Through a comprehensive evaluation of the evidence from 21 studies of CNM care, the review concludes that there is high quality evidence that women cared for by CNMs are less likely to experience a cesarean delivery, episiotomy, or severe perineal trauma. Women cared for by CNMs are also more likely to choose non-pharmacologic approaches to manage pain, and they have higher breastfeeding rates.

Are you surprised?  I’m not surprised! I feel like this just confirms what we already knew: midwives establish better relationships, answer more questions, are more sensitive, check all the boxes on the customer satisfactions card…but more than that, they actually deliver better outcomes—fewer cesareans, fewer lacerations, increased rates of breasfeeding and natural delivery.  Of course!  It’s just very affirming to see it in writing.

To read the full review as a pdf file, follow this LINK!

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!

Most of the early press on the film has been encouraging rather than caustic, and everything I had heard by word-of-mouth was nothing but positive. I actually know many of the midwives and nurses and one or two of the doctors that are feautured in it, and I trusted their voices and their ability to speak accurately about birth and midwifery. Even so, I must admit I’m always a bit trepidatious when it comes to anything about midwives in the mainstream media. I’m always worried that somehow the media will get it wrong—they won’t get the full picture, they won’t understand the smaller details, they’ll paint our profession in broad, misinformed strokes, or they’ll fall back on stereotypes—with the end result being that the much-needed media attention, instead of being a welcome and helpful boon, actually does nothing more than continue to misinform and confuse the public about exactly what it is we do. It’s often a mixed blessing. I was also concerned that this film might be disregarded as too far out on the fringe—that it would come across like a very slanted Michael Moore documentary and therefore not have the universal appeal needed in order for it to be taken seriously by the mainstream public.

These fears were somewhat allayed when the announcer for the film—a man—came out and assured the men in the audience that if they were expecting to suffer through a “chick flick”, they were in for a very pleasant surprise. Apparently he had been on the Tribeca Film Festival selection committee, and it was one of the other men on the committee who had first approached him about the film, saying that he had really kind of liked it and needed a second opinion. As it turns out, the film’s biggest supporterters on the selection committee were these two men, both of whom had known absolutely nothing about birth prior to watching the film, but had found it to be a very fascinating, informative and well-researched documentary. The announcer kept it short and sweet, and then, without further adieu, the lights went down, and the film began.

The Business of Being Born sets out to explore the business of maternity care in our country. Along the way, the film raises a lot of difficult questions, which it then attempts to answer: why are the infant and maternal mortality rates in the US the second worst in the world when compared to other developed countries? Why do midwives deliver 60-80% of all births in other developed countries, but only 8% here? Why is our cesarean rate so high, especially when compared to other countries which have a much lower cesarean rate but much better overall outcomes? Why are so many mothers so disatisfied with their birth experience or maternity care? Why do so many of our births occur in hospitals? Why is the prevailing attitude towards birth one of fear, rather than of trust and normalcy? You know, just the sort of complicated questions which keep midwives up at night, but which very few other people ever stop to think about (I’m pretty sure it was Pat Burkhardt, director of the NYU Midwifery program, who rightly points out that most people do more research on buying a new car or appliance or camera than they do on their choices and options when it comes to birth). The film tackles these complicated questions from several angles, including the vicious circle of medicated birth (epidural leading to pitocin leading to more epidural leading to nonreassuring fetal status leading to cesarean, all done in cute cartoon format), the pervasive fear-mongering of birth on TV and in the media, the status symbol of “too posh to push” and “designer deliveries”, insurance issues, malpractice issues, even touching upon possible implications of disturbing the delicate “love cocktail” of hormones present in unmedicated births which facilitates bonding and maternal instinct. Quite a big mouthful to bite off for one small film.

The opening sequence of the film begins at 3:25 am, as a homebirth midwife (Cara Muhlhahn) prepares her birth bag before heading out to a birth. This footage is interspersed with people discussing their initial perceptions of midwifery and midwives. Not surprisingly, many of the people being questioned have either never heard of midwives before, or assumed that they were untrained granny-midwife types. A few people express disbelief that anyone would choose to have birth somewhere other than a hospital, or with someone other than a doctor. One man says something like “I didn’t even know midwives still existed”. We cut back to the homebirth midwife in her apartment, packing her bag. The idea that midwives are untrained grannies more likely to treat you with herbs than a prescription is quietly challenged by her preparations: we see her checking her oxygen tank, preparing her suture and syringes, counting vials of pitocin and other medicines, packing liters of IV fluid still neatly sealed in their bags, along with IV tubing, and then setting off to the birth.

Without a doubt, one of the best things about this film is the sheer number of unmedicated births that it shows. While attending and seeing births was something that was familiar and commonplace to many people at the turn of the century, in its move from the home to the hospital, birth has become isolated from everyday life, no longer thought of as a routine, normal occurrence. Today, most people have never been to a birth prior to having their own baby. What few births people do see are usually on TV, where they’re either wildly dramatic, such as the screaming, frantic woman on ER, or complicated and scary, such as on A Baby Story, where it seems like routine, normal vaginal births are often passed over in favor of dramatic life-and-death births, which probably garner much better ratings. Also, whenever birth is seen on TV, it is unfailingly (inevitably) set in the hospital. However, The Business of Being Born thankfully turns all of this on its head, showing what real, normal, uncomplicated, unmedicated birth actually looks like—something most people have probably never seen before. The audience is exposed, perhaps for the first time, to the sights and sounds of unmedicated labor. Instead of screaming and drama, women are shown rocking and swaying, moaning and grunting and sweating. Instead of beeping machines and alarms sounding, heads emerge from between legs in relative silence as the mothers are left undisturbed, pushing with quiet concentration and determination. We’re shown births attended by midwives in homes and birthing centers, births in tubs and pools, births squatting and standing; we even see Ricki Lake’s homebirth, in a bathtub.

While many famous, leading authorities (Michel Odent, Marsden Wagner, Ina May Gaskin, Robbie Davis-Floyd, to name a few) and many leaders in the New York City birthing community spend a lot of time discussing the issues behind the business of birth in the film, it’s often the images themselves which speak the loudest. Forget what the experts are saying: the audience is actually able to see it, with their own eyes. The images of women concentrating and pushing with power and strength, in tubs, kneeling on beds, supported by their partners, squatting or rocking, versus the images of women flat on their backs in the hospital, covered in tubes and oxygen masks, being told to “push!”, their legs in stirrups or held by staff, supine on gurneys being wheeled to the operating room, provides a message far more clear and visceral than any book or 5-hour lecture on the subject could manage. This, more than any other aspect of the film, probably provides the greatest education to the audience.

One of the issues raised at the talk-back session after the show was the decision to include director Abby Epstein’s birth in the film. Although she was planning on having a homebirth with Cara Muhlhahn, she went into labor at 35 weeks, and because her baby was breech, she needed a cesarean. While including this birth at the end of the film does put a bit of a damper on the natural-birth/homebirth high of the film, at the same time it demonstrates a very crucial point: homebirth and midwifery care is safe care. Midwives don’t take stupid risks, they have good clinical judgement, and they make good calls; they’re not going to try to deliver a premature breech baby at home. I also think it’s important for the audience to see that birth doesn’t always go according to plan, and that flexibiilty and the ability to roll with a change in circumstance is one of the most important aspects of a successful birth experience, and that support during these difficult transitions is also key. This birth also shows the system working exactly the way it should: the midwife takes care of the low-risk patient, but when low-risk becomes high-risk, the patient is transferred to the back-up doctor, and seamless, excellent healthcare is provided to the woman.

Perhaps the only problem with this is the fact that the care is almost too seamless. When Abby Epstein mentioned to her doctor that she was planning a homebirth, his enthusiastic response is just a little too quick. You can’t help but wonder: if the camera hadn’t been there, capturing the moment, would he have so readily offered to serve as back-up, or would he have tried to talk her out of having a homebirth using scare tactics or punitive manipulation? (This is by no means a statement on this particular doctor in the film, whom I personally know to be very supportive of midwives and midwifery, but rather a statement on the larger, more generalized attitudes of doctors towards midwifery and homebirth). In reality, it’s rarely so smooth a transition, and doctors are rarely so enthusiastic when they hear that their patients are planning a homebirth. While the film touches briefly on the competition between doctors and midwives and the fact that many doctors are vehemently anti-homebirth, the smooth transition of care between Abby Epstein’s homebirth midwife and back-up doctor is potentially misleading. The audience can walk away from the film thinking that this is a very easy thing to arrange, when actually, one of the biggest barriers to providing homebirth as a viable option to more women in this country is the lack of back-up providers and the challenges faced in trying to arrange appropriate back-up; rather than being smooth and easy, it’s often complex, frustrating and fraught with politics.

My only other critique of the film is that it is perhaps a bit too black and white: homebirth v. hospital, midwife v. doctor, unmedicated, natural childbirth v. monstrosity of tubes and terror. While the film did follow a hospital-based midwife (Catherine Tanksley), and showed midwives in hospitals, the emphasis seemed to be on homebirth. The truth is that in this country far more midwives practice in hospitals than they do in homes, and the word “midwife” is not synonymous with “unmedicated childbirth”. While midwives are experts in normal, unmedicated births, we’re not anti-epidural or anti-hospital. We can prescribe narcotics and pain relief in labor, we can order epidurals, we can support a woman through a medicated birth experience just as easily as an unmedicated birth—it really just boils down to the desires, needs and expectations of the woman and her family. Unfortunately, I can very easily see a woman walking away from this film and thinking “well, midwives are great for natural childbirth, but I want an epidural, so I guess that means I’ve got to go to a doctor”. While all of the beautiful, natural homebirths in this film are a joy and privilege to watch, I think one or two equally beautiful and joyous hospital births attended by midwives might have added a more balanced perspective to the film.

Nevertheless, overall I thought the film was truly amazing; it brought tears to my eyes on several occassions. Rather than being far out on the left fringe as I had feared, I was actually blown away by how mainstream and accessible it was. It begins with the assumption that the audience knows absolutely nothing about birth and the business of birth in this country, and then moves on from there, using a simple and easy-to-understand, yet powerful and engrossing format and narrative. Forget the Ricki Lake Show; I think this film will be a new highlight in her career, and I’m very grateful that a film like this has finally been made. I want all of my friends, my beloved boy, my family, my peers, to see this film so that they can finally see and understand exactly what it is that I do, and why I do it, and what I believe in. Hopefully this film will be picked up by a national distributor and shown in cities all over the country; hopefully soon it will be playing at a theater near you. If it is, you’ll have to go and see it—and bring all of your friends with you!

I’ve been meaning to post this post for ages, but was never able to finish it during the school year last year. All of this comes from the research project that I worked on last year for 2 semesters as part of my research class, and even though I had to radically alter the goal and purpose of my research proposal in the end, along the way I had the opportunity to do some of the research I was really interested in doing in the first place, and it definitely needs to be shared. This is rather a long post, and it gets somewhat technical in places, but bear with me; a lot of the information here can help you fend off an unnecessary induction or cesarean, so it’s well worth reading. And with that, here we go:

Premature rupture of membranes (or prelabor rupture of membranes, aka PROM) occurs when a woman’s water breaks before she actually goes into active labor. It can happen to women at any point in their pregnancy, and when it happens to women who are still preterm, the danger to herself and her baby is much higher, as are the risks of infection (and many studies have demonstrated that in fact, preterm PROM, aka PPROM, is often caused by infection in the first place). However, the majority of PROM occurs in women who are at term gestation (37+ weeks)—90% of all cases, in fact (Zamzami, 2005), and it’s pretty common, too: PROM at term occurs in 8% of all births. (Hannah et. al., 1996)

In our hospitals today, there is sort of an unspoken rule—let’s call it the 24-Hour Rule. It goes something like this: if you haven’t delivered your baby within 24 hours of breaking your water, something is going to have to be done. In many cases, this something is induction, and in many cases, waiting a full 24 hours before inducing is something that never happens. Providers are often way too impatient and antsy for that, and will generally talk a woman into induction long before the 24 hours has passed. Many providers have the policy of immediately inducing a woman with PROM, either by using prostaglandin gels like cervadil followed by IV oxytocin (pitocin), or by just starting on the pit right away. The rationale for this type of management (often called active management) stems from research that was done in the 1960s (Shubeck, 1966; Rusell & Anderson, 1962) which found that the longer a woman was ruptured, the greater the chance of infection, chorioamnionitis (an acute infection of the chorion, which is part of the placenta), and maternal and/or fetal sepsis.

These early studies advocated immediate induction, and were the beginning of active management. The idea that the length of PROM is responsible for maternal infection is something which has sort of been hard-wired into modern obstetrical practice right now, and in my own experience, I have seen the 24-Hour Rule in effect many a time. Providers often use it to justify the need for an induction or augmentation, i.e. “we need to get your labor moving along, because you’ve been ruptured now for 8 hours…12 hours…18 hours…and you’re still not in active labor”, and as studies have shown, inductions and augmentations, especially for PROM, often lead to cesarean (Mozurkewich & Wolf, 1997; Grant et. al., 1992; Tan & Hannah, 2001). I have seen this deadline held over women’s heads before, and in my most humble opinion, it does absolutely NOTHING to help a woman relax, labor effectively, and have a vaginal delivery. (What’s that old Bradley joke about telling a man he better orgasm soon or else his penis will have to be cut apart to get to the sperm? No pressure, now!)

The thing is…the research from the ’60s, which forms the basis of the 24-Hour Rule, has more holes in it than swiss cheese. For one thing, these studies were retrospective, instead of prospective, which means that they relied on going back and looking at records after the births had already occurred, and never tried to control for any of the gazillion variables that might have affected these birth outcomes other than PROM. Similarly, these early studies were non-randomized, meaning that there might have been selection bias at play which could have muddied the findings. Additionally, both term and preterm pregnancies were mixed together when examining the effects of PROM, which seriously confounds results since preterm infants are much more susceptible to infection, and as I mentioned above, preterm PROM often occurs because of infection in the first place (McGregor & French, 1997). These studies had very imprecise definitions for infection, and the management protocols used were neither uniform or clearly discussed. And of course, NICUs and antibiotic therapy have improved so much in the past 40 years that many of the babies that died of infection in these early studies probably wouldn’t have died if they had been born today. So, as you can see, the studies from the 1960s had a lot of problems, and the fact that modern obstetrical practices are still based in part on the findings in these studies is an even BIGGER problem.

What have more recent studies shown? Well, many studies have shown that strict adherence to active management is often unnecessary, and in some cases, does more harm than good (seems to be a repeating theme when you start to look at obstetrical research—funny, that. And here is where it gets very technical. I’m putting the rest of this behind a cut, for those of you who are interested.)

Kappy et. al. (1979) challenged the 24-Hour Rule, asserting that active management unnecessarily increased the cesarean section (CS) rate, and that expectant management of PROM could reduce the rising CS rate while at the same time keep infection to a minimum. Using a prospective, nonrandomized, observational design, the rates of infection were studied in 110 women with preterm PROM and 78 women with term PROM. In both groups, patients were managed expectantly until they either delivered or signs and symptoms of infection appeared, at which point the patients were induced. No digital examinations were performed on patients until they were in active labor, and no tocolytic agents or prophylactic antibiotics were given unless a patient showed signs and symptoms of infection, at which point the patient was induced. Kappy et. al. found that only 13% of all term women had clinical signs of infection at delivery, and only 3% had chorioamnionitis. There were no maternal deaths, and no neonatal deaths attributed to sepsis. Unlike earlier studies, Kappy et. al. separated preterm and term births, used standardized and clearly defined indicators of PROM (sterile speculum exam to detect vaginal pooling, followed by positive nitrazine tests and microscopic ferning to confirm rupture) and standardized and precise definitions of infection (clinical signs confirmed by positive blood, sputum, spinal or placental cultures). The weaknesses of this study included its nonrandomized design, the fact that no effort was made to control for infectious risk factors such as GBS, and only infants showing clinical signs of infection were cultured. Nevertheless, Kappy et. al. were able to conclude that “the conservative approach in the term pregnancy with PROM…seems to decrease the incidence of cesarean sections without an appropriate increase in the infectious morbidity”.

Duff et. al. (Duff, Huff & Gibbs, 1984) supported these results with a randomized control trial that demonstrated that “expectant management resulted in a lower frequency of both cesarean delivery and intrapartum infection than…the practice of immediately inducing labor”. In this study, 134 women with PROM were assigned either to an oxytocin induction group or to an expectant management group where they were observed as inpatients until the onset of labor. The researchers found a statistically significant increase in the number of cesarean deliveries and intra-amniotic infections in the induction group versus the expectant group—20% versus 7%, p<0.05, for cesarean deliveries, and 17% versus 4%, p <0.05, for intra-amniotic infections. This study used a non-blinded, randomized, prospective design (in other words, one of the strongest study designs you can use, and the “gold standard” for research), standardized definitions for maternal and neonatal infection, and uniform and clearly defined indications for cesarean section. Women participating in the study were from a homogenous population of carefully screened low-risk women at term without complicating risk factors such as diabetes, postdates pregnancy, meconium-stained fluid, hypertensive disorders, intraamniotic infection or malpresentation. However, again no mention was made of GBS status, potential bias could have occurred in the use of two distinct management teams, not all neonates were screened for sepsis, and the use of antibiotics during management was not specified.

A study conducted by Grant et. al. (1992) also found that expectant management significantly lowered the cesarean rate while at the same time posing no additional infectious risk to women or infants. In this study, 444 term primigravidas with PROM were blindly randomized to either an immediate induction group or induction the following morning (9-33 hours later, depending on when the woman arrived on the unit). It was found that there were fewer cesareans in the group that was allowed to wait 9-33 hours before induction (11.1% versus 17.4%, p = 0.06) with no significant increase in the rates of neonatal or maternal infection. It’s also interesting to note that women in the immediate induction group were more likely to ask for epidural anesthesia (70.3% versus 57.3%, p < 0.005), which supports the idea that induction leads to increased demand for epidurals, and that epidurals lead to increased cesarean rates.

The largest study to date, the TERM PROM study (Hannah et. al., 1996), examined 5041 women from 72 centers throughout Canada, Israel, Australia and the UK with PROM at term who were randomized to one of four groups: immediate induction with oxytocin (induction-oxytocin); immediate induction with vaginal prostaglandin gel first, followed by oxytocin if active labor had not started (induction-prostaglandin gel); expectant management for up to 4 days unless signs of infection or fetal distress were noted, followed by oxytocin induction if labor had not started after four days (expectant-oxytocin); and expectant management for up to 4 days, followed by induction with prostaglandin gel (expectant-prostaglandin). The study protocol was standardized and well-defined, and the randomization process was blinded (i.e. a very rigorous study design). Vaginal exams were discouraged; however, approximately one third of the women, equally divided among all four groups, received vaginal exams during the initial cervical assessment. Approximately 78% of the women in both expectant management groups went into labor spontaneously within 4 days of PROM and did not require induction. The researchers found no differences in the rate of neonatal infections or cesareans, but an increase in maternal infectious morbidity was noted in the women of the expectant management groups, with 8.6% of the expectant groups developing clinical chorioamnionitis versus 4% in the immediate induction groups.

Unlike earlier studies, a similar number of babies in all four groups were sampled and cultured for neonatal sepsis, regardless of what management group their mothers had been assigned to. Overall, this study presented a very strong case for arguing that immediate induction does not increase the cesarean rate, and that expectant management may increase maternal infection rates. Nevertheless, it still had a few weaknesses. For one thing, multiparas were pooled with nulliparas, and there was no standardization of Bishop’s score (cervical ripeness); 6-15% of the women had ripe cervices, versus 29-54% which were considered unripe, and in 33-65% of the women, the cervical status was unknown. Additionally, the researchers stated that “digital vaginal examinations were avoided,” but the expectant management groups had considerably more digital vaginal exams than the immediate induction groups. This is very important to note, given that digital vaginal exam after PROM has been found to be an independent risk factor for maternal and fetal infection.(Shutte et. al., 1983; Lenihan, 1984)

Even more recent studies (Zanzami, 2005) have found that in the absence of other obstetric and maternal or fetal risk factors, PROM at term is not an additional risk factor on its own. “Expectant management of PROM at term enhances a patient’s chance of normal delivery without an incrase in fatal and/or maternal morbidity.”

Now, this is not to say that other studies haven’t found the contrary to be the case. For example, Wagner et. al. (1989) found an increase in infection rates in babies born to women with PROM who had been managed expectantly versus actively, although this study also found that the number of vaginal exams performed increased the infection rate (which other studies have confirmed). Rydhstrom & Ingemarsson (1991) found no difference in the cesarean rates in a randomized trial between active management and expectatant management, and Akyol et. al. (1999) actually found that the cesarean rate was lower in the immediate induction group of their study when compared to the expectant management group who were randomized to induction after 24 hours had passed. However, it’s important to note that this increase in cesarean rate was in a group of women who had already failed to go into spontaneous labor within 24 hours. The majority of women will go into labor within 24 hours, so inducing those who didn’t might imply other variables at work which would make induction particularly unsuccessful.

My thoughts on the subject? If your water breaks and your labor doesn’t start right away, that’s fine: 8-12% of all women experience this problem, and it happens most often at term. If the fluid is clear and you can feel the baby moving, call your provider by all means and discuss your options with her, but try to stay home for as long as possible! Go for a walk, bake some cookies, scrub out the bathtub, do some yoga, try to get those contractions to kick in (just don’t have sex, now that your membranes are ruptured). Most women will go into labor on their own within 24 hours, and so long as NO digital vaginal exams are performed (i.e. using fingers; a sterile speculum exam is somewhat better, but still isn’t 100% risk-free), the risks of infection are low. If your provider urges an induction, ask for more time; studies have shown that inductions for PROM often don’t work that well, and women who are induced have a higher risk for developing an infection or having a cesarean (Zanzami, 2005; Hannah et. al., 1996), in part because once the induction process begins, vaginal exams and other interventions which increase the rate of infection, like internal monitoring, are often done.

Talk with your provider about giving your body AT LEAST 12 (and preferably 24) hours to get going on its own, and chances are very good that it will. If, after 24 hours you’re still not in active labor, don’t panic; about 15-20% will not do so within 24 hours (Kappy et. al. 1979). In a clinical trial that measured a 12-hour expectant management regimen versus a 72-hour regimen, the rates of infection, chorioamnionitis and neonatal morbidity were the same in both groups. (Shalev et. al, 1995) In other words, you can probably wait up until 72 hours, so long as no signs and symptoms of infection occur (although your risk of infection does marginally increase the longer you’re ruptured, especially after 24 hours). Also, keep in mind that one of the side effects of an epidural is fever! One of the warning signs of infection is a rising temperature, but if you’ve just had an epidural, it could be from the epidural, and not really an infection at all—especially if your provider has kept his/her fingers out of your vagina! (Goetzl, et. al. 2001)

(Having just issued all of this advice, though, please go read my Quick Disclaimer before you go forth holding my word as gospel. I’m not a midwife! I’m a student, and I have NO idea what your personal situation might be. Each labor and birth is unique, full of a million and one variables, and needs to be handled individually by a health care provider you trust.)

References:

Akyol, D., Mungan, T., Unsal, A. & Yuksel, K. (1999) Prelabour Rupture of the Mmebranes at Term—No advantage of Delaying Induction for 24 Hours. Australia and NZ Journal of Obstetrics & Gynecology, 39(3): 291-295.

Duff, P., Huff, R.W. & Gibbs, R. (1984) Management of Premature rupture of Membranes and Unfovarable Cervix in Term Pregnancy. Obstetrics & Gynecology 63(5): 697-702.

Duncan, S.L.B & Beckley, S. (1992) Prelabour rupture of the membranes—why hurry? British Journal of Obstetrics and Gynaecology, 99: 543-545.

Ezra, Y., Michaelson-Cohen, R., Abramov, Y. & Rojansky, N. (2004) Prelabor rupture of the membranes at term: when to induce labor? European Journal of Obstetrics & Gynecology and Reproductive Biology, 115:23-27.

Grant, J.M., Serle, E., Mahmood, T., Sarmandal, P., & Conway, D.I. (1992). Management of prelabour rupture of membranes in term primigravidae: a report of a randomized prospective trial. British Journal of Obstetrics & Gynaecology, 99(7): 557-562.

Goetzl, L., Cohen, A., Frigoletto, F., Ringer, S.A., Lang, J., & Lieberman, E. (2001). Maternal Epidural Use and Neonatal Sepsis Evaluation in Afebrile Mothers. Pediatrics, 108(5): 1099-1102.

Hannah, M.E., Ohlsson, A., Farine, D., Hewson, S.A., Hodnett, E.D., Myhr, T.L. et. al. (1996). Induction of Labor Compared with Expectant Management for Prelabor Rupture of the Membranes at Term (TERM PROM study). New England Journal of Medicine, 334(16), 1005-1010.

Kappy A.K. et. al. (1979) Premature Rupture of Membranes: A conservative approach. American Journal of Obstetrics & Gynecology 134(6): 655-661.

Lenihan, J.P. (1984) Relationship of Antepartum Pelvic Examinations to Premature Rupture of the Membranes. Obstetrics & Gynecology, 83(1): 33-37.

Marshall, V.A. (1993) Management of premature rupture of membranes at or near term. Journal of Nurse-Midiwfery, 38(3): 140-145.

McGregor, JA, French, JI. (1997) Evidence-based prevention of preterm birth and rupture of membranes: infection and inflammation. Journal of the Society of Obstetricians and Gynaecologists of Canada, 13: 835-852.

Mozurkewich, E.L. & Wolf, F.M. (1997) Premature rupture of membranes at term: a meta-analysis of three management schemes. Obstetrics & Gynecology, 89(6):1035-1043.

Rhdhstrom, H & Ingemarsson, I. (1991) No Benefit from consevative management in nulliparous women with premature rupture of membranes (PROM) at term. Acta Obstetrica Gynecologica Scandinavia, 70: 543-547.

Russell, K., & Anderson, G. (1962) The aggressive management of ruptured membranes. American Journal of Obstetrics and Gynecology, 83(7): 930-937.

Shalev, E., Peleg, D., Eliyahu, S. & Nahum, Z. (1995). Comparison of 12- and 72- hour Expectant Management of Premature Rupture of Membranes in Term Pregnancies. Obstetrics & Gynecology, 85(5): 766-768.

Shetty, A., Burt, R. Rice, P & Templeton, A. (2005) Women’s perceptions, expectations and satisfaction with induced labour—A quastionnaire-based study. European Journal of Obstetrics & Gynecology and Reproductive Health.

Shubeck, F., Benson, RC., Clark Jr, WW., Berendes, H., Weiss, W., & Deutschberger, R. (1966). Fetal hazard after rupture of membranes. A report from the Collaborative Project. Obstetrics & Gynecology, 28(1), 22-31.

Shutte, M.F., Treffers, P.E., Kloostermoan, G.J. & Soepatmis, S. (1983) Management of premature rupture of membranes: The risk of vaginal examination to the infant. American Journal of Obstetrics & Gynecology, 146(4): 395-400.

Tan, BP & Hannah, M.E. (2001) Oxytocin for prelabour rupture of membranes at or near term (Cochrane Review). In: The Cochrane Library, No. 2., Oxford: Update Software, 2001.

Wagner, M.V., Chin, V.P., Peters, C.J., Drexler, B., & Newman, L.A. (1989) A Comparison of Early and Delayed Induction of Labor with Spontaneous Rupture of Membranes at Term. Obstetrics & Gynecology, 74(1):93-97.

Zamzami, Y. (2005) Prelabor Rupture of membranes at term in low-risk women: induce or wait? Achives of Gynecology and Obstetrics, Oct. 6: 1-5 [e-pub. ahead of print.]

“Merck and the FDA have not been completely honest with the people about the pre-licensure clinical trials,” said NVIC president Barbara Loe Fisher. “Merck’s pre and post-licensure marketing strategy has positioned mass use of this vaccine by pre-teens as a morality play in order to avoid talking about the flawed science they used to get it licensed. This is not just about teenagers having sex, it is also about whether Gardasil has been proven safe and effective for little girls.”

The FDA allowed Merck to use a potentially reactive aluminum containing placebo as a control for most trial participants, rather than a non-reactive saline solution placebo. A reactive placebo can artificially increase the appearance of safety of an experimental drug or vaccine in a clinical trial. Gardasil contains 225 mcg of aluminum and, although aluminum adjuvants have been used in vaccines for decades, they were never tested for safety in clinical trials. Merck and the FDA did not disclose how much aluminum was in the placebo.

Animal and human studies have shown that aluminum adjuvants can cause brain cell death and that vaccine aluminum adjuvants can allow aluminum to enter the brain, as well as cause inflammation at the injection site leading to chronic joint and muscle pain and fatigue. Nearly 90 percent of all Gardasil recipients and 85 percent of aluminum placebo recipients reported one or more adverse events within 15 days of vaccination, particularly at the injection site. Pain and swelling at injection site and fever occurred in approximately 83 percent of Gardasil and 73 percent of aluminum placebo recipients. About 60 percent of those who got Gardasil or the aluminum placebo had systemic adverse events including headache, fever, nausea, dizziness, vomiting, diarrhea, myalgia. Gardasil recipients had more serious adverse events such as headache, gastroenteritis, appendicitis, pelvic inflammatory disease, asthma, bronchospasm and arthritis.

Hmm. This certainly throws a new wrinkle in the story.

You can read the full article over at Red Orbit.

I was listening to a discussion on the radio this morning about Gardasil and the issues that surround its use, and opinions seem to be pretty reasonable on all sides of the debate. Conservative group are not opposing the vaccine itself, but are arguing against making it mandatory. From the NY Times article on the subject:

“Despite rumors to the contrary, our organization doesn’t oppose the vaccine and we have taken no position regarding mandatory laws,” said Wendy Wright, president of Concerned Women of America, a conservative group based in Washington.

Some groups support the vaccine but oppose mandatory vaccinations because cervical cancer is caused by a sexually transmitted virus.

“We can prevent it by the best public health method, and that’s not having sex before marriage,” said Linda Klepacki of Focus on the Family, a Christian advocacy organization based in Colorado Springs.

That’s a very good strategy, but what if the husband you’ve saved yourself for just so happens to have HPV? While not having sex is certainly a sure-fire way to avoid HPV and other sexually transmitted diseases, women can still get HPV on their wedding night from their very first sexual contact. A vaccine doesn’t promote promiscuity, but rather protects you from a very very very very very common STD that many people (men especially) do not even know they have.

Making this vaccine mandatory may help ensure that it’s covered by insurance companies and federal programs which might otherwise choose not to pay for such an expensive drug (a 3-part series over 6 months, costing $120 per shot, so $360 total). From the same Times article above:

A federal program is expected to provide the vaccine to 45 percent of the children in the United States for whom it is recommended. But state programs that cover other children are having trouble buying other expensive vaccines.

North Carolina, for instance, spends $11 million annually to provide every child with seven vaccines. Gardasil alone would probably cost at least another $10 million.

“Increasingly, states are asked to make a Sophie’s choice about which diseases they will allow children to be hospitalized or killed by,” said Dr. Paul Offit, director of infectious diseases at Children’s Hospital of Philadelphia.

It will be interesting to see how all of this unfolds, but for now, it’s enough just to know that this vaccine has finally been approved. As Dr. Sedlis (the guest professor who lectured us on the interpretation of pap smears) jokingly said, if this vaccine becomes widespread, gynecologists are going to be out of a job in 20 years, since pap smears and the mangement of abnormal paps is their bread and butter. This is a vaccine that could possibly someday eliminate the need for routine pap screening for all women, and make cervical cancer, which is already rare in this country, all but obsolete. That’s pretty powerful stuff!

Addendum:
Slate Article: very astute break down of many of the issues surrounding the vaccine, including the costs, benefits and risks and moral issues, well worth reading.
Moderately Insane: HPV Insanity: interesting break down the risks v. benefits of the HPV vaccine, in very plain English.
Women’s Health News post on HPV vaccine, full of amazing resources, per usual.

Obstetrical interventions pass for science, even though their use in normal pregnancy is irrational. According to anthropologist Robbie Davis-Floyd, obstetrical interventions fulfill a rational societal function by diminishing our high-tech society’s extreme fear of birth. Specific cultural services are performed when obstetricians “bring forth a new social member through a maze of wires and electronic bleeps.” Obstetrical rituals convey core values that center around science and technology. Belief in them as “necessary” sustains patriarchal institutional management. We let monitors, intravenous devices, and drugs give birth instead of women, turning the bodies of women who give birth into “machines.” Faith in technology provides a comfortable refuge from the unknown.

Even though this article was written in 1993, almost everything it discusses is still true, or even more true. The c-section rate is no longer 23%, it’s a whopping 29%. Things keep getting worse, not better. No joke. This article is AMAZING, complete with references! Go read it IMMEDIATELY! I cannot stress this enough. We should print out copies of this and tape it to the walls of hospitals, or hand it out on the street, or just randomly place it in mailboxes. This article needs to become public knowledge, ASAP. The time to rediscover midwifery is NOW.

The word goes something like this: About five years ago, I was broke (notice how much has changed in the intervening five years!). I had recently befriended a woman who lived in my neighborhood, and one evening, while hanging out at her house, I noticed that she had a bunch of terry cloth pads laid out next to her sewing machine, made from a cut-up bath towel. When I asked her what they were for, she introduced me to the concept of alternative, reuseable menstrual gear. I was, to put it mildly, a bit flabbergasted. Keep in mind, I was a good girl from the midwest, who’d only been living in New York City for two years at that point, and still hadn’t fully lost my shy, midwestern ways. The message that our society sadly pounds into the skulls of young women (myself included) is that your period is dirty, something that needs to be kept secret and “sanitary”, and most definitely hidden from others. As girls, we’re taught that menstruation is an unfortunate part of growing up, a curse, or at the very least, a major, monthly pain in the ass—something that needs to be tolerated and dealt with, but rarely something that should be celebrated and enjoyed. As part of our induction into womanhood, we’re inundated with ads from the feminine “hygiene” industry, promoting the benefits of this product over that, and encouring the idea that the selection of a feminine hygiene brand is an important rite of passage. All of this just compounds the sense of shame and embarrassment that so many of us feel about our bodies—magazines are full of ways for us to “fix” our bodies, lose weight and attract the man of our dreams by wearing the right clothes and smelling the right way. Commercials for pads and tampons rave about how fresh, clean and discrete their products are. Douches urge us to “cleanse” our (naturally dirty?) vaginas so that they’re strawberry-scented or flower-fresh (and cause untold infections in the process through drastic vaginal flora disruption).

The feminine hygiene industry is a billion dollar industry that feeds off of women’s insecurities and doubts, and has us all suckered into the idea that spending $200 on menstrual products a year is just an unavoidable part of being a woman. Let me put it this way: do you think men would spend $200 a year on hygiene products if they too had an unavoidable monthly biological process that was part of their healthy life-cycle? I’m guessing not. If men had menstrual cycles, I bet health insurance companies would have started covering the expense of their supplies long ago, since, after all, these products would be essential to the health of the insured, same way insurance companies will pay for prenatal vitamins, or the needles and glucometers of diabetics. Why should women be expected to pay out-of-pocket for something that’s part of their yearly health and wellness? (This is somewhat similar to the “logic” used when health insurance companies will pay for viagra, but refuse to cover birth control…but that’s a rant I’ll save for another day). Women have been using cloth for centuries. It’s only very recently that we’ve been expected to pay every month for the pleasure of bleeding onto pearly white, cotton pads.

One woman, in her lifetime, will go through close to 11,000 pads or tampons. That’s a huge amount of uneeded waste going straight to the landfill. The women on this earth account for 51% of the population. If all of us use 11,000 pads in our lifetimes…that’s gotta be a landfill the size of Australia! It’s worth switching to re-useable products for that reason alone, but wait, there’s more: disposable pads suck! Not only do they take up way too much space, and get tossed out after only a few hours of use, but the packaging that comes with the products (the boxes and applicators) are also nothing but landfill fodder, and often end up washing up on beaches. While the FDA assures us that tampon companies no longer use chlorine-bleaching processes to get those pure, snow-white results they’re looking for, this was a practice that was used for decades before the FDA recently outlawed it, and untold amounts of toxic dioxins have been released into our environment because of it, disrupting ecosystems and bioaccumulating in lakes and rivers. (The FDA was also very quick to dismiss the idea that the dioxins in tampons can cause TSS or possibly cancer, but even without the dioxins, tampons are still perfectly capable of causing TSS on their own, just by being such a lovely, squidgy vector for bacteria and infetion). Sadly, dioxin is a very persistent chemical, and even though companies now use chlorine-free bleaching processes, the damage has already been done. Our children and grandchildren will be drinking and eating trace amounts of dioxin in their water and food for decades to come, thanks to the toxic feminine hygiene industry. And I ask you this: why is it necessary that the cotton and rayon of pads and tampons be bleached in the first place? They’re not sterile products that are used for surgery or wounds; they don’t have to be bleached.

Anyway, to make a long story short, my initial reaction to my friend’s cotton pads was “eeewwww!!”, however, it didn’t take long for her arguments to make sense to me: 1) I was broke, and the idea of saving $200 a year not spending that money on pads was very appealing, and 2) I have always been trying to find ways to make my environmental footprint on this earth a little bit lighter, and using cloth pads seemed like a really simple thing to change, which actually has a very large cumulative impact. So I purchased a starter kit of reuseable cloth pads to take care of all my monthly needs and voila!, I was hooked. I’ll let others extol the virtues of free-bleeding, but for my own part, there was something deliciously empowering about taking this aspect of my life out of commercial, profit-driven hands, and into my own capable, human hands. There was also something immensely satisfying about blowing raspberries at the TV screen whenever an ad for tampons came on, and feeling smug and pleased with the knowledge that while other women spent money on pads every month, I didn’t! Course, this method required a certain non-squeamishness when it came to blood, and a willingness to wear heavy cloth pads in my underwear once a month (which did, I must admit, feel like I had a phone book between my legs every now and then), and of course I had to soak them and launder them appropriately. For about two years, this routine suited me just fine (and cloth pads are great, and continue to work well for millions of women around the world)…but then…THEN…I discovered the joys of the Keeper.

Believe me, once I was finally sold on the beauty and sustainability of cloth pads, I was a true-blue, born-again convert, however, I have found that I prefer the Keeper to cloth pads, which means that in my book, it’s really very VERY good. This little cup is a latex product that fits inside of your vagina and functions a lot like an OB tampon, collecting your menstrual flow without drying out your vaginal walls. It requires insertion with your fingers, and periodic emptying (your collected flow can be conveniently emptied into the toilet, then the Keeper can be wiped off and reinserted); I must admit, it does take a little bit of effort to learn how to get it in and out, but once you master it, this is by far the easiest form of menstrual protection I have ever used, AND it’s ecologically friendly, sustainable, reuseable, and relatively cheap, given that you only have to buy one, and then you’re set for the next 10 years. Another beauty of using a menstrual cup is the fact that you don’t have to change your cup nearly as often as you have to change a tampon. On light days, towards the end of my bleeding cycle, I can happily put my Keeper in during my morning shower, and leave it in all day, and forget that it’s even there. And then, at the end of your cycle, all you have to do is wash it out with antibacterial soap, let it soak overnight in a bowl of water mixed with a tablespoon of hydrogen peroxide, white vinegar or tea tree oil, and that’s it. So, for those of you who like functionality of tampons (and the lack of phone-book-between-your-legs), but would also like to stop feeding the fat purse of the toxic feminine hygiene industry, and do our planet a major favor, a menstrual cup is definitely the way to go. The Mooncup and Divacup are also every bit as fantastic as the Keeper, they’re just made out of silicone instead of latex, so for those of you with latex allergies, rest assured, there are menstrual cups out there for you, too!

That’s pretty much the end of my schpiel. I know that what works for some women certainly won’t work for all women, but I urge you to think about your menstrual choices. Once you start using alternative methods, you begin to wonder why you ever needed a 7th-grade introduction to feminine hygiene products in the first place. I started using alternative methods about five years ago, and I haven’t once looked back.

For further reading:

The Wise Wound by Shuttle, Redgrove & Drabble.

The Woman in the Body by Emily Martin.