How to Keep Normal Labor Normal – Part 7 – Procedures

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. 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 fifth “P” of my 10 “P’s” of keeping labor shorter and birth safer — procedures.

A primary dictum of ethical medical care is to not cause harm. Therefore, increased evidence of outcome or evidence based decision making is clear in the literature. “While enthusiasm for … evidence-based medicine is growing, several barriers … persist.”(67)

One of the best discourses on this topic merits repeating:

“First, ‘seduction by authority’ has reigned for centuries. Decisions about a new technology must be based on the weight of the scientific evidence, not on the perceived prestige of its proponent, as occurred … with electronic fetal monitoring.”

“A second impediment is the ‘false idol of technology.’ Many American physicians not only accept new technology without critical appraisal, but they also seem to worship it. Some of this penchant for mew gadgets and procedures relates to the fundamental problem of physicians’ being paid for doing things to patients, rather than for keeping them well … Awareness is now growing, that doing things to patients … may actually make them sick — as well as poor.”

“A third hurdle is the inevitable tendency to let sleeping dogmas lie.  That routine episiotomy for delivery has prevailed for over a half century without critical assessment and that widespread electronic fetal monitoring continues, despite recent studies, reflect the inertia that drives medical practice.”

“A fourth problem is the pursuit of pedantry in medical education.  As noted by Pickering, medical education in the United States is, to a large extent, worship at the improbable shrine of useless information.  We produce ‘scientific illiterates’ who are filled like an overstuffed sofa with the products of science, but who are not scientific in their approach to clinical questions or new technologies.”

“A fifth stubborn problem is the paradigm of clinical practice: numerators in search of a denominator.  Many of us practice medicine by the last disaster we encountered — or heard about.”

“Doing everything for everyone is neither tenable nor desirable.  What is done should be inspired by compassion and guided by science … As physicians, we are ethically bound to be sure that the tests, procedures, and treatments we provide are worth the money, pain, and inconvenience that they cost. The methods to assess technologies are well accepted and widely available; what remains to be seen is whether we as a profession and a nation have the moral courage to use them”(67)

It would appear that physicians involved in maternity care for the last 60 years have been guilty, in large part of many if not all of the above charges. The current debates about continuous EFM and routine episiotomy occupy a fair amount of literature debate.

Routine episiotomy

Routine episiotomies are still performed by the majority of obstetrician-gynecologists, but the practice has been increasingly criticized.

One critical review says that, “routine episiotomy for uncomplicated spontaneous vertex vaginal deliveries is not indicated.”(5)

The first North American randomized controlled trial on episiotomy reported that “there is no evidence that liberal or routine episiotomy prevents perineal trauma or pelvic floor relaxation. Virtually all severe perineal trauma was associated with median episiotomy. It is our recommendation that liberal or routine use of episiotomy be abandoned.”(68)

Of interest is the suggestion that “(there is) an intriguing association between episiotomy utilization and other procedures and management style.”(40)

“The question, ‘Do you routinely perform episiotomies?’, if answered in the affirmative, is highly predictive of providers who routinely perform a variety of interventions (whether indicated or not), who have ‘high-control,’ ‘medical model,’ or ‘maximin approach’ labor philosophies, and who have higher rates of cesarean birth secondary to ‘dystocia’ ”(69) and “… we have determined that physicians who use episiotomy frequently and routinely often do so as part of an interventionalistic pattern or style of practice.”(40)

Interestingly, this interventionalistic style resulted in patients who “… experienced less satisfaction with the birth experience (p<0.01) than the patients of physicians who viewed the procedure very unfavorably.”(40)  This observation, if valid, would also support the “first P” of the provider’s philosophy.

Routine continuous electronic fetal monitoring

The critical reviews, editorials, and comments on continuous EFM exist in the writings both of those who support and oppose routine obstetrical intervention.

The latter group appreciates comments such as those attributed to one of the first developers of fetal monitoring, Edward Hon, M.D., “Not all women should be electronically monitored … most women in labor are better off at home than in the hospital with a fetal monitor … Most obstetricians don’t understand the monitor. They’re dropping the knife with each drop in the fetal heart rate. The cesarean section is considered as a rescue mission of the baby by the white knight, but actually you’ve assaulted the mother.”(29)

Less polemic comments, however, equally encourage physicians interested in keeping normal labor normal to consider avoiding the monitor:

“Routine EFM has not been shown to improve perinatal outcomes. There is an association between routine EFM and an increased frequency of cesarean sections.  Periodic auscultation is at least as effective as EFM in detecting fetal distress in otherwise low-risk women and promotes greater patient-provider contact.”(5)

Another review suggests that “if an unnecessary cesarean section is considered a morbidity outcome of labor, then continuous electronic monitoring is contraindicated in normal patients.”(13)

Recently a protocol to help maternity caregivers increase their rate on intermittent auscultation (thus attempting to increase the rate of “normal labor”).(71)

A reasonable summary of the issue of avoiding routine or potentially unnecessary procedures or interventions was found in one critical review which encouraged providers of maternity care to “… critically assess the effects of each medical practice or procedure on the childbearing family’s comfort and sense of mastery, as well as on their safety. Aspects of care for which safety benefits are small or unproved should remain subject to the choices and preferences of the woman giving birth.”(5)

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:

(5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care.   J Fam Pract 1991;33:281-292.
(13) Scherger JE.  Management of normal labor and birth.  Primary Care 1993;20:713-719.
(29) Hon, E. In: Young D. Crisis in obstetrics-the management of labor. Int J Childbirth Education 1987, August: 13-5.
(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.
(67) Grimes DA.  Technology follies: the uncritical acceptance of medical innovation.  J Am Med Assoc 1993;269:3030-3033.
(68) Klein MC, Gauthier RJ, Jorgensen SH.  Does episiotomy prevent perineal trauma and pelvic floor relaxation?  [article].  Online J Curr Clin Trials [serial online] 1992 Jul 1;1992(Doc No 10).
(69) Klein MC.  Personal communication.
(70) Cohen, W.  In: Young D. Crisis in obstetrics – the management of labor. Int J Childbirth Education 1987, August: 13-5.
(71) Sandmire HF, DeMott RK.  Auscultation of the fetal heart presents advantages over electronic monitoring.  Wis Med J 1995;94:661-3.