Monthly Archives: September 2009

Spare the Rod? Is Spanking a Child Harmful or Helpful? – Part 3 – Does physical punishment establish the moral righteousness of hitting other persons?

Opposition to parents spanking their children has been growing significantly in elite circles over the past few years. And, my blogs on spanking are among the most read of those I publish. Therefore, I’ve decided to, with the help of the research of my friends Den Trumbull, MD, S. DuBose Ravenel, MD, to look a the arguments used against spanking, to see if they hold any water. This is the third of a 12 part series.

Argument #2: Physical punishment establishes the moral righteousness of hitting other persons who do something which is regarded as wrong.

Counterpoint:

According to an investigation by Drs. Trumbull and Ravenel, performed for the Family Research Council, the “spanking teaches hitting” belief has gained in popularity over the past decade, but is not supported by objective evidence.

A distinction must be made between abusive hitting and nonabusive spanking.

A child’s ability to discriminate hitting from disciplinary spanking depends largely upon the parents’ attitude with spanking and the parents’ procedure for spanking.

There is no evidence in the medical literature that a mild spank to the buttocks of a disobedient child by a loving parent teaches the child aggressive behavior.

The critical issue is how spanking (or, in fact, any punishment) is used more so than whether it is used.

Physical abuse by an angry, uncontrolled parent will leave lasting emotional wounds, and will cultivate bitterness and resentment within a child.

The balanced, prudent use of disciplinary spanking, however, is an effective deterrent to aggressive behavior with some children.

A six year longitudinal study of a racially mixed population of 1112 children ages 4 to 11 years in Archives of Pediatric and Adolescent Medicine concluded:

“Regression analysis within subgroups yielded no evidence that spanking fostered aggression in children younger than 6 years and supported claims of increased aggression for only 1 subgroup: 8-11-year-old white boys in single-mother families.”

For the higher risk subgroup, it was speculated that spanking may serve as “a proxy for other family problems such as lost parental authority, poor management practices, stress, or lack of support.”

In these cases, the study authors suggest “for families experiencing severe family management problems, spanking is not a viable solution to these problems and may exacerbate them.”

One review concludes that the familial setting has a profound effect upon the outcome of the disciplinary measure.[2]

Remarkably, studies have concluded that childhood aggressiveness has been more closely linked to maternal permissiveness and negative criticism than to even abusive physical discipline.[3]

It is unrealistic to expect that children would never hit others if their parents would only exclude spanking from their discipline options.

Most children in their toddler years (long before they are ever spanked) naturally attempt to hit others when conflict or frustration arises. The continuation of this behavior is largely determined by how the parent or caregiver responds.

If correctly disciplined, the hitting will become less frequent. If ignored or ineffectively disciplined, the hitting will likely persist and even escalate.

Thus, instead of contributing to greater violence, spanking can be a useful component in an overall plan to effectively teach a child to stop aggressive hitting.

Citations:

[2] Gunnoe, M. L. and Mariner C. L., “Toward a developmental-contextual model of the effects of parental spanking on children’s aggression,” Archives of Pediatric & Adolescent Medicine 151 (1997): 768-775.

[3] Olweus, Dan, “Familial and Tempermental Determinants of Aggressive Behavior in Adolescent Boys: A Causal Analysis,” Developmental Psychology 16 (1980): 644-660.

Here’s the entire series:

You can read more of my blogs on spanking here:

By the way, an introduction is in order. Den A. Trumbull, MD is a board-certified pediatrician in private practice in Montgomery, Alabama. He is Vice President of the American College of Pediatricians. S. DuBose Ravenel, MD is a board-certified pediatrician in private practice in High Point, North Carolina. He served for 11 years on the pediatric faculty of the University of North Carolina School of Medicine prior to entering private practice.

After a tragic loss, family steps up in swine flu vaccine trials

News reports tell us about the fact that many parents are feeling cautious about the Swine flu (2009 H1N1 flu) vaccine. Here’s a tragic story about a family who chose not to immunize their children against the flu and their activism about the Swine flu vaccine. Continue reading

An uninsured gorilla in Colorado Springs receives specialist service faster than a Canadian human might

There’s been big news at our local zoo, the Cheyenne Mountain Zoo, here in Colorado Springs. Rafiki,  a 25-year-old silverback lowland gorilla, took ill. When he did, medical attention was available immediately. Some of the finest doctors in the world converged upon him, determined to quickly find and fix whatever was wrong. Fortunately, his waiting time for tests was far less than many people in countries with nationalized healthcare. Continue reading

The Ten Commandments of Preventive Medicine – Part 6 – Alcohol

In my latest book, 10 Essentials of Happy, Healthy People, I teach people how to utilize these ten essentials that are necessary to live a happy and highly healthy life. Under The Essential of Self-Care, teach what I call “The 10 Commandments of Preventive Medicine. Here’s the sixth installment of this ten-part series. Continue reading

What’s the most convicting argument against abortion?

The baby. The unborn child is the best argument against abortion. The one thing in which the pro-abortion movement experienced the most success was stripping the unborn child of his or her personhood. “Just a clump of cells,” they said. “Just tissue,” they tried to tell pregnant women. “Nothing more than a blob of flesh,” they told moms-to-be. Medical science has proven them wrong. Continue reading

The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World – Part 2 – Canada

In the midst of our national debate about healthcare reform, people on both sides of the debate seem to pick and choose among the facts and myths about the nationalized healthcare available in a number of other countries. The fact is that every nationalized health care system in the world is battling issues of rapidly rising costs and decreasing access to care. But, these systems also have some very attractive benefits. So, let’s take a look at the pro’s and con’s of the Canadian system.

Continue reading

Spare the Rod? Is Spanking a Child Harmful or Helpful? – Part 2 – Do studies show that spanking is an improper form of discipline?

Opposition to parents spanking their children has been growing significantly in elite circles over the past few years. And, my blogs on spanking are among the most read of those I publish. Therefore, I’ve decided to, with the help of the research of my friends Den Trumbull, MD, S. DuBose Ravenel, MD, to look a the arguments used against spanking, to see if they hold any water. This is the second of a 12 part series. Today we’ll start looking at the arguments used against spanking.

Argument #1: Many psychological studies show that spanking is an improper form of discipline.

Counterpoint:

According to an investigation by Drs. Trumbull and Ravenel, performed for the Family Research Council, researchers John Lyons, Rachel Anderson, and David Larson of the National Institute of Healthcare Research conducted a systematic review of the research literature on corporal punishment.[1]

Among their many findings, they reported that 83% percent of the 132 identified articles published in clinical and psychosocial journals were merely opinion-driven editorials or reviews or commentaries. All were devoid of new empirical findings.[1]

Moreover, most of the empirical studies were methodologically flawed by grouping the impact of abuse with spanking.

The best studies of appropriate, loving spanking (that EXCLUDED from the definition of spanking forms of child abuse or violence) demonstrated beneficial, not detrimental, effects of spanking.

They concluded, as do I, that there is insufficient evidence to condemn parental spanking and adequate evidence to justify its proper use.

Citation:

[1] Lyons, Dr. John S., Anderson, Rachel L., and Larson, Dr. David B., “The Use and Effects of Physical Punishment in the Home: A Systematic Review.” Presentation to the Section on Bio-Ethics of the American Academy of Pediatrics at annual meeting, Nov. 2, 1993.

Here’s the entire series:

By the way, an introduction is in order. Den A. Trumbull, MD is a board-certified pediatrician in private practice in Montgomery, Alabama. He is Vice President of the American College of Pediatricians. S. DuBose Ravenel, MD is a board-certified pediatrician in private practice in High Point, North Carolina. He served for 11 years on the pediatric faculty of the University of North Carolina School of Medicine prior to entering private practice.

You can read more of my blogs on spanking here:

Surgeon Reports Abortion Ups Breast Cancer Risk

According to LifeNews.com, a prominent breast cancer surgeon and professor has written a new article for a medical publication saying that abortion increases a woman’s risk of contracting breast cancer. On the other hand, miscarriage has no effect while a full-term pregnancy lowers the breast cancer risk. Continue reading

The Ten Commandments of Preventive Medicine – Part 5 – Dental Health

In my latest book, 10 Essentials of Happy, Healthy People, I teach people how to utilize these ten essentials that are necessary to live a happy and highly healthy life. Under The Essential of Self-Care, teach what I call “The 10 Commandments of Preventive Medicine. Here’s the fifth installment of this ten-part series. Continue reading

The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World – Part 1

In the midst of our national debate about healthcare reform, people on both sides of the debate seem to pick and choose among the facts and myths about the nationalized healthcare available in a number of other countries. The fact is that every nationalized health care system in the world is battling issues of rapidly rising costs and decreasing access to care. But, these systems also have some very attractive benefits. So, let’s take a look at the pro’s and con’s of each system.

Continue reading

How to Keep Normal Labor Normal – Part 3 – Philosophy

This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Today we’ll look at the costs of “birth philosophy.” Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the first “P” of my 10 “P’s” of keeping labor shorter and birth safer — philosophy.

In the past, labor has been viewed by many (perhaps most) physicians as a process that can and must be managed by physicians for their pregnant patients.

Standard obstetrical text books discuss the three “P’s” of labor management:

  • Power,
  • Passage, and
  • Passenger.

Some have expand these basic 3 to include a fourth “P”: either “Positions” (meaning position changes during labor and delivery) or “Psyche” (meaning psychosocial preparation and support).

However, there is appearing in the literature increasing comment that most labor does not need to be interventionally managed and that knowing when and how not to intervene may be an higher order skill than routinely intervening.(26-28)

Said another way, “if you mess around with a process that works well 98% of the time, there is potential for much harm.”(29)

“In populations where medical intervention is used only when clearly necessary, more than 90% of women will have a healthy birth outcome without any intervention.”(13)

Asking the birthing literature the question, “What then can maternity care providers do to keep normal labor normal?” has lead this me to develop what I call the “Ten ‘P’s’ of keeping normal labor normal.” In this blog we’ll look at the first “P.”

1) Philosophy

There appears to exist among maternity care professionals a philosophical spectrum that extends from that which views labor as a “natural process” to that which views labor as a “disease process.”

Maternity care givers always lean towards one end or the other of this philosophical spectrum as “… underlying these contrasting views are incompatible assumptions about the nature of women.”(16)

“One model assumes that women are capable, reasoning beings who can actively manage their birth experience, whereas the other sees them as possessing a reproductive system that is unreliable, inefficient, and tricky, thus requiring expert monitoring and management.”(30)

The “disease process” approach to maternity care has been expounded since the onset of the specialty of obstetrics, at least in America, where founders of the specialty reported, “Childbirth is a decidedly pathologic process … analogous to being impaled on a pitch fork”(31) and “… the fundamental reason why obstetrics is on such a low plane in the opinion of the profession … (and) in the mind of the public, is just because pregnancy and labor are considered normal, and therefore anybody, a midwife, a medical student, or even a neighbor knows enough to take care of such a function.(32) “By declaring labor and delivery a ‘disease,’ it was possible for an obstetrician to attain the same professional status as his (sic) medical and surgical colleagues.”(33)

Recent reviews are sharply critical of this philosophy: “(I use) the metaphor of production in the workplace for the act of reproduction in the medical model, in which women are seen as powerless and separate in some sense from their bodies.  The uterus is viewed as a machine, the woman as a laborer, and the physician as the supervisor-mechanic-fixer.”(34)

Partially as a result of this philosophy “… the current US pregnancy care system commonly applies technological interventions to most mothers.”(26)

Others have clearly elucidated the opposite end of this philosophical spectrum: “Whether childbirth is experienced as a natural physiologic, family-oriented event or a ‘high-tech’ medical procedure has far more to do with the attitude and approach of a parturient’s medical and nursing attendants than with her clinical condition.”(27)

“Whereas common obstetric practice manages the parturient’s physician functions to conform to a medically determined ideal (the medical pathway), the more conservative ‘physiologic pathway’ gains maximum benefit from her inherent physical and psychological resources to make childbirth more natural, more satisfying, and safer.”(27)  “This approach to pregnancy care recognizes that most women do not need to be technologically delivered of their babies but, rather, need to be allowed to have their babies simply and physiologically born.”(26)

“The term “family-centered maternity care” (FCMC) developed (in the 1970s) as a consumer reaction to the depersonalization of birth that had been the management standard for childbirth during the first half of the century.

The philosophy and focus shifted from technologization to personalization, from birth as a biomedical event to birth as a normal developmental task.”(28)

The existing technological system used in most hospitals is “… an expensive system and tended to overlook and sometimes ignore the individual woman and her childbirth process … and (is) called … high-tech, low touch obstetrics.”(26)

Therefore, “it is not surprising that … women have been the prime instigators in a movement toward … efforts to naturalize and humanize childbirth.”(26)

After consumers came nurses who stated in 1978 that, “… family-centered birthing should be the norm in American obstetrics …”(35)

At about the same time the term “family-centered birthing” appeared in a physician’s article, but only as an alternative: “The Homestyle Delivery Program, an alternative birth service at UC Davis … was developed … in response to the needs and desires of patients and physicians to participate in a more natural family centered birthing process.”(36)

It wasn’t until 1993 that this term entered the mainstream physician literature: “We need to recognize that the attempt to model obstetrics in family practice after highly a technical obstetrician-gynecologist model has failed. A different paradigm — family-centered birthing — is more appropriate …”(37) and could be “… called the low-tech, high-touch obstetrical approach … as family-centered birthing is both a philosophy and a learned group of skills and practices that emphasize a natural process, and not a disease. Women must be encouraged, equipped, and enabled, without unnecessary and nonindicated intervention, to complete one of the most essential roles given to them, to birth their children.”(26)

One obstetrician’s interventionalistic policies were lampooned by Sheila Judge, the night midwifery sister at Sheppey General Hospital, in 1968:  “Blood pressure erratic, they lose an ounce — That’s enough! The boss will pounce!”(38)

For midwives or general practitioners who sought to emulate their interventionalistic obstetrical colleagues, she wrote:  “Aseptic, scientific, and quite spell free, is how modern midwifery aims to be — The newest procedures are always the greatest, it’s bound to be good if it’s the latest!”(38)

One amusing analogy of the technologically obsessive states that, “The bomb squad approach to maternity care, which asserts that every pregnant woman is a time bomb ready to ‘go off’ and needs a bomb disposal squad, is to most family physicians and midwives dissatisfying, unsafe, and unsatisfactory, particularly for the provision of routine family-centered maternity care.”(39)

One author showed that “physician beliefs … (link) directly to clinical actions and their consequences …”(40) ; however, there is little in the literature describing how or if maternity caregivers can or will change from one end of the philosophical spectrum to the other, but that which exists indicates that this process is both difficult and prolonged and usually progresses along a somewhat predictable continuum.(26,41)

What does the research say about one philosophical approach or the other?

“To date, all studies of … expectant, non-interventional style of pregnancy care have shown, that when applied to low-risk women, the approach has excellent outcomes, compared to similar women managed in more interventionalistic methods.  This appears to be true whether the maternity care providers are family physicians, midwives, or obstetricians.”(26)

There should be no question that “… it is critical that the style of practice be geared toward keeping healthy patients healthy.”(42)

It does appear that a care giver’s belief and philosophy effects the maternity care that they practice.

Here’s the entire series:

  1. Philosophy,
  2. Partners,
  3. Professionals,
  4. Pain control,
  5. Procedures,
  6. Patience,
  7. Preparation,
  8. Positions,
  9. Payment, and
  10. Prayer.

Citations:

  • (13) Scherger JE.  Management of normal labor and birth.  Primary Care 1993;20:713-719.
  • (26) Larimore WL. Family-centered birthing: history, philosophy, and need. Fam Med 1995;27:132-138.
  • (27) Fenwick L. Birthing: techniques for managing the physiologic and psychosocial aspects of childbirth. Perinatal Nurs 1984, May/June:51-62.
  • (28) Midmer DK. Does family-centered maternity care empower women? The development of the woman-centered childbirth model. Fam Med 1992;24:216-21.
  • (29) Hon, E. In: Young D. Crisis in obstetrics-the management of labor. Int J Childbirth Education 1987, August: 13-5.
  • (30) Moore M, Hopper U. Do birth plans empower women? Evaluation of a hospital birth plan. Birth 1995;22:29-36.
  • (31) Pomeroy, DeLee JB, In: Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980. Obstet Gynecol Surv 1983;38:322-338.
  • (32) DeLee JB, In: Fishbein M. Joseph Bolivar DeLee: crusading obstetrician. New York: EP Dutton, 1949.
  • (33) King CR. Where is the woman in obstetrics and gynecology? Pharos 1989;52:8-11.
  • (34) Martin E. The woman in the body. A cultural analysis of reproduction. Open University Press, 1987.
  • (35) Joint statement endorses family centered birthing. Am Nurse 1978;10:1, 11.
  • (36) Rollins AJ, Kaplan JA, Ratkay ME, Goodlin RC, et. al. A homestyle delivery program in a university hospital. J Fam Pract 1979;9:407-14.
  • (37) Larimore WL. Family-centered birthing: a niche for family physicians. Am Fam Physician 1993;47:1365-6.
  • (38) Mathews D. Birth of the midwife/obstetrician. Lancet 1995;345:532.
  • (39) Larimore WL, Reynolds JL. Family practice maternity care in America: ruminations on reproducing an endangered species – family physicians who deliver babies. J Am Bd Fam Pract 1994;7:1-11.
  • (40) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, et.al. Physicians’ beliefs and behavior during a randomized controlled trial of episiotomy. Can Med Assoc J 1995;153:769-79.

What do I do if I think I have the 2009 H1N1 Swine flu?

I’ve blogged before about “How to Tell the Difference Between a Cold and the Flu (or Swine or H1N1 influenza).” What used to be called the “Novel H1N1 flu,” or the “Swine Fly,” is now officially called the 2009 H1N1 flu. But, no matter what it’s called, if you are coming down with the flu, what should you do?

Continue reading

Spare the Rod? Is Spanking a Child Harmful or Helpful? – Part 1 – Introduction

My blogs on spanking are among the most read of those I publish. This may be due to the fact that opposition to parents spanking their children has been growing significantly in elite circles over the past few years. Therefore, I’ve decided to, with the help of the research of my friends Den Trumbull, MD, S. DuBose Ravenel, MD, to look a the arguments used against spanking, to see if they hold any water. First, some introductory comments to begin this 12 part series.

Drs. Trumbull and Ravenel write:

No doubt much of this opposition springs from a sincere concern for the well-being of children. Child abuse is a reality, and stories of child abuse are horrifying.

But while loving and effective discipline is quite definitely not harsh and abusive, neither is it weak and ineffectual. Indeed, disciplinary spanking can fall well within the boundaries of loving discipline and need not be labeled abusive violence.

Critics, however, claim that spanking a child is abusive and contributes to adult dysfunction.

In fact, most of these allegations arise from studies that fail to distinguish what I will define as “appropriate spanking” from other forms of punishment, including forms discipline that are child abusive.

It’s shocking for most parents to learn that studies commonly include abusive forms of physical punishment (such as kicking, punching, and beating) under the umbrella of “corporal punishment,” of which mild or appropriate spanking is a subset.

Trumbull and Ravenel point out, “Furthermore, the studies usually include, and even emphasize, corporal punishment of adolescents, rather than focusing on preschool children, where spanking is more effective.”

This blurring of distinctions between spanking and physical abuse, and between children of different ages, gives critics the illusion of having data sufficient for condemning all disciplinary spanking.

Is it any surprise to anyone that child abuse and severe punishment would be associated with negative outcomes? Of course not! Any civilized parent would be shocked by these types of abuse.

But this is a far cry from judiciously used mild spanking employed by many, if not most, loving parents. The excessive punishment of some misguided, angry or cruel parents should not become an argument to not discipline at all.

The real issue, then, for the vast majority of loving, caring parents is not whether they should spank, but how they spank.

So, what is appropriate or mild spanking?

An important scientific conference defined appropriate or mild spanking as:

  • physically non injurious,
  • intended to modify behavior, and
  • administered to the extremities or buttocks.

I would add that such discipline is never administered in anger, and should be used with children from about 18 months to six years of age.

To my knowledge, this form of spanking has been shown to be effective, especially when used in conjunction with other forms of discipline, such as time outs, reasoning, and other disciplinary tools. Furthermore, it has NEVER been shown to be harmful to children.

In fact, studies have shown an INCREASE in child abuse in homes where appropriate spanking does NOT occur. Why? Eliminating mild or appropriate spanking takes away a strong, useful, effective, and suitable tool from a parent.

Not all children need to be spanked, and not all parents should spank their children — especially parents prone to anger, hostility, abuse, or outbursts. However, a parent that does not teach that there are consequences to behaviors will leave it to the police and others to do that later in the child’s life.

Parents, for millennia, in virtually every recorded culture, have spanked their young children, when necessary, to teach them and to shape and mold their character to ultimately benefit their children.

Now, unfortunately, parents are being fed confusing information by anti-spanking advocates. Perhaps some discipline is in order for those guilty of fictionalized reporting.

Anyway, there are several arguments commonly leveled against disciplinary spanking that we will examine in this series.

Of these arguments, Trumbull and Ravenel say, “Interestingly, most of these arguments can be used against other forms of discipline. Any form of discipline (time-out, restriction, etc.), when used inappropriately and in anger, can result in distorting a child’s perception of justice and harming his emotional development.”

So, starting next week, we’ll examine these topics:

By the way, an introduction is in order. Den A. Trumbull, MD is a board-certified pediatrician in private practice in Montgomery, Alabama. He is Vice President of the American College of Pediatricians. S. DuBose Ravenel, MD is a board-certified pediatrician in private practice in High Point, North Carolina. He served for 11 years on the pediatric faculty of the University of North Carolina School of Medicine prior to entering private practice.

You can read more of my blogs on spanking here:

Experts recommend N95 masks over surgical masks to stop spread of H1N1

In an earlier blog, I told you that the only facial apparatus that is likely to protect you from the 2009 H1N1 influenza virus is what they call a “respirator,” which refers to an N95 or higher filtering facepiece respirator certified by the U.S. National Institute for Occupational Safety and Health (NIOSH). Now a new study proves this correct. Continue reading

Is the 2009 H1N1 Swine Flu Vaccine Safe? An Update

I’m getting tons of emails and questions at the practice about the safety of the Swine flu vaccine (the Swine flu is now officially called the “2009 H1N1 influenza). Will it be safe? Will it cause cancer? Will it contain preservatives or adjuvants? One friend wrote: Are you taking it? Are you recommending it to your family. Here are my answers and the latest update: Continue reading

How many uninsured people need additional help from taxpayers?

To my surprise, the most popular blogs I’ve ever written are on healthcare reform. So, now that we are on the eve of the Senate unveiling its healthcare proposal, I want to put you in the decision-maker’s seat. Which of the uninsured would you cover, if you could make the decision? I hope you’ll take the time to consider this blog and then post your vote in the comment section below. Continue reading

The Ten Commandments of Preventive Medicine – Part 4 – Marriage

In my newest book, 10 Essentials of Happy, Healthy People, I teach people how to utilize ten essentials that are necessary to live a happy and highly healthy life. Under The Essential of Self-Care, teach what I call “The 10 Commandments of Preventive Medicine. Here’s the fourth installment of this ten-part series. Continue reading

Retail medical clinics offer low-cost care at similar quality to physicians’ offices

A study published in the Annals of Internal Medicine has found that “retail clinics provide less costly treatment than physician offices or urgent care centers for 3 common illnesses, with no apparent adverse effect on quality of care or delivery of preventive care.” The 3 illnesses were otitis media, pharyngitis, and urinary tract infection (UTI). Continue reading

Vaccine Myth #2: Vaccines Don’t Work

This is the second entry in a series from my book God’s Design for the Highly Healthy Child.

Probably the best recent example of the positive impact of vaccines is the Hib vaccine, which prevents meningitis, ear infections, and other serious infections caused by the bacterium Haemophilus influenzae type B (Hib).

When the current Hib vaccine was introduced to this country in 1990, Hib was the most common cause of bacterial meningitis.

For decades, Hib had caused approximately 15,000 cases of meningitis and 400 to 500 deaths every year. After the current Hib vaccine was introduced, the incidence of Hib meningitis declined to fewer than fifty cases per year—typical of all widely used vaccines. Continue reading

Faith-Based Health and Healing – Part 5 – What Causes Sickness?

Theologians tell us that, in one sense, from a Biblical perspective, all sickness has its ultimate origin in sin because human suffering stems from the fall and the sin of Adam and Eve (Genesis 2:15 – 17; Romans 1:28 – 32). But that’s not the way many people think of sin causing sickness. It’s very common for me to see patients who believe that their sickness or disease is caused by a specific sin or wrong decision. There are others who believe that all illness is due to specific sin. Is this true or false?

More Information: Continue reading

How to Keep Normal Labor Normal – Part 2 – The Costs of Abnormal Labor

This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Today we’ll look at the costs of “abnormal labor.” Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth.

The medical literature has many, many articles that discuss the potential risks and costs for not keeping normal labor normal; including:

  • increased dystocia (dysfunctional, abnormal labor),
  • increased fetal distress, and
  • the increase in unnecessary operative deliveries.

(1)  Increased dystocia

Although, “… dystocia has remained a poorly defined term,”(1) for the purposes of this paper “… dystocia is divided into two major categories.

The first category of dystocia, true cephalopelvic disproportion, is characterized by failure of descent of the head after complete dilation and includes the diagnosis of persistent occiput posterior.

The second category, inefficient uterine action, is defined as failure of the cervix to dilate (<1cm/h with no more than 7 contractions per 15 min) and the head to descend … (and) is divided into four subcategories:

  1. unsuccessful attempt at induction,
  2. error in the diagnosis of labor (defined as regular painful uterine contractions that are accompanied by one or more of four additional criteria:
    • dilation,
    • effacement in primiparas,
    • rupture of the membranes, and
    • loss of the mucous plug or bloody show(3)),
  3. inadequate response to treatment, and
  4. oxytocin not given.”(2)

Undoubtedly “ …the most significant step toward a solution to the problem of dystocia … has been the recognition of certain fundamental differences between nulliparous and parous women…”(3) and recognizing that dystocia can be caused by certain management practices.  However, “… lack of objectivity (in defining dystocia) may result in variations in practice patterns seen for dystocia.”(1)

Preventing dystocia will, by definition, help keep normal labor normal.

(2)  Increased fetal distress and “fetal distress”

To diagnosis fetal distress when it does not exist is not in the best interest of the laboring woman.

“Like dystocia, fetal distress has remained a poorly defined term.”(1) Surgical or operative intervention “for the diagnosis of ‘fetal distress’ appears to vary depending on institutional and other nonclinical factors,”(1) and “…the observation that cesarean deliveries for ‘fetal distress’ peak during nighttime hours raises the possibility that the interpretation of fetal monitoring tracing is influenced by physician and patient fatigue or other clinical factors.”(1)

Much reliance for the diagnosis of fetal distress has “been placed on the interpretation of fetal monitor tracings, which has been shown to have great interrater variability.”(4) This has caused some to critically question the routine use of continuous electronic fetal monitoring (EFM).(5-13)

“Of concern is not only the lack of benefit (of EFM) to women in labor, but also the high false-positive rate of electronic recording resulting in more diagnosis of ‘fetal distress’ and increased intervention in labor, including cesarean section.”(13)

Clearly, preventing true or false fetal distress will, by definition, help keep normal labor normal.

3)  Increased cesarean delivery rate

There have been strong calls in the literature for physicians to improve their cesarean rates.(5,6,1326)

For example, “In the US in 1992, 22.6% of deliveries were C/S (of 3.97 million births). The projected optimum would be 5-12%, and in 1992 only 90 hospitals in the US were <15%: 35% (were for) previous CS (50-55% should be VBAC, instead of 25.4%), 34% (for) dystocia (abnormal progress in labor), 12% breech (version should work about 66%), 9% “Fetal distress” (50-90% reduced with intermittent auscultation).”(14)

If these projections are correct, keeping normal labor normal by avoiding, as much as possible, dystocia and false diagnosis of fetal distress could reduce cesarean rates by 20 – 40%.

In the US, the cesarean section rate is “iatroepidemic”(17) according to Emanuel Friedman, MD, who says, “physicians should be forbidden to do a cesarean in the latent phase of second stage labor … 70% of cesareans are unnecessary for women with protraction disorders and 50% are unnecessary for arrest disorders.”(17)

Others would say, “The most common indication for a first cesarean section is dystocia (difficult or prolonged labor), which accounts for about one third of all cesarean sections in the United States, approximately twice as high a rate as in other countries with similar medical care systems.”(15)

With labor dystocia, “…provider, payer, and institutional biases have been implicated in causing variations in cesarean delivery rates.”(1,22,23)

“There is general agreement that a solution to the problem of dystocia would go a long way toward resolving the contentious issue of high cesarean birth rates.”(2)

In addition to dystocia, “…cesarean delivery for fetal dystocia is responsible for some of the increase in cesarean section rates.”(1,24,25)

Mortimer Rosen, MD points out, “Managing labor is still an art…the rising cesarean rate suggests that the art of patient care may be in jeopardy.”(17)

Here’s the entire series:

  1. Philosophy,
  2. Partners,
  3. Professionals,
  4. Pain control,
  5. Procedures,
  6. Patience,
  7. Preparation,
  8. Positions,
  9. Payment, and
  10. Prayer.
    REFERENCES:
    (1) Hueston WJ, McClaflin RR.  Variations in cesarean delivery for fetal distress. J Fam Pract 1996;43:461-7.
    (2) Byrd JA, Lytton DE, Vogt SC, et. al.  Diagnostic criteria and the management of labor. J Fam Pract 1988;27:595-599.
    (3) O’Driscoll K, Foley M, MacDonald D.  Active management of labor as an alternative to cesarean section for dystocia. Obstet Gynecol 1984;63:485-490.
    (4) Tussing AD, Wojtowycz MA.  Health maintenance organizations, independent practice associations, and cesarean section rates. Health Serv Res 1994;29:75-93.
    (5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care. J Fam Pract 1991;33:281-292.
    (6) Cibils LA.  On intrapartum fetal monitoring. Am J Obstet Gynecol 1996;174:1382-9.
    (7) Paneth N, Bommarito M, Stricker J.  Electronic fetal monitoring and later outcome. Clin Invest Med 1993, Apr 16:159-65
    (8) Rosen MG, Dickinson JC.  The paradox of electronic fetal monitoring: more data may not enable us to predict or prevent infant neurologic morbidity. Am J Obstet Gynecol 1993;168:745-51.
    (9) Sandmire HF.  Whither electronic fetal monitoring? Obstet Gynecol 1990;76:1130-4.
    (10) Snydal SH.  Responses of laboring women to fetal heart rate monitoring. A critical review of the literature. J Nurse Midwifery 1988;33:208-16
    (11) Prentice A, Lind T.  Fetal heart rate monitoring during labour–too frequent intervention, too little benefit? Lancet 1987;2(8572):1375-7.
    (12) Neilson JP. EFM vs intermittent auscultation in labour. [revised 04 May 1994] In: Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995. Available from BMJ Publishing Group, London.
    (13) Scherger JE.  Management of normal labor and birth. Primary Care 1993;20:713-719.
    (14) Horton R.  Unnecessary caesarean sections in USA. Lancet 1994;343:1351-2.
    (15) Paul RH.  Toward fewer cesarean sections: the role of the trial of labor (editorial). NEJM 1996;335:735-6.
    (16) Lumley J, Astbury J.  Birth rites, birth rights.  Sphere Books, 1980.
    (17) Young D. Crisis in obstetrics – the management of labor. Int J Childbirth Education 1987, August: 13-5.
    (18) Sakala C.  Medically unnecessary cesarean section births: introduction to a symposium. Soc Sci Med 1993;37:1177-98.
    (19) Sakala C.  Midwifery care and out-of-hospital birth settings: how do they reduce unnecessary cesarean section births? Soc Sci Med 1993;37:1233-50.
    (20) LoCicero AK.  Explaining excessive rates of cesareans and other childbirth interventions: contributions from contemporary theories of gender and psychosocial development. Soc Sci Med 1993;37:1261-9.
    (21) Burns LR, Geller SE, Wholey DR.  The effect of physician factors on the cesarean section decision. Med Care 1995;33:365-82.
    (22) Goyert BL, Bottoms SF, Treadwell MC.  The physician factor in cesarean birth rates. N Eng J Med 1989;320:706-9.
    (23) McCloskey L, Pettitti DB, Hobel CJ.  Variations in the use of cesarean delivery for dystocia: lessons about the source of care. Med Care 1992;30:126-35.
    (24) Placek PJ, Taffel SM. Recent patterns in cesarean delivery in the United States. Obstet Gynecol Clin North Am 1988;15:607-27.
    (25) Farrell SJ, Anderson HP, Work BA. Cesarean section: indications and postoperative mortality. Obstet Gynecol 1980;56:696-700.

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