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Friday, April 1, 2011

Medical quackery in "modern" obstetrics

As a jumping off point from my last post (which would have been hideously long had I combined the two), I was left wondering how questionable medical practices and "quackery" could possibly relate to obstetrics. Obviously it wasn't all that hard.

No one's denying that a lot of advancements have been made in modern medicine, including obstetrics - mostly with monitoring devices, like ultrasound, fetal monitoring and the like. Mostly they have likely increased the survival rate of sickly, premature babies and those with major medical conditions that would have claimed their lives even a few decades ago. The surgery they can do before birth for spina bifida, for instance, is nothing short of mind-boggling, and technology that definitely benefits - if you need it.

But consider for a moment that the majority of the pregnant population is not at that great of risk. It often reminds me of the phrase, "Innocent until proven guilty." In the case of modern obstetrics, it's often the way around. As Marsden Wagner has often said, in modern obstetrics physicians often see pregnancy and birth not as a normal process, but as a disaster waiting to happen.

As a result, everyone is treated the same - with more technology and drugs, some of which is either providing dubious efficacy at best, or may create more harm than good. Some questionable obstetrical quackery might include:

• Ultrasounds. Many question their safety, ultimately, and claim they generate excess heat and sound, which is transmitted directly to the unborn child. At any rate, even those who say they are safe agree that using it too much is probably not a good idea. While used diagnostically, like in the case of an unborn baby with spina bifida, they can detect conditions that can now be treated before birth so as to greatly improve outcomes. (For the record, the Spina Bifida Assocation says that it occurs roughly in 7 out of every 10,000 births.)

I often hear about women who get numerous ultrasounds, sometimes almost at every appointment. Some are given transvaginal ultrasounds for dating purposes in early pregnancy, even though they already know their last menstrual period and even their date of conception (which really isn't that hard for some of us, contrary to popular belief). In all of my pregnancies, I probably have had no fewer than three each time, some of which for legitimate reasons (unexplained vaginal bleeding) and to "re-check" for clubfoot (not life-threatening the least).

• Pushing in the lithotomy position, or flat on your back. Really it depends on the situation, as there are very few times when this position is beneficial. For the rest of those times, it makes it harder to birth your baby, and is convenient only for the physician, so he can get a head-on view of the baby crowning.

Somewhere I've read that culturally, women did not give birth flat on their backs until male practitioners took over the in field; before they often gave birth on birthing stools with female midwives. It actually creates a more narrow pelvic opening, which can often translate into a stalled vaginal delivery and a cesarean. For decades, if not centuries, this is the most typical mode of birth, which is likely what has negatively shaped many people's ideas about birth to this day.

• Episiotomies for everyone! Although not quite as popular as they used to be, they are still routinely performed even without much need. Which makes me wonder just how many doctors no longer routinely perform this procedure, if I'm still hearing about women getting them all the time?

It appears that the biggest benefit from them is that it speeds delivery, and God knows that mostly-impatient OB's are all about that. Because an extra half an hour or so to wait for the baby to come down on its own is just too much to ask.

Continuous electronic fetal monitoring. While it seemed like a good idea at the time, fetal monitoring has become the standard of care in hospitals when determining if your baby is in distress or not. Too bad it more often than not falsely identifies babies in distress when they really aren't, which often leads to cesareans for no reason. Conversely, while it was originally invented to detect cases of cerebral palsy, it can't seem to accurately predict that, either. ("The false positive rate of EFM for predicting cerebral palsy is greater than 99 percent.") Yet it's used, continuously, on a majority of laboring women.

Not only does the strip alone falsely predict when a baby is truly in distress, but you are essentially confined to bed because of the monitor, which is another risk factor for cesarean. Interestingly enough, if true distress is suspected, they can break your water and insert a fetal monitor on the baby's head, which can also lead to cesarean (once the water is broken).

• Repeated vaginal exams will tell you something important. I referenced this in another post. If your doctor tells you that he really needs to do one to determine your "progress" or lack thereof, you might want to reconsider. At the very least, ask him or her point blank "What is this exam going to tell me? Why is it needed?" One woman I heard from asked her doctor this and he sheepishly replied that it basically told him "nothing."

• Being deprived of food and fluids in labor. Although some hospitals are doing away with this policy, not all are jumping on the bandwagon. Based on an archaic study done in the 1940s, it was determined that if you ate anything in labor, it could cause you to aspirate the stomach contents should you need general anesthesia. Sadly, as a result, women are also being deprived of much-needed calories and energy that they could use to endure long labors.

• A crazy high induction rate. Compare, if you will, the medically-indicated induction for a high-risk mother to chemo for the cancer patient: yes, the cancer patient would likely benefit from chemo and radiation, and it should be carried out posthaste. Likewise, if you truly need to be induced for a good reason, which does not include "baby too big," "fluid too low," or "I need a vacation and you're sick of being pregnant." In those circumstances, inducing without clear medical need is like using that radioactive toothpaste I mentioned in my last post - it might not sound harmful at first, but could potentially create serious risks and complications down the road (like longer, harder, more difficult labor or a cesarean).

• A crazy high cesarean rate. For pretty much the same reasons above - no one is arguing that sometimes, cesarean really is the best option. However, how many women that make up that 32 percent c-section rate are led to believe there is no other choice? Or that VBAC is too dangerous for them? What percentage truly electively choose cesarean for no reason? When you hear about things like "Patient choice" when it comes to c-sections, you really need to look individually at the women who are "choosing" these procedures and why: "because my doctor said so" (end of story), "Because my doctor told me my uterus could shatter!" and "My baby was getting too big, so we decided to deliver by cesarean," or "I was told it was dangerous to go past 40 weeks, so we decided to induce and it ended in cesarean." Until you ask women themselves what their prenatal care was like leading up to the c-section (like, did they include "My doctor brought up inductions at every office visit from 32 weeks on," words like "patient choice" don't mean very much.

• Discouraging natural, normal birth. Again, many people treat birth like an accident waiting to happen, instead of "normal until proven otherwise." You may find that in spite of all our "risk factors," things can and often do go well, if only allowed to. Boxing women into a category that defines them as "risky" is less like acknowledging that something could happen because of these factors, and more saying, "It will happen." Unless you see a crystal ball on your doctor's desk, (or there is some clearly defined, proven medical condition going on) tread lightly.

Many doctors scoff at natural birth because they either haven't attended one, or think that because 90 percent of all their other laboring patients are medicated to the gills that you should be, too. They also dismiss it because they either don't realize or don't want you to realize that often times, the midwifery model of care can mean less intervention and fewer cesareans.

While technology can be a life-saving thing, it becomes more of a risk when used incorrectly or too often. It's for this reason, that even with all the modern drugs and technology that we have, that the US continues to have an alarmingly high rate of neonatal deaths for an industrialized nation.

More reading:
Obstetrical Myths - Henci Goer


Enjoy Birth said...

Thanks for this great review of all the things moms don't HAVE to do! It is so important moms know this.

MamaL said...

Though a lot of research, I found out that many "elective" c-sections are incorrectly labeled as such when the woman was actually told that her baby was in danger and rushed to the OR.

That's not elective and labeling it as such has majorly skewed the statistics.