The Obstetrician’s Lament

There is an astounding collection of writing going up on The Unnecesarean regarding the growing rift between obstetricians and the out-of-hospital birth community.  All of this is in response to the The Obstetrician’s Lament, written by OB-GYN Anette Fineberg, MD, which came out in the May edition of ACOG’s Green Journal (Obstetrics and Gynecology).  I will post the full text of “The Obstetrician’s Lament” here, (courtesy of Navelgazing Midwife) since most readers here will not have a subscription to ACOG:

A few weeks ago, during a prenatal visit, a woman pregnant with twins told me she would love to have a home birth, but did not have the $4,000 cash required upfront to do so. She was afraid of potential interventions in the hospital. After a discussion of her fears as well as potential complications that can abruptly occur in a twin birth, she admitted she would prefer a hospital birth if she could maintain some control over the situation. This is not a woman who cares more about the birth experience than the baby, but she was tempted, and in some ways I can understand her concerns. My cousin’s wife had her twin induction halted at 4 cm because the new obstetrician on call did not do breech extractions for second twins. Her only option became cesarean delivery.

I recently received a phone call from a woman 2 hours away who had planned a home birth for her second baby after having an easy first birth. When the fetus, which was anticipated to be a little smaller, was found to be a breech, the midwife sent the woman to the local obstetricians. They would only deliver the fetus by cesarean delivery. The midwife offered the woman a home breech birth, but admitted she had only delivered one breech (stillbirth) in her career. The woman appropriately questioned the safety of this, and was referred to us. She met the criteria for our vaginal breech protocol, and had an easy vaginal breech birth in our hospital. Unfortunately, this is becoming a rarity. A colleague of mine in another state watched the residents she was supervising emotionally bully a young woman and her mother into a cesarean delivery. The young woman had a rapidly progressing active labor with a normal-sized frank breech fetus. Had the residents been open to the idea, my colleague easily could have taught them how to deliver a vaginal breech.

The running joke in our community is that the only way to get a vaginal birth after cesarean delivery (VBAC) is to have the birth at home. Unfortunately, this is a reality rather than a joke. Our small community hospital, owing to regional liability insurance constraints, stopped allowing VBACs in 2002 after many years of  successfully offering them. This has led many women to risk home birth rather than travel to a tertiary care center to attempt VBAC. I recently counseled a woman against having a cesarean delivery who had a BMI of 52 and who arrived in active labor at over 35 weeks of gestation with two previous successful VBACs. I spent the following months defending that recommendation, despite her considerable operative risks and high likelihood of success.

Recent news and media excitement about the benefits and increased safety of home birth over hospital birth have made the former seem like a very attractive alternative. A growing notion among women in our region, and perhaps across the country, is that hospitals and obstetricians are a more risky option than lay-home midwives for birth. Although my initial reaction is disbelief, perhaps we should look at how we, the  obstetricians, contribute to this trend.

Each of these women deserves an honest discussion about the fetal and maternal risks of each birthing option. However, our lack of experience as obstetricians colored by our fear of liability is narrowing women’s choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions. I sense a mounting tension, because many obstetricians do not have the willingness, time, or skills to provide maternal choices.

I believe we are at a crossroad in maternity care in this country, and I am saddened that obstetricians are considered the culprits. Our contracting skill set as obstetric providers, as well as the prevailing risk-adverse culture among physicians and hospitals, have given support to home birth. We can all agree that VBAC, twins, and breech should not be managed at home, yet we frequently demand complete control of the situation and eliminate some appropriate choices in the hospital. I understand that it can be very unnerving to be ultimately responsible for the outcome, as we are, and yet pushed into situations outside of our comfort zones. However, our unwillingness to budge in these situations is causing us to lose the battle regarding what is really important to most obstetricians: safety for mothers and babies.

Certainly, we can be proud of the dramatic decrease in maternal mortality in the last century. But, despite the highest per capita expenditure of health care in the world, infant and maternal mortality rates in the United States are higher than in all of western Europe. We have the third-highest cesarean delivery rate in the world.

According to a recent study, nearly half of all primigravidas attempting vaginal delivery are induced, and half of cesarean deliveries for dystocia are done before 6 cm of dilation, presumably before active labor. It is amazing how many women begging for elective induction change their minds when told it doubles their cesarean  delivery risk.

We need to draw lines around patient safety, but must they be so rigid? Most midwives know from experience that Friedman’s curve is too strict. A recent study validates that knowledge. I sincerely hope it is taken seriously. Expectant management of ruptured membranes at term has been declared unsafe and of no benefit. The study that settled the question did not account for the number of vaginal examinations women received, and group B strep was not treated, both important variables. Most women do go into labor in 24 to 72 hours. The Cochrane systematic review concludes that, because the differences in outcome are not substantial, women need to be given the appropriate information to make a decision. This very rarely occurs in the hospital setting. The Term Breech Study closed the door on vaginal breech delivery even for the lowest-risk women in most obstetricians’ minds (including the residents I mentioned above). This, despite the opinion of the College that it may be appropriate in carefully selected situations. In any case, vaginal breech delivery is not completely avoidable, and should not be relegated to the history books with vaginal delivery for previa and high forceps.

Our mission has become more difficult in the last 20 years as mothers have become older, heavier, and of lower parity. Many women, admittedly, do have unrealistic expectations. Although I am eternally grateful for the obstetric skills I learned in residency, I have been amazed in my 14 years of practice to see much of the dogma I also absorbed disproven with experience and patience (both my own, my colleagues’, and the midwives I have worked with in the hospital setting). Collaborative practice with midwives is a good start, but in order for obstetricians to be more than providers of cesarean deliveries (a thankless and, in most cases, technically simple procedure) we need to have conversations with our patients that are not one sided and allow for true informed consent. Many of the obstetric disasters we have all seen and which color our  perspective (which David Grimes has called “numerators in search of denominators”) are at least in some part iatrogenic if examined deeply enough. That failed induction for convenience with early artificial rupture of  membranes and chorioamnionitis. The first cesarean delivery done at age 15 after 2 hours of pushing with an epidural that then leads to the fifth cesarean years later, and then accreta and life-threatening hemorrhage, are both typical examples. We need to recognize and own those aspects of obstetric management that are driving our skyrocketing cesarean delivery rate but having no positive effect on maternal or infant morbidity and mortality.

Admitting what is truly evidence based versus what is tradition and culture is a good start. It is essential that we offer real choices to our patients. We need to recover and disseminate the skills that make obstetrics an art and a privilege. Seek out mentors skilled in forceps, vaginal breeches, and breech extractions before it is too late. Then learn to be patient, so that you very rarely need to use them

I find this letter to be very brave and commendable, and while this may sound strange, I am actually really proud of ACOG for publishing it in the first place.  Kudos to Dr. Fineberg for writing this, especially given that she may very well experience a backlash from her colleagues for even suggesting that VBACs, vaginal breech deliveries and vaginal twin deliveries (with breech extraction for the second twin) are things which OBs should be offering their clients, let alone her suggestion that OBs may be partially responsible for driving women with complications to seek homebirth in the first place.

Even more fascinating to me, though, are the commentaries which are going up on The Unnecesarean right now, all written by a collection of different obstetricians who are willing to step forth and give their unvarnished opinion on the true state of things (and huge kudos to them, as well!).  Here are links to their articles:

Lamenting the System, by Dr. Jill Arnold

Lament in Stereo, by Dr. Lauren A. Plante

A Comeback for VBAC?, by Dr. Poppy Daniels

Another Obstetrician’s Lament, by Dr. Gustavo San Roman

An Obstetrician’s Hope, by Dr. David Hayes

The VBAC comments I found particularly compelling, given the sorry state of VBACs in this country right now (see my post below on the new NIH Consensus Guidelines).  The sad truth is, VBACs are no longer being offered as a viable option simply because of politics and a growing culture of fear (aided by our culture of litigation) which states that just because uterine rupture is (occasionally, super rarely) possible, there needs to be 24-hour on-call anesthesia, and an obstetrician on-call ready to brandish a knife at the drop of a hat…and because of this (occasional, super rare) risk, it’s better to not offer VBACs if you don’t have these emergency measures in place.  Nevermind the increasing risks associated with repeat cesareans, the growing rate of cesarean complications, placenta percreta/ acreta etc. etc.  But Dr. Poppy Daniels has addressed this on The Unecessarean more eloquently than I have time to right now, so I’ll let you follow the links.

Besides, I have much more exciting news to share! Stay tuned for a very personal birth story, coming up next!