years preceding 1996 with 1996 and finds no difference. I expect this is because Cytotec probably wasn’t in common use in its first year. I venture to predict that if researchers looked at a later year, rupture rates associated with prostaglandin would have climbed even higher than they were during the study years.
References
1. ACOG. Vaginal birth after previous cesarean delivery. Practice Bulletin 1998, No 2.
2. ACOG. Vaginal delivery after previous cesarean birth. Practice Patterns 1995; No 1.
3. Associated Press. Study: labor risky after a caesarean. July 5, 2001.
4. Flamm BL. Once a cesarean, always a controversy. Obstet Gynecol 1997;90(2):312-5.
5. Goer H. Cesareans: Everything you need to know, 2001.
6. Goer H. The Thinking Woman’s Guide to a Better Birth. New York: Perigee Books, 1999.
7. Lydon-Rochelle M et al. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345-3-8.
8. McMahon MJ et al. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996;335(10):689-95.
9. Olney RS et al. Chorionic villus sampling and amniocentesis: recommendations for prenatal counseling. MMWR 1995;44(RR-9):1-12.
10. Phelan JP. Rendering unto Caesar cesarean decisions. OBG Management 1996 Nov:6.
11. Reuters Medical News. Prostaglandin-induced labor linked to high risk of uterine rupture after c-section. Jul 4, 2001.
12. Rageth JC, Juzi C, and Grossenbacher H. Delivery after previous cesarean: a risk evaluation. Swiss Working Group of Obstetric and Gynecologic Institutions. Obstet Gynecol 1999;93(3):332-7.
13. Stolberg SG. A risk is found in natural birth after caesarean. New York Times. Jul 5, 2001.
“A Risk Is Found in Natural Birth After Caesarean” New York Times
“Study: Labor Risky After a Caesarean.” Associated Press
From the above titles and the articles that followed them, readers would think that a new study published in the prestigious New England Journal of Medicine showed that planned repeat cesarean was safer than vaginal birth after cesarean (VBAC, pronounced “vee-back”). However, the study concluded nothing of the kind. Slanted by quotations from Dr. Michael Greene, an associate editor of the New England Journal who wrote an accompanying editorial, the newspaper, TV and radio reports were actually another salvo in the disinformation campaign to eliminate VBAC. Before we get to why obstetricians want to discredit VBAC, let’s look first at what the study really said.
What did the study really say?
Reuters Medical News was perhaps the sole major news outlet to get it right. They ran their piece under: “Prostaglandin-Induced Labor Linked to High Risk of Uterine Rupture after C-Section.” The researchers ascertained this by comparing the rate at which the uterine scar gave way in some 20,000 women in Washington State who had a second child after having the first by cesarean.
They found that the odds were:
1 in 625 with a planned repeat cesarean,
1 in 192 with starting labor on their own,
1 in 130 with an induction of labor but without using prostaglandin to
soften the cervix first,
1 in 41 with labor inductions that included prostaglandin.
While potentially serious, the scar giving way, though, is not the crucial issue in determining the safety of VBAC, but rather what happens to the mother and baby as a result. Even when uterine rupture occurred, only one-third of the women experienced a surgical complication during the emergency cesarean that would usually follow. As for irremediable harm, for a woman beginning labor spontaneously, the chance of ending up with a hysterectomy was 1 in 5,000 and of losing the baby was 1 in 3,300.
For women being induced without use of prostaglandin, the odds went up only slightly, but when labor induction included prostaglandin, they soared to 1 in 900 for hysterectomy and 1 in 770 for infant death.
In point of fact, this study had nothing to say about the merits of planned cesarean versus VBAC because it only considered uterine rupture. And while VBAC women have a slightly greater risk of this, cesarean section introduces a host of other complications that occur much less often with vaginal birth. To evaluate which is better, you have to compare outcomes between women having a planned repeat cesarean with women planning VBACs. Those studies exist. Among thirty studies comprising 56,300 VBACs, the rate of stillbirths and newborn deaths attributable to uterine rupture was 1 in 3,300, the same as in the Washington State women beginning labor spontaneously. Those odds did not differ significantly from the perinatal mortality rate in 29,900 women having planned cesareans. In other words, VBAC was no riskier for babies than planned cesarean.
By contrast, according to a Swiss study of 29,000 women with prior cesareans, women having planned cesareans for a subsequent birth were three times as likely to have hysterectomies as women planning VBACs: 1 in 220 versus 1 in 625. In addition, every time a woman elects a cesarean over a VBAC, she rolls dice that are loaded more and more heavily against her, especially if she desires more children.
Studies show that accumulating cesareans increase the risk of:
*infertility
*chronic pain and bowel problems
*the embryo implanting outside of the uterus (ectopic pregnancy)
*the placenta overlaying the cervix (placenta previa)
*the placenta detaching before the birth (placental abruption)
*the placenta growing into or through the muscular wall of the uterus
(placenta accreta or percreta).
The last three are life-threatening; placenta accreta particularly so. Planned repeat cesarean also puts babies at risk for breathing difficulties. One problem, persistent pulmonary hypertension, can be deadly.
Objective readers of the New England Journal study would conclude neither that VBAC was unduly risky nor even that VBAC women should never be induced.
3 things they would conclude are:
*The first cesarean should be avoided both because of the inherent risks of
major surgery and because it introduces risks into future pregnancies.
*Induction of labor should only be done when the risks of awaiting labor
outweigh the risks of inducing it -- a situation that occurs far less often
than the typical obstetrician thinks it does.
*When induction seems the most prudent course, don’t use prostaglandins.
Are OBs really objective about VBAC? Obstetric opposition to VBAC isn’t about safety. Obstetricians have been quite open about their motivation to condemn VBAC.
In 1996, a prominent obstetrician and the editor of an obstetric trade magazine proposed a prototype of what he called an “informed consent” form. It described the dreadful things that could go wrong with a VBAC but said nothing about the equally dreadful things that could go wrong with a repeat cesarean, let alone the dangers of accumulating scars for future pregnancies. Few women would be brave enough to attempt a VBAC after reading this form. This doctor frankly admitted that the form was intended to forestall lawsuits and that using it would “send your [cesarean] rate soaring.” Since then, malpractice insurance companies have widely adopted it and begun recommending that their obstetrician clients use this form or others like it. Many of them have.
The obstetricians’ professional trade organization, the American College of Obstetricians and Gynecologists , has been equally forthcoming about why it reversed its position on VBAC. Despite no change in the data, it issued new guidelines in 1998 that took a much more negative view of VBAC than the previous guidelines. A stated rationale for the about face was that “adverse events during trial of labor have led to malpractice suits.”
The desire to avoid malpractice suits doesn’t necessarily mean obstetricians don’t have a legitimate concern about VBAC. However, the logical discrepancies and inconsistencies that riddle obstetric arguments and pronouncements reveal that they aren’t, in fact, expressing genuine interest in promoting safe and effective care.
Let me cite some examples.
The new guidelines recommend that hospitals not permit VBAC unless they can perform immediate emergency cesareans. This has had a chilling effect on VBACs, because most community hospitals can’t do this, especially at night or on weekends. But the general hospital population has about the same potential for an emergency in labor as the potential for the scar giving way. If it isn’t safe for VBAC labors in hospitals that cannot perform an immediate cesarean, then it isn’t safe for any woman to labor there.
Leaving aside that cesareans impose other risks that balance out the risk of uterine rupture during a VBAC, commentators on the Washington State data deemed the 1 in 3,300 chance of losing the baby during a spontaneous VBAC labor was sufficient to mandate planned repeat cesarean. The odds of amniocentesis precipitating a miscarriage fall somewhere between 1 in 200 and 1 in 400, more than ten times the risk of the baby dying from a VBAC-related uterine rupture. Yet obstetricians aren’t lobbying for an end to amniocentesis on the grounds that it is too hazardous.
Another tip-off is a willingness to distort data. The 1998 VBAC guidelines cite a single study as the other rationale besides reducing liability for revising the guidelines. The sole study with this finding, it concluded that “major maternal complications” were twice as likely in women laboring compared with women having elective cesareans,. However, as a preeminent VBAC researcher points out, the authors coded wound infections and hemorrhage requiring transfusion as “minor complications,” both of which occurred more often in the planned cesarean group. If you make these major complications, as would normally be the case, the difference between the two groups disappears. Even without doing this, he adds, major complication rates were quite low--a bit less than one percent in the planned cesarean group, a bit more than one percent in the labor group.
Dr. Greene, the New England Journal editorialist obstetrician, provides another example of data distortion. He leaps from the limited finding that VBAC, at least barring prostaglandin use, slightly increases the risk of uterine rupture to the sweeping statement that VBAC is more dangerous than repeat cesarean. He treats a risk factor, uterine rupture, as the actual devastating outcome, stillbirth or newborn death. Both are such elementary errors of proper scientific approach for an assistant editor at a prominent medical journal that it strongly suggests he has an axe to grind.
To be fair, not every obstetrician who won’t do VBACs is willfully engaging in deception. Some are unconsciously suiting the facts to their beliefs. Some have been convinced by those they take as authorities that repeat cesarean is best. Some are glad to have an excuse to not do what they never wanted to do in the first place. Some have reluctantly bowed to pressure from their malpractice insurance company, hospital policy or colleagues. The result for you, though, is the same: the experts you trust to advise you on what is safest for you and your baby have abandoned that responsibility. With few exceptions, when obstetricians tell you planned repeat cesarean is the better option, they aren’t talking about your or your baby’s wellbeing; they are talking about their own.
Note: For those of you aware of the dangers of Cytotec (misoprostol), a prostaglandin implicated in high rates of uterine rupture in VBAC labors, the study states that Cytotec had only been introduced in 1996, the last year of the study. The study compares uterine rupture rates with induction involving prostaglandin in the years preceding 1996 with 1996 and finds no difference. I expect this is because Cytotec probably wasn’t in common use in its first year. I venture to predict that if researchers looked at a later year, rupture rates associated with prostaglandin would have climbed even higher than they were during the study years.
References
1. ACOG. Vaginal birth after previous cesarean delivery. Practice Bulletin 1998, No 2.
2. ACOG. Vaginal delivery after previous cesarean birth. Practice Patterns 1995; No 1.
3. Associated Press. Study: labor risky after a caesarean. July 5, 2001.
4. Flamm BL. Once a cesarean, always a controversy. Obstet Gynecol 1997;90(2):312-5.
5. Goer H. Cesareans: Everything you need to know, 2001.
6. Goer H. The Thinking Woman’s Guide to a Better Birth. New York: Perigee Books, 1999.
7. Lydon-Rochelle M et al. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345-3-8.
8. McMahon MJ et al. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996;335(10):689-95.
9. Olney RS et al. Chorionic villus sampling and amniocentesis: recommendations for prenatal counseling. MMWR 1995;44(RR-9):1-12.
10. Phelan JP. Rendering unto Caesar cesarean decisions. OBG Management 1996 Nov:6.
11. Reuters Medical News. Prostaglandin-induced labor linked to high risk of uterine rupture after c-section. Jul 4, 2001.
12. Rageth JC, Juzi C, and Grossenbacher H. Delivery after previous cesarean: a risk evaluation. Swiss Working Group of Obstetric and Gynecologic Institutions. Obstet Gynecol 1999;93(3):332-7.
13. Stolberg SG. A risk is found in natural birth after caesarean. New York Times. Jul 5, 2001.
Rebuttal to Rationales for Denial of VBAC
© 2003 by Henci Goer
More and more women who want a vaginal birth after cesarean (VBAC, "vee-back") are discovering that it is difficult or impossible to obtain one. Doctors and hospitals offer the rationales that elective repeat cesarean surgery is safer for the baby and that the hospital lacks the ability to handle the need for emergency cesarean should the uterine scar give way during labor. The validity of those arguments depends on the answers to three questions:
• First, is planned repeat cesarean surgery safer than planned vaginal birth? The answer is "no." Dozens of studies totaling tens of thousands of women have conclusively shown that elective repeat cesarean is more hazardous for the woman, no safer for the baby, and poses serious risks to the woman's future reproductive life. What is more, with appropriate care, 7 out of 10 women or more will give birth vaginally thus ending their exposure to the hazards of cesarean surgery.
• Second, is it reasonable for hospitals to refuse VBAC based on the argument that they don't have the staff or equipment to deal with potential emergencies? Again, the answer is "no." Emergencies occur in non-VBAC labors, and there are other situations that increase the chances of needing an emergency cesarean where hospitals don't make special exceptions such as induction of labor and epidural analgesia. If a hospital isn't safe for a VBAC labor, it isn't safe for any woman to labor there.
• Finally, should doctors and hospitals have the right to refuse VBAC on the grounds that cesarean surgery is safer for the baby? The answer is "no" here as well. Even if cesarean delivery were safer, which it is not, VBAC denial violates a woman's right to informed refusal, a right explicitly guaranteed her by the American College of Obstetricians and Gynecologists (ACOG).[1] In addition, medical ethics and human rights forbid coercing or forcing a person to undergo a medical procedure of any kind--let alone major surgery--in order to benefit another person. And that includes when the beneficiary will otherwise surely die, which is hardly the case with VBAC.
ACOG's current VBAC guidelines openly admit the real reason for refusing VBAC, as do many obstetricians: the desire to avoid malpractice suits arising from VBAC labors.[2] The guidelines set standards for VBAC management, standards, it should be noted, that establish the standard of care and will be used in malpractice litigation. They include recommendations that a physician be "immediately available" throughout active labor and that there be "availability of anesthesia and personnel for emergency cesarean delivery." The former unduly burdens busy physicians, and the latter cannot be met by most community hospitals. The guidelines themselves acknowledge that no research supports these recommendations. They are based on "consensus and expert opinion." In other words, the recommendations provide seemingly compelling reasons to deny VBAC and have the authoritative weight of ACOG behind them, but, in fact, they were devised by a group of physicians with a strong, self-interested motivation to suppress VBAC and with no scientific evidence to back them up. ACOG's Code of Professional Ethics enjoins obstetricians to resolve conflicts of interest according to what is best for the patient, a principle that obstetricians clearly have abandoned in this case.
A fact sheet on the hazards of cesarean section published by the Coalition for Improving Maternity Services can be downloaded at www.motherfriendly.org/resources.
________________________________________
1. ACOG. Informed refusal. Committee Opinion No 237, June 2000.
"Once a patient has been informed of the material risks and benefits involved with a treatment, test, or procedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test, or procedure or whether to make a choice among a variety of treatments, tests, or procedures. In the exercise of that autonomy, the informed patient also has the right to refuse to undergo any of these treatments, tests, or procedures. . . . Performing an operative procedure on a patient without the patient's permission can constitute 'battery' under common law. In most circumstances this is a criminal act. . . . Such a refusal [of consent] may be based on religious beliefs, personal preference, or comfort."
2. ACOG. Vaginal birth after previous cesarean delivery. Practice Bulletin No. 5, 1999.
More and more women who want a vaginal birth after cesarean (VBAC, "vee-back") are discovering that it is difficult or impossible to obtain one. Doctors and hospitals offer the rationales that elective repeat cesarean surgery is safer for the baby and that the hospital lacks the ability to handle the need for emergency cesarean should the uterine scar give way during labor. The validity of those arguments depends on the answers to three questions:
• First, is planned repeat cesarean surgery safer than planned vaginal birth? The answer is "no." Dozens of studies totaling tens of thousands of women have conclusively shown that elective repeat cesarean is more hazardous for the woman, no safer for the baby, and poses serious risks to the woman's future reproductive life. What is more, with appropriate care, 7 out of 10 women or more will give birth vaginally thus ending their exposure to the hazards of cesarean surgery.
• Second, is it reasonable for hospitals to refuse VBAC based on the argument that they don't have the staff or equipment to deal with potential emergencies? Again, the answer is "no." Emergencies occur in non-VBAC labors, and there are other situations that increase the chances of needing an emergency cesarean where hospitals don't make special exceptions such as induction of labor and epidural analgesia. If a hospital isn't safe for a VBAC labor, it isn't safe for any woman to labor there.
• Finally, should doctors and hospitals have the right to refuse VBAC on the grounds that cesarean surgery is safer for the baby? The answer is "no" here as well. Even if cesarean delivery were safer, which it is not, VBAC denial violates a woman's right to informed refusal, a right explicitly guaranteed her by the American College of Obstetricians and Gynecologists (ACOG).[1] In addition, medical ethics and human rights forbid coercing or forcing a person to undergo a medical procedure of any kind--let alone major surgery--in order to benefit another person. And that includes when the beneficiary will otherwise surely die, which is hardly the case with VBAC.
ACOG's current VBAC guidelines openly admit the real reason for refusing VBAC, as do many obstetricians: the desire to avoid malpractice suits arising from VBAC labors.[2] The guidelines set standards for VBAC management, standards, it should be noted, that establish the standard of care and will be used in malpractice litigation. They include recommendations that a physician be "immediately available" throughout active labor and that there be "availability of anesthesia and personnel for emergency cesarean delivery." The former unduly burdens busy physicians, and the latter cannot be met by most community hospitals. The guidelines themselves acknowledge that no research supports these recommendations. They are based on "consensus and expert opinion." In other words, the recommendations provide seemingly compelling reasons to deny VBAC and have the authoritative weight of ACOG behind them, but, in fact, they were devised by a group of physicians with a strong, self-interested motivation to suppress VBAC and with no scientific evidence to back them up. ACOG's Code of Professional Ethics enjoins obstetricians to resolve conflicts of interest according to what is best for the patient, a principle that obstetricians clearly have abandoned in this case.
A fact sheet on the hazards of cesarean section published by the Coalition for Improving Maternity Services can be downloaded at www.motherfriendly.org/resources.
________________________________________
1. ACOG. Informed refusal. Committee Opinion No 237, June 2000.
"Once a patient has been informed of the material risks and benefits involved with a treatment, test, or procedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test, or procedure or whether to make a choice among a variety of treatments, tests, or procedures. In the exercise of that autonomy, the informed patient also has the right to refuse to undergo any of these treatments, tests, or procedures. . . . Performing an operative procedure on a patient without the patient's permission can constitute 'battery' under common law. In most circumstances this is a criminal act. . . . Such a refusal [of consent] may be based on religious beliefs, personal preference, or comfort."
2. ACOG. Vaginal birth after previous cesarean delivery. Practice Bulletin No. 5, 1999.
Wednesday, November 26, 2008
A VBAC Birth Story
I don’t usually blog about births I’ve attended but I am still on such a euphoric high from the one I attended yesterday that I had to write it down. Almost two years ago I was “M’s” doula for the birth of her first baby. After 40 + hours of labor and 9 cm. of dilation there was a shift change and the power hungry doctor who came on immediately diagnosed “M” with CPD (cephalopelvic disproportion--- meaning her baby was too big for her pelvis) and ordered a section. FHTs (fetal heart tones) were fine, mom was tired but still eager to continue with labor, there were no other indicators of danger to mama/baby but this doctor wanted to get the show on the road so she insisted that a c-section would be the only way to get this baby out healthy.
We were all devastated. Most of all “M” of course, who had been through all of that work just to have it end in a surgical delivery. Her baby girl weighed in at a *whopping* 7 lbs. 8 oz. so it kind of compounded her frustration when she realized she’d consented to surgery based on a complete misdiagnosis.
Cut to this week: “M”, now pregnant with baby two, has chosen to go with a Nurse-Midwife this time knowing that her goal of a healthy VBAC (Vaginal Birth After Cesarean) would be more likely realized with a midwife than an OB. Her Midwife practices out of St. Joseph’s hospital in Phoenix which is a 30-45 min. drive from their house in Mesa but it was well worth the drive to have the benefits of the midwifery model of care.
Sunday night “M” called me to tell me labor had started but that it was still early on so she was trying to go on about her regular routine. By bedtime labor had settled down so she decided to go to bed. Fortunately she was able to get a pretty good night’s sleep because her labor eased off almost entirely. Monday morning as soon as she was up and around it started back up and by Mon. afternoon her membranes had ruptured which started labor in earnest.
I drove in from Queen Creek to meet up with “M” and offer support and to be closer since we were in for such a long drive. After I arrived I watched “M” through a few contractions and timed them for an hour and when I could see that she was having about 8 an hour I decided to stay. We just took it easy all day. “M” realized that whenever she was active her labor would pick up so she and her husband “J” took a couple of long walks around the neighborhood.
A little after 9 pm, “M” expressed that she was starting to feel frustrated and antsy about not making the kind of progress she was hoping she would. I think she started to see the clock looming overhead and was worried that she was going to end up with another section for FTP (Failure to progress.) We had a long pep talk about the fact that any progress was good progress and clearly she was in a good labor pattern. I reminded her that she could do this and that this time she was going to have an awesome delivery. After the pep talk I suggested that they hide out in the bedroom and watch a movie to take some of the pressure off about progress since it seemed to be stressing her out. About an hour later “M’s” mother in law and I were chatting when “J” came down the hall and said, “M needs you for a minute.”
When I got to the bedroom “M” was looking very uncomfortable and said that things had REALLY picked up. She was having a contraction and I could see a vast difference between this one and the ones she’d been having. We decided it was time to go in to the hospital since we were so far away.
We arrived at L&D triage about 11pm and they were so busy that it took a little over 3 hours just to get a room. In triage at around 3am we found out that “M” was dilated to about 5cm and 80% effaced. She was disappointed because she thought she’d be further along. Around 4:45 after checking into her room a second check by the Nurse-Midwife on call revealed little to no change and her contractions had slowed up again. I wasn’t terribly worried though because I see that a lot. It’s a classic flight or fight response. Many animals in nature will cease laboring altogether if they sense danger or interference, as a defense mechanism against predators trying to get their babies. Many, many women who go to the hospital in labor, find that when they arrive their labor slows up.
A lot happened over the next16 hours but it was mostly a lot of watching and waiting with gradual and steady progress. We joked a lot and the mood in the room was light and optimistic in spite of the tedium. Since “M's" membranes were ruptured they didn’t check her very often trying to minimize the risk of introducing infection but she did get checked at around 6 am where she was found to be 6cm and 100% effaced and another check at about 10am showed that she had reached 8 cm.
Finally during the 11:00 hour she started to feel pushy during contractions but we worked on blowing those away some. She started saying, “Ow, ow, ow.” So I asked, “What is it that is causing the ‘ow’, your back, your hips?” She emphatically nodded when I said hips so I started applying counter pressure on her hips squeezing them together. At this point I was really happy because I had to assume that if she was feeling her hips spread that the baby was really engaged in the pelvis. I assured her that this was good news and that since this was an unfamiliar sensation to her that she was clearly further into this labor than she’d gotten with her first baby. She seemed relieved to know that things were finally happening.
Pretty soon the Nurse-Midwife came by to check on her and she could see that we were past the point of no return. She said she was going to do a couple of more rounds and that we should call if there was any change before she came back. She had only been gone a few minutes when “M” said she really, really felt pushy so I took a peek and she was definitely right. We hit the call button and the nurse and the Midwife were both back in no time. “M” had been on her knees bent over the back of the bed and really didn’t want to change positions so when the Midwife came back I said, “She’s pretty happy like this. Are you comfortable with this for birth position?” The Midwife kind of smirked and raised her eyebrow in thought and said, “I haven’t done one of these in years but yeah, I can do that. I actually gave birth to one of my own babies this way and I loved it.”
On the next contraction I could tell “M” was still trying to hold back from pushing so I told her she didn’t need to do that anymore and that she should give it her best. She started pushing with a vengeance and I could tell that she wasn’t just pushing for this baby but also for her first one that she never got to push out. It was so fulfilling to get to watch her live out her dream. She was having the time of her life. She only pushed for a few contractions (I couldn’t count because she didn’t seem to have a break between them.) and had her baby out at 12:06 pm.
I confess that I also had some selfish enjoyment from this particular birth since I was able to basically assist the Midwife with the catch. It was just she and I at the end of the bed, the awesome nurse we had just stepped back and let “M’s” team (“M’s” husband, mother in law and myself) have free reign of things. When the baby was out the Midwife wanted to hand him through “M’s” legs to her but he got tangled up in all of that goofy surgical draping so I was able to untangle him and try to lift “M’s” leg to help get him through and then the Midwife and I both saw the problem at the same time and jinxed each other when we said, “His cord is too short.” We both kind of laughed at that and then she clamped it so “M’s” husband could cut it. Finally we kind of simultaneously flipped “M” over so that she could hold the baby and the Midwife handed him up to her.
That was an awesome moment as I realized this mom; ecstatic to meet this new baby; was almost equally ecstatic to have proved that she was capable of giving birth to her baby despite what she’d been told. We looked at each other for a second and I just said, “You DID IT!”
When all was said and done, “Baby J” was 8 lbs. 3 oz. A full 11 oz. bigger than the baby she was supposedly too small to give birth to. What vindication for “M” and how awesome that she was able to experience what she had longed to experience for so long. It was two long days of exhausting work but she did it and it was all worth it. It was a totally amazing experience that I will never forget being a part of so Thank You to “M and J” for letting me bear witness to your miracle.
We were all devastated. Most of all “M” of course, who had been through all of that work just to have it end in a surgical delivery. Her baby girl weighed in at a *whopping* 7 lbs. 8 oz. so it kind of compounded her frustration when she realized she’d consented to surgery based on a complete misdiagnosis.
Cut to this week: “M”, now pregnant with baby two, has chosen to go with a Nurse-Midwife this time knowing that her goal of a healthy VBAC (Vaginal Birth After Cesarean) would be more likely realized with a midwife than an OB. Her Midwife practices out of St. Joseph’s hospital in Phoenix which is a 30-45 min. drive from their house in Mesa but it was well worth the drive to have the benefits of the midwifery model of care.
Sunday night “M” called me to tell me labor had started but that it was still early on so she was trying to go on about her regular routine. By bedtime labor had settled down so she decided to go to bed. Fortunately she was able to get a pretty good night’s sleep because her labor eased off almost entirely. Monday morning as soon as she was up and around it started back up and by Mon. afternoon her membranes had ruptured which started labor in earnest.
I drove in from Queen Creek to meet up with “M” and offer support and to be closer since we were in for such a long drive. After I arrived I watched “M” through a few contractions and timed them for an hour and when I could see that she was having about 8 an hour I decided to stay. We just took it easy all day. “M” realized that whenever she was active her labor would pick up so she and her husband “J” took a couple of long walks around the neighborhood.
A little after 9 pm, “M” expressed that she was starting to feel frustrated and antsy about not making the kind of progress she was hoping she would. I think she started to see the clock looming overhead and was worried that she was going to end up with another section for FTP (Failure to progress.) We had a long pep talk about the fact that any progress was good progress and clearly she was in a good labor pattern. I reminded her that she could do this and that this time she was going to have an awesome delivery. After the pep talk I suggested that they hide out in the bedroom and watch a movie to take some of the pressure off about progress since it seemed to be stressing her out. About an hour later “M’s” mother in law and I were chatting when “J” came down the hall and said, “M needs you for a minute.”
When I got to the bedroom “M” was looking very uncomfortable and said that things had REALLY picked up. She was having a contraction and I could see a vast difference between this one and the ones she’d been having. We decided it was time to go in to the hospital since we were so far away.
We arrived at L&D triage about 11pm and they were so busy that it took a little over 3 hours just to get a room. In triage at around 3am we found out that “M” was dilated to about 5cm and 80% effaced. She was disappointed because she thought she’d be further along. Around 4:45 after checking into her room a second check by the Nurse-Midwife on call revealed little to no change and her contractions had slowed up again. I wasn’t terribly worried though because I see that a lot. It’s a classic flight or fight response. Many animals in nature will cease laboring altogether if they sense danger or interference, as a defense mechanism against predators trying to get their babies. Many, many women who go to the hospital in labor, find that when they arrive their labor slows up.
A lot happened over the next16 hours but it was mostly a lot of watching and waiting with gradual and steady progress. We joked a lot and the mood in the room was light and optimistic in spite of the tedium. Since “M's" membranes were ruptured they didn’t check her very often trying to minimize the risk of introducing infection but she did get checked at around 6 am where she was found to be 6cm and 100% effaced and another check at about 10am showed that she had reached 8 cm.
Finally during the 11:00 hour she started to feel pushy during contractions but we worked on blowing those away some. She started saying, “Ow, ow, ow.” So I asked, “What is it that is causing the ‘ow’, your back, your hips?” She emphatically nodded when I said hips so I started applying counter pressure on her hips squeezing them together. At this point I was really happy because I had to assume that if she was feeling her hips spread that the baby was really engaged in the pelvis. I assured her that this was good news and that since this was an unfamiliar sensation to her that she was clearly further into this labor than she’d gotten with her first baby. She seemed relieved to know that things were finally happening.
Pretty soon the Nurse-Midwife came by to check on her and she could see that we were past the point of no return. She said she was going to do a couple of more rounds and that we should call if there was any change before she came back. She had only been gone a few minutes when “M” said she really, really felt pushy so I took a peek and she was definitely right. We hit the call button and the nurse and the Midwife were both back in no time. “M” had been on her knees bent over the back of the bed and really didn’t want to change positions so when the Midwife came back I said, “She’s pretty happy like this. Are you comfortable with this for birth position?” The Midwife kind of smirked and raised her eyebrow in thought and said, “I haven’t done one of these in years but yeah, I can do that. I actually gave birth to one of my own babies this way and I loved it.”
On the next contraction I could tell “M” was still trying to hold back from pushing so I told her she didn’t need to do that anymore and that she should give it her best. She started pushing with a vengeance and I could tell that she wasn’t just pushing for this baby but also for her first one that she never got to push out. It was so fulfilling to get to watch her live out her dream. She was having the time of her life. She only pushed for a few contractions (I couldn’t count because she didn’t seem to have a break between them.) and had her baby out at 12:06 pm.
I confess that I also had some selfish enjoyment from this particular birth since I was able to basically assist the Midwife with the catch. It was just she and I at the end of the bed, the awesome nurse we had just stepped back and let “M’s” team (“M’s” husband, mother in law and myself) have free reign of things. When the baby was out the Midwife wanted to hand him through “M’s” legs to her but he got tangled up in all of that goofy surgical draping so I was able to untangle him and try to lift “M’s” leg to help get him through and then the Midwife and I both saw the problem at the same time and jinxed each other when we said, “His cord is too short.” We both kind of laughed at that and then she clamped it so “M’s” husband could cut it. Finally we kind of simultaneously flipped “M” over so that she could hold the baby and the Midwife handed him up to her.
That was an awesome moment as I realized this mom; ecstatic to meet this new baby; was almost equally ecstatic to have proved that she was capable of giving birth to her baby despite what she’d been told. We looked at each other for a second and I just said, “You DID IT!”
When all was said and done, “Baby J” was 8 lbs. 3 oz. A full 11 oz. bigger than the baby she was supposedly too small to give birth to. What vindication for “M” and how awesome that she was able to experience what she had longed to experience for so long. It was two long days of exhausting work but she did it and it was all worth it. It was a totally amazing experience that I will never forget being a part of so Thank You to “M and J” for letting me bear witness to your miracle.
Wednesday, July 30, 2008
My philosophy about Episiotomy
I am frequently asked by clients my opinion on their birth decisions. Generally speaking my reaction is to introduce them to information from experts and then suggest that they make their decisions based on what they have gleaned from the literature along with their own intuition. Rarely do I insert my personal philosophy into these discussions because I don’t always see the decisions as black and white.
Episiotomy is one of the few topics that to me IS black and white. It may sound radical but my personal philosophy on routine (or prophylactic) episiotomy is that is is genital mutilation and I don’t feel it has a place in normal labor and delivery.
I know…“Come on Tracie, don’t tiptoe…tell us how you really feel.” I am speaking bluntly about this topic because I have seen the needless suffering it causes and I got tired of feeling helpless when hearing women’s heartbreaking stories of physical and emotional pain.
The turning point for me was when a close friend was telling me that over a year after her son’s birth she was still unable to have intercourse without intense pain at her repair site. When it came out in the conversation that she could have refused the episiotomy she said to me, “Tracie! Why didn’t you tell me this BEFORE I had one.”
Of course the reason I didn’t was that I figured it wasn’t my business and I didn’t want to be perceived as opinionated. (Can you imagine someone thinking that I am opinionated? Shocking!) After this incident I realized that I felt far more regret over my friend’s pain that I would have about possibly having an awkward moment if I were told to mind my business. I vowed to myself that I would never again let my concern for how I am perceived interfere with opportunities to educate women about protecting their bodies. So with that said, here is my take on episiotomy---take it or leave it.
One of the most common fears I hear from women is that they’ll have a big baby or at least a baby with a big head. Often that fear is heightened by practitioners who threaten that they will likely experience severe tearing if they don’t submit to an episiotomy. This is supported by well meaning friends and family who in their own experience believe this fallacy for one reason or another.
The presumption is that a) All women will need one because “there is no way something that big can fit through an opening that small” b) Episiotomy will protect the perineum from tearing.
These two presumptions are absurd on so many levels but let’s talk about why they are fallacies.
Fallacy #1: Actually has two components; “...there isn’t room for the baby to come out without an episiotomy” and “...if I don’t get one I will tear.” Allow me to interject a personal experience here. While I realize that this is anecdotal only, sometimes things make the most sense to me when I hear a real story instead of a statistic.
My first baby only weighed 7lbs. 5oz. but his head was nearly 15 in. I was told prior to delivery that I was likely carrying a baby well over 9 lbs. based on the size of his noggin. While I admit it was no picnic pushing him out, the point is, I did---and I did it without an episiotomy and without perineal tearing. (I did have a very small hymenal tear that I never felt or noticed, and lets face it--I haven’t needed that old hymen in years.) Was I able to do this because of my maternal super powers? No. I am about as average as women come. The point of the anecdote is simply that a big head does not mean a traumatic delivery. But there is more to the story.
I had discussed my passionate objection to episiotomy with my OB prior to the birth. Although for the most part he agreed that they are “usually unnecessary” he also made clear that he felt they had their place in delivery and that if it appeared that I might tear he would want to perform one. I told him I’d rather roll the dice and take my chances with tearing. We agreed to disagree and his attitude was pretty much, “Hey lady, it’s your funeral.”
Skip ahead to birth day: At the point that my son was crowning my doctor noticed "blanching” (which is where the skin is stretched so tight it appears white from lack of blood flow to that area---blanching often precedes tearing). He looked up at me and said, “I think you are going to tear. Are you sure you don’t want an episiotomy?” I politely declined. (After I told him what he could do with his @%&* scissors, I am pretty sure I offered to give him an episiotomy. I confess; I am not always my sweet self when I am in transition).
On the next contraction I gave one more push and my son practically fell out of me. After the birth; when my perineum was still intact; the doctor very sweetly said, “Good call on not getting that episiotomy.” I thought it took some humility for him to admit that.
I tell this story to illustrate how modern obstetrics is primed to believe that women can’t give birth without intervention and how that belief is passed onto the consumer because we believe that doctors always know better than us. I like to think that the conclusion of this experience was that I became empowered and my doctor learned something about women’s abilities.
Fallacy #2: An episiotomy will protect you from tearing. This is completely unreasonable. “You might tear, so lets cut you just to be safe.” This is just about as ridiculous as saying, “You might get hit by a car today, so just in case, go lay down in the driveway and I’ll run you over.”
Interestingly in obstetrical lingo a tear is called a laceration and an episiotomy is also called a laceration so what exactly does performing a laceration do to prevent a laceration. Do you see the circular logic? Let’s put it this way, if you refuse an episiotomy then the worst thing that could happen is that you might have a laceration. If you get an episiotomy then you will definitely have a laceration.
It should be noted that most women will not tear at all and of the few tears that DO occur, the majority are so insignificant as to not require suturing. When they do need suturing it is a few stitches instead of the extensive repair of several layers of fascia which is required with all episiotomies.
Here is a visual. Hold up your index finger and thumb and look at the U shaped tissue that connects the two. Imagine that is the perineum. Now with your other hand make a pair of scissors and snip the tissue there. Notice that you are not just incising the front side of that, you are also cutting the back side. This means that a 1 in. cut is really a 2 in. cut. Now imagine that you are also cutting into the muscle that is beneath that tissue.
This is how an episiotomy is performed. Unlike a tear which only occurs at the point that is stretched tightest, the episiotomy takes in all layers of skin that come in contact with the surgical scissors. This is the reason that severe tearing such as fourth degree tearing occurs almost exclusively after an episiotomy has been performed. It is extremely rare for severe tearing of any kind to occur when there has been no episiotomy.
If you have concerns about tearing even a little bit, then start researching ways to avoid it. There is really no reason to tear if certain precautions are taken. Here are a few prevention tips:
1) Completely avoid the lythotomy position. (Lying on your back with your legs in the air.) Not only is it very uncomfortable and inhibits the natural use of gravity, but the pressure on the perineum is unnatural and frequently causes tearing.
2) Talk to your doctor/midwife about providing perineal support and (if necessary) manipulation (pushing the skin back and easing the baby’s head through--kind of like putting on a tight turtle neck). If they are unwilling or unable to assist you---CHANGE PROVIDERS.
3)Absolutely do not submit to an episiotomy. There is a MUCH greater risk of 4th degree tearing when one has been performed. (Think about trying to tear a piece of fabric without cutting it and then think about how if you give it a “little snip” it can be easily torn.)
4) Learn all you can about controlled crowning through breathing and holding back for a contraction just at the point of crowning to allow that little bit of stretch that takes place right then.
5) Avoid meds especially epidural because the more in control of your muscles that you are the more able to push effectively and to hold back when needed. You are also able to adopt appropriate positions for pushing such as squatting, hands and knees, c position, etc. and your instinct will tell you what is best for you at the time. (Be open to whatever your instincts tell you)
Where did we lose sight of the fact that for thousands of years women gave birth without being rescued by a surgeon? (And that is in fact what episiotomy is---surgery.) Why is it that we believe ourselves to be so different than our predecessors when it comes to the fundamental ability to give birth?
Women’s bodies were made to give birth---that’s why we get hormones that relax our bones (relaxin), and why we get hormones to open our cervix (oxytocin) and why the uterus begins the process of expelling the baby. Babies’ bodies were made to be born---that’s why they have bones in their heads that overlap and mold to the smallest point possible, and why their shoulders pop under their shoulder blades, and why they squirm and turn instinctively in the direction opposite to where they are encountering resistance from bone (the pelvis). Have faith in the process and forget the rhetoric you may hear from negative people...it’s not worth listening to if it contradicts the facts and science of human anatomy.
Episiotomy is one of the few topics that to me IS black and white. It may sound radical but my personal philosophy on routine (or prophylactic) episiotomy is that is is genital mutilation and I don’t feel it has a place in normal labor and delivery.
I know…“Come on Tracie, don’t tiptoe…tell us how you really feel.” I am speaking bluntly about this topic because I have seen the needless suffering it causes and I got tired of feeling helpless when hearing women’s heartbreaking stories of physical and emotional pain.
The turning point for me was when a close friend was telling me that over a year after her son’s birth she was still unable to have intercourse without intense pain at her repair site. When it came out in the conversation that she could have refused the episiotomy she said to me, “Tracie! Why didn’t you tell me this BEFORE I had one.”
Of course the reason I didn’t was that I figured it wasn’t my business and I didn’t want to be perceived as opinionated. (Can you imagine someone thinking that I am opinionated? Shocking!) After this incident I realized that I felt far more regret over my friend’s pain that I would have about possibly having an awkward moment if I were told to mind my business. I vowed to myself that I would never again let my concern for how I am perceived interfere with opportunities to educate women about protecting their bodies. So with that said, here is my take on episiotomy---take it or leave it.
One of the most common fears I hear from women is that they’ll have a big baby or at least a baby with a big head. Often that fear is heightened by practitioners who threaten that they will likely experience severe tearing if they don’t submit to an episiotomy. This is supported by well meaning friends and family who in their own experience believe this fallacy for one reason or another.
The presumption is that a) All women will need one because “there is no way something that big can fit through an opening that small” b) Episiotomy will protect the perineum from tearing.
These two presumptions are absurd on so many levels but let’s talk about why they are fallacies.
Fallacy #1: Actually has two components; “...there isn’t room for the baby to come out without an episiotomy” and “...if I don’t get one I will tear.” Allow me to interject a personal experience here. While I realize that this is anecdotal only, sometimes things make the most sense to me when I hear a real story instead of a statistic.
My first baby only weighed 7lbs. 5oz. but his head was nearly 15 in. I was told prior to delivery that I was likely carrying a baby well over 9 lbs. based on the size of his noggin. While I admit it was no picnic pushing him out, the point is, I did---and I did it without an episiotomy and without perineal tearing. (I did have a very small hymenal tear that I never felt or noticed, and lets face it--I haven’t needed that old hymen in years.) Was I able to do this because of my maternal super powers? No. I am about as average as women come. The point of the anecdote is simply that a big head does not mean a traumatic delivery. But there is more to the story.
I had discussed my passionate objection to episiotomy with my OB prior to the birth. Although for the most part he agreed that they are “usually unnecessary” he also made clear that he felt they had their place in delivery and that if it appeared that I might tear he would want to perform one. I told him I’d rather roll the dice and take my chances with tearing. We agreed to disagree and his attitude was pretty much, “Hey lady, it’s your funeral.”
Skip ahead to birth day: At the point that my son was crowning my doctor noticed "blanching” (which is where the skin is stretched so tight it appears white from lack of blood flow to that area---blanching often precedes tearing). He looked up at me and said, “I think you are going to tear. Are you sure you don’t want an episiotomy?” I politely declined. (After I told him what he could do with his @%&* scissors, I am pretty sure I offered to give him an episiotomy. I confess; I am not always my sweet self when I am in transition).
On the next contraction I gave one more push and my son practically fell out of me. After the birth; when my perineum was still intact; the doctor very sweetly said, “Good call on not getting that episiotomy.” I thought it took some humility for him to admit that.
I tell this story to illustrate how modern obstetrics is primed to believe that women can’t give birth without intervention and how that belief is passed onto the consumer because we believe that doctors always know better than us. I like to think that the conclusion of this experience was that I became empowered and my doctor learned something about women’s abilities.
Fallacy #2: An episiotomy will protect you from tearing. This is completely unreasonable. “You might tear, so lets cut you just to be safe.” This is just about as ridiculous as saying, “You might get hit by a car today, so just in case, go lay down in the driveway and I’ll run you over.”
Interestingly in obstetrical lingo a tear is called a laceration and an episiotomy is also called a laceration so what exactly does performing a laceration do to prevent a laceration. Do you see the circular logic? Let’s put it this way, if you refuse an episiotomy then the worst thing that could happen is that you might have a laceration. If you get an episiotomy then you will definitely have a laceration.
It should be noted that most women will not tear at all and of the few tears that DO occur, the majority are so insignificant as to not require suturing. When they do need suturing it is a few stitches instead of the extensive repair of several layers of fascia which is required with all episiotomies.
Here is a visual. Hold up your index finger and thumb and look at the U shaped tissue that connects the two. Imagine that is the perineum. Now with your other hand make a pair of scissors and snip the tissue there. Notice that you are not just incising the front side of that, you are also cutting the back side. This means that a 1 in. cut is really a 2 in. cut. Now imagine that you are also cutting into the muscle that is beneath that tissue.
This is how an episiotomy is performed. Unlike a tear which only occurs at the point that is stretched tightest, the episiotomy takes in all layers of skin that come in contact with the surgical scissors. This is the reason that severe tearing such as fourth degree tearing occurs almost exclusively after an episiotomy has been performed. It is extremely rare for severe tearing of any kind to occur when there has been no episiotomy.
If you have concerns about tearing even a little bit, then start researching ways to avoid it. There is really no reason to tear if certain precautions are taken. Here are a few prevention tips:
1) Completely avoid the lythotomy position. (Lying on your back with your legs in the air.) Not only is it very uncomfortable and inhibits the natural use of gravity, but the pressure on the perineum is unnatural and frequently causes tearing.
2) Talk to your doctor/midwife about providing perineal support and (if necessary) manipulation (pushing the skin back and easing the baby’s head through--kind of like putting on a tight turtle neck). If they are unwilling or unable to assist you---CHANGE PROVIDERS.
3)Absolutely do not submit to an episiotomy. There is a MUCH greater risk of 4th degree tearing when one has been performed. (Think about trying to tear a piece of fabric without cutting it and then think about how if you give it a “little snip” it can be easily torn.)
4) Learn all you can about controlled crowning through breathing and holding back for a contraction just at the point of crowning to allow that little bit of stretch that takes place right then.
5) Avoid meds especially epidural because the more in control of your muscles that you are the more able to push effectively and to hold back when needed. You are also able to adopt appropriate positions for pushing such as squatting, hands and knees, c position, etc. and your instinct will tell you what is best for you at the time. (Be open to whatever your instincts tell you)
Where did we lose sight of the fact that for thousands of years women gave birth without being rescued by a surgeon? (And that is in fact what episiotomy is---surgery.) Why is it that we believe ourselves to be so different than our predecessors when it comes to the fundamental ability to give birth?
Women’s bodies were made to give birth---that’s why we get hormones that relax our bones (relaxin), and why we get hormones to open our cervix (oxytocin) and why the uterus begins the process of expelling the baby. Babies’ bodies were made to be born---that’s why they have bones in their heads that overlap and mold to the smallest point possible, and why their shoulders pop under their shoulder blades, and why they squirm and turn instinctively in the direction opposite to where they are encountering resistance from bone (the pelvis). Have faith in the process and forget the rhetoric you may hear from negative people...it’s not worth listening to if it contradicts the facts and science of human anatomy.
Episiotomy
The following is excerpted from Obstetric Myths vs. Research Realities by Henci Goer
Myth: A nice clean cut is better than a jagged tear.
Reality: "Like any surgical procedure, episiotomy carries a number of risks: excessive blood loss, haematoma formation, and infection. . . . There is no evidence . . . that routine episiotomy reduces the risk of severe perineal trauma, improves perineal healing, prevents fetal trauma or reduces the risk of urinary stress incontinence." Sleep, Roberts, and Chalmers 1989
Routine or prophylactic episiotomy (as opposed to episiotomy for specific indication such as fetal distress) is the quintessential example of an obstetrical procedure that persists despite a total lack of evidence for it and a considerable body of evidence against it.
In a branch of medicine rife with paradoxes, contradictions, inconsistencies, and illogic, episiotomy crowns them all. The major argument for episiotomy is that it "protects the perineum from injury," a protection accomplished by slicing through perineal skin, connective tissue, and muscle. Obstetricians presume spontaneous tears do worse damage, but now that researchers have gotten around to looking, every study has found that deep tears are almost exclusively extensions of episiotomies. This makes sense, because as anyone who has tried to tear cloth knows, intact material is extremely resistant until you snip it. Then it rips easily.
By preventing overstretching of the pelvic floor muscles, episiotomies are also supposed to prevent pelvic floor relaxation. Pelvic floor relaxation causes sexual disatisfaction after childbirth (the concern was the male partner, of course, hence, the once-popular "husband's knot," an extra tightening during suturing that made many women's sex lives a permanent misery), urinary incontinence, and uterine prolapse. But older women currently having repair surgery for incontinence and prolapse all had generous episiotomies. In any case, episiotomy is not done until the head is almost ready to be born. By then, the pelvic floor muscles are already fully distended. Nor has anyone ever explained how cutting a muscle and stitching it back together preserves its strength.
Perhaps the most absurd rationale of all is brain damage from the fetal head's "pounding on the perineum." A woman's perineum is soft, elastic tissue, not concrete. No one has ever shown that an episiotomy protects fetal neurologic well-being, not even in the tiniest, most vulnerable preterm infants, let alone a healthy, term newborn (Lobb, Duthie, and Cooke 1986; The 1990, both abstracted below).
Meanwhile, episiotomy, like any other surgical procedure, carries the risk of blood loss, poor wound healing, and infection. Infections are painful. Sutures must be removed to drain the wound, and later the perineum must be restitched.
Obviously an infection could start in a repaired tear, but substantial numbers of women who do not have episiotomies have intact perineums…It bears repeating that women with no episiotomy hardly ever suffer deep tears.
Despite two decades of evidence to the contrary, most doctors and some midwives still cling to the liberal use of episiotomy. The Canadian multicenter randomized controlled trial (Klein et al. 1992, ) could not get doctors to abandon it. Episiotomy rates were reduced by only one-third in the so-called restricted arm of the study. More than half of primiparas (first time mothers) in the restricted group (57%) still had episiotomies, as did nearly one-third of multiparas (women who have given birth previously) (31%). "The intensity with which physicians adhere to the belief that episiotomy benefits women is well illustrated by the behavior of many of the participating physicians in this trial. Many were unwilling or unable to reduce their episiotomy rate according to protocol."
If episiotomy lacks scientific rationale, what drives its use? As Robbie Davis-Floyd (1992), medical anthropologist, writes, episiotomy fits underlying cultural beliefs about women and childbirth. It reinforces beliefs about the inherent defectiveness and untrustworthiness of the female body and the dangers this poses to women and babies. So DeLee (1920), imbued with these beliefs, writes:
Labor has been called, and still is believed by many, to be a normal function. . . . Yet it is a decidedly pathologic process. . . . If a woman falls on a pitchfork, and drives the handle through her perineum, we call that pathologic--abnormal, but if a large baby is driven through the pelvic floor, we say that is natural, and therefore normal. If a baby were to have its head caught in a door very lightly, but enough to cause cerebral hemorrhage, we would say that it is decidedly pathologic, but when a baby's head is crushed against a tight pelvic floor, and a hemorrhage in the brain kills it, we call this normal.
Having invented the problem, he proffers a solution: as soon as the head passes through the dilated cervix, anesthetize the woman with ether, cut a large mediolateral episiotomy, pull the baby out with forceps, and manually remove the placenta, then give the woman scopolamine and morphine for the lengthy repair work and to "prolong narcosis for many hours postpartum and to abolish the memory of labor." Repair involves pulling down the cervix with forceps to examine it and stitch any tears and laboriously reconstructing the vagina to restore "virginal conditions." While few modern obstetricians are willing to go as far as DeLee, these beliefs about women still pervade obstetrics, and they fuel episotomy.
Episiotomy serves another purpose. Davis-Floyd observes that surgery holds the highest value in the hierarchy of Western medicine, and obstetrics is a surgical specialty. Episiotomy transforms normal childbirth--even natural childbirth in a birthing suite--into a surgical procedure.
Davis-Floyd also points out that episiotomy, the destruction and reconstruction of women's genitals, allows men to control the "powerfully sexual, creative, and male-threatening aspects of women." This is what lurks behind DeLee's emphasis on surgically restoring "virginal conditions." It also partially explains why most trials of episiotomy have been done in European countries where normal birth is conducted by female midwives, not in the U.S. or Canada, where birth is conducted (until recently) by male doctors: women are not subconsciously threatened by birth. Klein et al. attribute the greater success of a British "restricted" versus "liberal" use of episiotomy trial in achieving fewer episiotomies and more intact perineums to "the increased comfort of British midwives in attending births with the intention of preserving an intact perineum."
In short, routine episiotomy has a ritual function but serves no medical purpose. If any reader believes otherwise, I challenge him or her to find a credible study done in the past 15 years that supports those beliefs.
Summary of Significant Points
Episiotomies do not prevent tears into or through the anal sphincter or vaginal tears. In fact, deep tears almost never occur in the absence of an episiotomy. (Abstracts 1-12, 16, 19-20, 23-28)
Even when properly repaired, tears of the anal sphincter may cause chronic problems with coital pain and gas or fecal incontinence later in life. In addition, anal injury predisposes to rectovaginal fistulas. (Abstracts 11, 15, 21-22)
If a woman does not have an episiotomy, she is likely to have a small tear, but with rare exceptions the tear will be, at worst, no worse than an episiotomy. (Abstracts 1, 2, 5, 8-10, 14, 16, 24-25)
Episiotomies do not prevent relaxation of the pelvic floor musculature. Therefore, they do not prevent urinary incontinence or improve sexual satisfaction. (Abstracts 1-4, 7, 12-16)
Episiotomies are not easier to repair than tears. (Abstracts 1, 3, 9)
Episiotomies do not heal better than tears. (Abstracts 1, 5-6, 12-15, 21)
Episiotomies are not less painful than tears. They may cause prolonged problems with pain, especially pain during intercourse. (Abstracts 1, 2, 7, 12, 14-15, 19-20)
Episiotomies do not prevent birth injuries or fetal brain damage. (Abstracts 1, 3, 5-7, 12, 14, 17-18, 27)
Episiotomies increase blood loss. (Abstracts 1, 12, 19)
As with any other surgical procedure, episiotomies may lead to infection, including fatal infections. (Abstracts 1, 12, 19, 22)
Epidurals increase the need for episiotomy. They also increase the probability of instrumental delivery. Instrumental delivery increases both the odds of episiotomy and deep tears. (Abstracts 5, 11-12, 21, 25-26)
The lithotomy position increases the need for episiotomy, probably because the perineum is tightly stretched. (Abstracts 10, 25, 27)
The birth attendant's philosophy, technique, skill, and experience are the major determinants of perineal outcome. (Abstracts 2, 5-7, 9-10, 25-27)
Some techniques for reducing perineal trauma that have been evaluated and found effective are: prenatal perineal massage, slow delivery of the head, supporting the perineum, keeping the head flexed, delivering the shoulders one at a time, and doing instrumental deliveries without episiotomy. (Others, such as perineal massage during labor or hot compresses have yet to be studied.) (Abstracts 23-24, 28)
Independent of specifically contracting the pelvic floor muscles (Kegels), a regular exercise program strengthens the pelvic floor. (Abstract 13)
References
Cunningham FG, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 18th ed. Norwalk, CT: Appleton and Lange, 1989.
Davis-Floyd RE. Birth as an American rite of passage. Berkeley: University of California Press, 1992.
DeLee JB. The prophylactic forceps operation. Am J Obstet Gynecol 1920;1:34-44.
Ewing TL, Smale LE, and Elliott FA. Maternal deaths associated with postpartum vulvar edema. Am J Obstet Gynecol 1979;134:173-179.
Golde S and Ledger WJ. Necrotizing fasciitis in postpartum patients: a report of four cases. Obstet Gynecol 1977;50(6):670-673.
Oxorn-Foote H. Human labor and birth. 5th ed. Norwalk, CT: Appleton-Century-Crofts, 1986.
Pritchard JA, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 17th Edition. Norwalk: Appleton, Century, Crofts, 1985.
Shy KK and Eschenbach DA. Fatal perineal cellulitis from an episiotomy site. Obstet Gynecol 1979;54(3):292-298.
Sleep J, Roberts J, and Chalmers I. The second stage of labour. In A guide to effective care in pregnancy and childbirth. Enkin M, Keirse MJNC, and Chalmers I, eds. Oxford: Oxford University Press, 1989.
Soper DE. Clostridial myonecrosis arising from an episiotomy. Obstet Gynecol 1986;68(3 Suppl):26S-28S.
Sutton GP et al. Group B streptococcal necrotizing fasciitis arising from an episiotomy. Obstet Gynecol 1985;66(5):733-736.
Myth: A nice clean cut is better than a jagged tear.
Reality: "Like any surgical procedure, episiotomy carries a number of risks: excessive blood loss, haematoma formation, and infection. . . . There is no evidence . . . that routine episiotomy reduces the risk of severe perineal trauma, improves perineal healing, prevents fetal trauma or reduces the risk of urinary stress incontinence." Sleep, Roberts, and Chalmers 1989
Routine or prophylactic episiotomy (as opposed to episiotomy for specific indication such as fetal distress) is the quintessential example of an obstetrical procedure that persists despite a total lack of evidence for it and a considerable body of evidence against it.
In a branch of medicine rife with paradoxes, contradictions, inconsistencies, and illogic, episiotomy crowns them all. The major argument for episiotomy is that it "protects the perineum from injury," a protection accomplished by slicing through perineal skin, connective tissue, and muscle. Obstetricians presume spontaneous tears do worse damage, but now that researchers have gotten around to looking, every study has found that deep tears are almost exclusively extensions of episiotomies. This makes sense, because as anyone who has tried to tear cloth knows, intact material is extremely resistant until you snip it. Then it rips easily.
By preventing overstretching of the pelvic floor muscles, episiotomies are also supposed to prevent pelvic floor relaxation. Pelvic floor relaxation causes sexual disatisfaction after childbirth (the concern was the male partner, of course, hence, the once-popular "husband's knot," an extra tightening during suturing that made many women's sex lives a permanent misery), urinary incontinence, and uterine prolapse. But older women currently having repair surgery for incontinence and prolapse all had generous episiotomies. In any case, episiotomy is not done until the head is almost ready to be born. By then, the pelvic floor muscles are already fully distended. Nor has anyone ever explained how cutting a muscle and stitching it back together preserves its strength.
Perhaps the most absurd rationale of all is brain damage from the fetal head's "pounding on the perineum." A woman's perineum is soft, elastic tissue, not concrete. No one has ever shown that an episiotomy protects fetal neurologic well-being, not even in the tiniest, most vulnerable preterm infants, let alone a healthy, term newborn (Lobb, Duthie, and Cooke 1986; The 1990, both abstracted below).
Meanwhile, episiotomy, like any other surgical procedure, carries the risk of blood loss, poor wound healing, and infection. Infections are painful. Sutures must be removed to drain the wound, and later the perineum must be restitched.
Obviously an infection could start in a repaired tear, but substantial numbers of women who do not have episiotomies have intact perineums…It bears repeating that women with no episiotomy hardly ever suffer deep tears.
Despite two decades of evidence to the contrary, most doctors and some midwives still cling to the liberal use of episiotomy. The Canadian multicenter randomized controlled trial (Klein et al. 1992, ) could not get doctors to abandon it. Episiotomy rates were reduced by only one-third in the so-called restricted arm of the study. More than half of primiparas (first time mothers) in the restricted group (57%) still had episiotomies, as did nearly one-third of multiparas (women who have given birth previously) (31%). "The intensity with which physicians adhere to the belief that episiotomy benefits women is well illustrated by the behavior of many of the participating physicians in this trial. Many were unwilling or unable to reduce their episiotomy rate according to protocol."
If episiotomy lacks scientific rationale, what drives its use? As Robbie Davis-Floyd (1992), medical anthropologist, writes, episiotomy fits underlying cultural beliefs about women and childbirth. It reinforces beliefs about the inherent defectiveness and untrustworthiness of the female body and the dangers this poses to women and babies. So DeLee (1920), imbued with these beliefs, writes:
Labor has been called, and still is believed by many, to be a normal function. . . . Yet it is a decidedly pathologic process. . . . If a woman falls on a pitchfork, and drives the handle through her perineum, we call that pathologic--abnormal, but if a large baby is driven through the pelvic floor, we say that is natural, and therefore normal. If a baby were to have its head caught in a door very lightly, but enough to cause cerebral hemorrhage, we would say that it is decidedly pathologic, but when a baby's head is crushed against a tight pelvic floor, and a hemorrhage in the brain kills it, we call this normal.
Having invented the problem, he proffers a solution: as soon as the head passes through the dilated cervix, anesthetize the woman with ether, cut a large mediolateral episiotomy, pull the baby out with forceps, and manually remove the placenta, then give the woman scopolamine and morphine for the lengthy repair work and to "prolong narcosis for many hours postpartum and to abolish the memory of labor." Repair involves pulling down the cervix with forceps to examine it and stitch any tears and laboriously reconstructing the vagina to restore "virginal conditions." While few modern obstetricians are willing to go as far as DeLee, these beliefs about women still pervade obstetrics, and they fuel episotomy.
Episiotomy serves another purpose. Davis-Floyd observes that surgery holds the highest value in the hierarchy of Western medicine, and obstetrics is a surgical specialty. Episiotomy transforms normal childbirth--even natural childbirth in a birthing suite--into a surgical procedure.
Davis-Floyd also points out that episiotomy, the destruction and reconstruction of women's genitals, allows men to control the "powerfully sexual, creative, and male-threatening aspects of women." This is what lurks behind DeLee's emphasis on surgically restoring "virginal conditions." It also partially explains why most trials of episiotomy have been done in European countries where normal birth is conducted by female midwives, not in the U.S. or Canada, where birth is conducted (until recently) by male doctors: women are not subconsciously threatened by birth. Klein et al. attribute the greater success of a British "restricted" versus "liberal" use of episiotomy trial in achieving fewer episiotomies and more intact perineums to "the increased comfort of British midwives in attending births with the intention of preserving an intact perineum."
In short, routine episiotomy has a ritual function but serves no medical purpose. If any reader believes otherwise, I challenge him or her to find a credible study done in the past 15 years that supports those beliefs.
Summary of Significant Points
Episiotomies do not prevent tears into or through the anal sphincter or vaginal tears. In fact, deep tears almost never occur in the absence of an episiotomy. (Abstracts 1-12, 16, 19-20, 23-28)
Even when properly repaired, tears of the anal sphincter may cause chronic problems with coital pain and gas or fecal incontinence later in life. In addition, anal injury predisposes to rectovaginal fistulas. (Abstracts 11, 15, 21-22)
If a woman does not have an episiotomy, she is likely to have a small tear, but with rare exceptions the tear will be, at worst, no worse than an episiotomy. (Abstracts 1, 2, 5, 8-10, 14, 16, 24-25)
Episiotomies do not prevent relaxation of the pelvic floor musculature. Therefore, they do not prevent urinary incontinence or improve sexual satisfaction. (Abstracts 1-4, 7, 12-16)
Episiotomies are not easier to repair than tears. (Abstracts 1, 3, 9)
Episiotomies do not heal better than tears. (Abstracts 1, 5-6, 12-15, 21)
Episiotomies are not less painful than tears. They may cause prolonged problems with pain, especially pain during intercourse. (Abstracts 1, 2, 7, 12, 14-15, 19-20)
Episiotomies do not prevent birth injuries or fetal brain damage. (Abstracts 1, 3, 5-7, 12, 14, 17-18, 27)
Episiotomies increase blood loss. (Abstracts 1, 12, 19)
As with any other surgical procedure, episiotomies may lead to infection, including fatal infections. (Abstracts 1, 12, 19, 22)
Epidurals increase the need for episiotomy. They also increase the probability of instrumental delivery. Instrumental delivery increases both the odds of episiotomy and deep tears. (Abstracts 5, 11-12, 21, 25-26)
The lithotomy position increases the need for episiotomy, probably because the perineum is tightly stretched. (Abstracts 10, 25, 27)
The birth attendant's philosophy, technique, skill, and experience are the major determinants of perineal outcome. (Abstracts 2, 5-7, 9-10, 25-27)
Some techniques for reducing perineal trauma that have been evaluated and found effective are: prenatal perineal massage, slow delivery of the head, supporting the perineum, keeping the head flexed, delivering the shoulders one at a time, and doing instrumental deliveries without episiotomy. (Others, such as perineal massage during labor or hot compresses have yet to be studied.) (Abstracts 23-24, 28)
Independent of specifically contracting the pelvic floor muscles (Kegels), a regular exercise program strengthens the pelvic floor. (Abstract 13)
References
Cunningham FG, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 18th ed. Norwalk, CT: Appleton and Lange, 1989.
Davis-Floyd RE. Birth as an American rite of passage. Berkeley: University of California Press, 1992.
DeLee JB. The prophylactic forceps operation. Am J Obstet Gynecol 1920;1:34-44.
Ewing TL, Smale LE, and Elliott FA. Maternal deaths associated with postpartum vulvar edema. Am J Obstet Gynecol 1979;134:173-179.
Golde S and Ledger WJ. Necrotizing fasciitis in postpartum patients: a report of four cases. Obstet Gynecol 1977;50(6):670-673.
Oxorn-Foote H. Human labor and birth. 5th ed. Norwalk, CT: Appleton-Century-Crofts, 1986.
Pritchard JA, MacDonald PC, and Gant NF, eds. Williams Obstetrics. 17th Edition. Norwalk: Appleton, Century, Crofts, 1985.
Shy KK and Eschenbach DA. Fatal perineal cellulitis from an episiotomy site. Obstet Gynecol 1979;54(3):292-298.
Sleep J, Roberts J, and Chalmers I. The second stage of labour. In A guide to effective care in pregnancy and childbirth. Enkin M, Keirse MJNC, and Chalmers I, eds. Oxford: Oxford University Press, 1989.
Soper DE. Clostridial myonecrosis arising from an episiotomy. Obstet Gynecol 1986;68(3 Suppl):26S-28S.
Sutton GP et al. Group B streptococcal necrotizing fasciitis arising from an episiotomy. Obstet Gynecol 1985;66(5):733-736.
Tuesday, July 29, 2008
Due Date
The concept of a due date is based on a gestational length established by fiat in the early 1800s. Franz Carl Naegele officially declared that pregnancy lasted 10 lunar months (10 x 28 days), counting from the first day of the last menstrual period). However, when Mittendorf et al. measured the median duration of pregnancy, they found that healthy, white, private care, primiparous women with well-established due dates averaged 288 days and multiparas averaged 283 days, values significantly differnet from both Naegele's rule and each other.
Others have found similar results. Mittendorf et al. also cited other studies showing racial differences in gestational length. For example, one showed that black women averaged 8.5 days fewer than white women of similar socioeconomic status.
Moreover, ultrasound-determined due dates are not accurate. One study used the date extablished by ultrasound at 16 to 18 weeks to test the validity of dating by the last normal menstrual period (LNMP). It found that as gestational age went past term positive predictive values for the LNMP declined from 95% to 12%. The authors took this to mean the LNMP was inaccurate, but, of course, the ultrasound date is the problem. Even first trimester measurements have an error bar of +/-5 days in the second trimester and +/-22 days in the third.
Few practitioners appreciate the limitaions of ultrasound or clinical data. Otto and Platt say the due date should not be changed unless the discrepancy is more than two weeks, yet they see doctors changing a due date by a few days, no trivial alteration if a woman will be induced when she exceeds a certain date.
Some risk does accrue in healthy postdate pregnancies (notably meconium passage and big babies) but it does not follow that we should induce all women. Studies have found that as gestational age goes from 37 to 44 weeks, perinatal mortality and morbidity distribute in a U-shaped pattern. If we try to eliminate postdate pregnancies on grounds of increased complications, should we not equally logically try to delay labor onset in the early term group?
-Henci Goer Obstetric Myths vs. Research Realities, Bergin & Garvey 1994
Others have found similar results. Mittendorf et al. also cited other studies showing racial differences in gestational length. For example, one showed that black women averaged 8.5 days fewer than white women of similar socioeconomic status.
Moreover, ultrasound-determined due dates are not accurate. One study used the date extablished by ultrasound at 16 to 18 weeks to test the validity of dating by the last normal menstrual period (LNMP). It found that as gestational age went past term positive predictive values for the LNMP declined from 95% to 12%. The authors took this to mean the LNMP was inaccurate, but, of course, the ultrasound date is the problem. Even first trimester measurements have an error bar of +/-5 days in the second trimester and +/-22 days in the third.
Few practitioners appreciate the limitaions of ultrasound or clinical data. Otto and Platt say the due date should not be changed unless the discrepancy is more than two weeks, yet they see doctors changing a due date by a few days, no trivial alteration if a woman will be induced when she exceeds a certain date.
Some risk does accrue in healthy postdate pregnancies (notably meconium passage and big babies) but it does not follow that we should induce all women. Studies have found that as gestational age goes from 37 to 44 weeks, perinatal mortality and morbidity distribute in a U-shaped pattern. If we try to eliminate postdate pregnancies on grounds of increased complications, should we not equally logically try to delay labor onset in the early term group?
-Henci Goer Obstetric Myths vs. Research Realities, Bergin & Garvey 1994
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