Ignoring medical evidence and studies seems to be what modern obstetrics does best.  I rant quite often about the blatant misuse of medical tests and procedures that are used during pregnancy and childbirth. It drives me crazy that so many people are blind to the fact that the vast majority of medical interventions used during labour and birth not only do NOT help, they many times facilitate problems and end up cascading into a waterfall of more interventions.  Worse is the fact that most of these interventions are PROVEN to either NOT work to the benefit of the labouring mother and/or her baby and yet they are still the daily special on the menus of the vast majority of hospitals in North America!

WHY?! 

Do not think that just because YOUR doctor does it "this way" or your hospital has standard procedures that they follow that they are right or that they are to the benefit of you and your baby.  We are living in a society that is forcing us to do our own research and make decisions that are the best for ourselves and our babies. We cannot afford to blindly trust in the omnipotent medical professionals to know whats best or right or even safe, because it's a proven fact that modern obstetrics is ignoring the evidence and just blithly doing whatever they want- be it from blindly following tradition, lack of study into new research, or driven by the need to make more money: because lets face it- a truly natural childbirth costs a fraction of one that's full of medical procedures and drugs and equipment.

Where’s The Evidence? 10 Ways Modern Obstetrics Ignores Evidence

I was recently both amused and not surprised to read a comment written by a physician who was disparaging midwives for their lack of scientific research and evidence-based practice.  The physician wrote:

“Modern obstetrics, in contrast, has always been, and continues to be based on scientific research.”

I will be one of the first to admit that midwives have been guilty of poor interpretation of statistics, embracing various clinical practices and promoting them as if they were evidence based when in reality they are not, and recommending things to their clients for which they have no evidence of benefit.  A clear example of this is the many midwives who still recommend evening primrose oil (EPO) to their clients in order to “ripen” the cervix, even though study after study has cast doubt upon EPO’s efficacy.
But what about the physician’s comment that modern obstetrics is based on science?  Could this be a case of the Emperor that has no clothes?  Modern obstetrics is riddled with accepted procedures that demonstrate how wide the gap is between practice and evidence.

• Inductions/elective c-sections for suspected macrosomia (big baby): I can’t count the times that I have had a patient put on my schedule for induction or elective c-section because the OB thinks her baby is getting big.  The best evidence shows that early induction or elective c-section have not improved outcomes for these babies, and may carry greater risk of complications.  Evidence, please?
• Pitocin to speed labor: Although evidence shows that pitocin given without indication of medical need is not beneficial and may increase fetal distress and/or risk of c-section, it continues to be widely used for any (or no) reason.  What science supports this practice?
• Amniotomy to speed labor: In my practice, I am almost always called by the nurse at some point early in the woman’s labor to “come and pop her bag and get this baby out”.  Despite the clear evidence that amniotomy does not significantly speed labor, and carries with it a risk of infection and increased fetal intolerance of labor, this practice is nearly universally performed on laboring women.  How is this based on science?
• Continuous electronic fetal monitoring. Another “sacred cow” of obstetrics that is not evidence based.  For low and moderate risk labors, intermittent monitoring has been shown to have outcomes as good as with continuous monitoring, without the increased rate of c-section associated with continuous monitoring.  Where’s the evidence?
• Requirement of “immediate” emergency services for women attempting a VBAC. Although the NIH states there is little evidence to support this recommendation, it continues to be the standard practice.  The effect of this policy is to create barriers to VBAC availability for many women.  Every OB I talk to about this problem admits there is not adequate evidence for this requirement, but seems at a loss (or doesn’t care) what to do about it.  What science is this continued practice based upon?
• Episiotomy: Still practiced by physicians in as many as 20% of births.  This procedure was taught for years as an essential to reducing pelvic floor problems in women later in life.  Only in the last few years has science supported what midwives have always practiced–avoiding episiotomy unless it is necessary to get the baby out quickly.  If modern obstetrics is always based on science and evidence, why do we get these polar opposite policies?
• Routine ultrasound to estimate fetal size: Although we know late term ultrasounds are very inaccurate in estimation of fetal weight, obstetricians continue to order them.  Where is the evidence for this practice?
• Immediate cord clamping: Most physicians I discuss this with will agree the evidence shows benefit of avoiding immediate cord clamping, but it is a hassle and takes a few minutes more.  They largely feel that it just doesn’t matter that much.  What science are they basing this opinon on?
• Directed (purple) pushing: In spite of clear evidence of benefit of spontaneous pushing, most doctors and nurses are still using the old “hold your breath and count to ten” method of pushing.  Most are aware of the evidence, but state they “feel” like more progress is being made when the mother is pushing long and hard.  Is modern obstetrics based on fact or feelings?
• Supine Pushing: Perhaps one of the best-documented practices in modern obstetrics is supine pushing.  This is a practice which has absolutely no evidence of benefit and plenty evidence of potential harm.  Yet almost every OB I know routinely delivers his/her patients in the supine position.  Why?

An organization which flip-flops as drastically as the American Congress of Obstetricians and Gynecologists (ACOG) did this year, in its dramatic loosening of VBAC guidelines, is hard pressed to defend the statement that their practices are evidence-based.   Did we suddenly discover new science that told us the woman who was refused a VBAC early in 2010 on the grounds that she was risking death to her baby and herself, is now out of danger and can safely attempt a VBAC?  Where is this amazing new information that ACOG discovered?
In my next post, I will be discussing the problem of evidence and how the average woman can decipher the myriad of conflicting information.

 HERE to read the original article on Birth Sense

For more information on medical interventions that are unnecessary in the vast majority of births, please read:

Conspiracy of Labour: Electronic Foetal Monitoring

"Canada’s reputation for low infant mortality takes stunning decline"

"In Defense of the Amniotic sac"

"Technology in Birth: First do no Harm"

Everything you NEED to know about pitocin!!

 

 

 

 

 

Conspiracy of Labour: Electronic Foetal Monitoring

Call it a moment of clarity. Call it an abrupt insight. Call it a grand conspiracy theory (of which I have many.... but that's another- many other- rants). It hit me all at once while I was in labour with Kael last month, though I forgot about it until this week.

Now I'm not a doctor or a scientist, so I don't have any insider information on this- but if there is a logical reason that I'm missing, please feel free to let me in on the secret.

WHY are Electronic Foetal Monitors (EFM) so ridiculously cumbersome and antiquated?

I was hooked up to one of those damn monitors when I was in labour almost 19 years ago with my eldest son- two palm sized clunky disks that have to be held against your pregnant contracting belly by two stretchy elastic belts and hooked up to a tangle of wires that lead to a metal box covered with dials and switches that pukes out a continuous strip of graph paper. (and possibly goes "ping"). I remember even back then thinking "this is ridiculous!!". Imagine my surprise when I went into the hospital last month while in labour with my youngest son only to discover that they had the same monitor!! I Swear!! It was exactly the same! Still ridiculously uncomfortable and stupidly designed...

Why?

No, really: WHY?!

Think about it:

-19 years ago Cellular phones were the size of tissue boxes. Now they are so small that they get lost in your pocket

-19 years ago Computers were monstrosities with 300MB of memory. Now we have cell phones that have 32GBs and still can get lost in your pocket. Hell! You can go to your corner electronics shop and buy a 1 TB external hard drive for less than you paid for a Sony Diskman back in 1991!!

-19 years ago if you got lost while out driving you had the choice of stopping and asking for directions or buying a map book the size of a small encyclopaedia. Now you have the choice of pressing the On Star button, or following the GPS on your dash board, punching the address into your GPS app. in your smartphone, or looking it up on Google maps on your laptop.

...Do you see where I'm going with this?

Technology in the last two decades has advanced in leaps and bounds in every industry known on this planet. So why has one of the most basic medical contraptions used in one of the busiest hospital departments has never even gotten a cosmetic make over, let alone a technological facelift? Even tongue depressors have been gussied up with flavours and colours!!

Here is where the conspiracy theory comes in. The only reason (that I can see) for the foetal monitoring system to of resisted any form of change is because.....

....Doctors and hospitals don't want it to change. Why would they? It completely works in their favour. Since science has already proven without a shadow of a doubt that EFM is not only NOT saving the lives of babies or mothers, and that it's actually causing more harm than good in 90% of labours, then we need to ask ourselves WHY it's still the regular procedure in every L&D ward in North America. Here are my thoughts on the subject.

Electronic Foetal Monitoring is used because:

- It keeps the labouring mother strapped to a bed. If she's tied up in a tangle of wires and straps, then she can't be wandering around the labour ward, can't be moving around to be comfortable and to assume positions that will ease her labour surges and facilitate an easier birth. No, it simply makes the lives of medical staff easier, by immobilizing the mother.

-If the mother is strapped to a bed and tied to this electronic monitor, then the hospital doesn't need to assign a nurse or birthing attendant to watch over her and take care of her and reassure her- why would they? They have the all powerful all omnipotent EFM there keeping track of every little bleep!

- If the mothers entire labour has been recorded on the EFM then the hospital and doctors have a permanent record of every second of the labour and something they can refer to in a court of law... that they can point to, to defend their need to interfere with medical interventions. The fact that these blips and bleeps can be interpreted anyway they want doesn't really matter... apparently.

- and of course the use of EFM makes lots of money for the medical machine!!! As the studies have shown for years, the more the EFM is routinely used, the more medical interventions are used, and the more interventions that are used, require the use of even further interventions to support and remedy the problems caused by the first interventions to begin with...which all costs money... lots and lots of money.

Apparently some knowledgeable people agree with me.

Margaret Lent wrote in her article entitled: The Medical and Legal Risks of the Electronic Fetal Monitor- Journal article, Stanford Law Review, Vol. 51, 1999

"The story of electronic foetal heart monitoring (EFM) reveals the problems posed to physicians and patients by the hasty acceptance of relatively unproven devices and techniques. When EFM was introduced in the 1960s, enthusiastic advocates promised that by enabling the continuous, electronic monitoring of the fetal heart rate during labor and delivery, EFM would enable physicians to detect dangerous heart rate patterns and to intervene more promptly than with intermittent auscultation, the long-employed technique of periodically monitoring fetal heart rate with an obstetrical stethoscope. Thus, announced EFM proponents, the device would reduce rates of neonatal illness and death. Based on these promises, EFM became the predominant form of fetal heart monitoring by the mid- to late 1970s.(1) However, experts now conclude that these promises remain unfulfilled and that EFM is, at best, a "disappointing story."(2) In the twenty-five years of its almost ubiquitous use, no randomized controlled trial has demonstrated that electronic monitoring does a better job of saving babies or improving infant health than intermittent auscultation.(3) Moreover, studies indicate that the inaccuracy of the technique prompts unnecessary interventions and contributes to the nation's excessively high rate of cesarean delivery, a major surgical procedure which places mother and infant at greater risk of injury and death than noncesarean delivery.(4) Despite the increased risks, the device remains employed in nearly all American delivery rooms. Continued high use of EFM is often attributed to physician concerns about medical malpractice liability and professional inertia. As one EFM critic has observed: "[Doctors] talk about [abandoning EFM] at conferences and at [medical] rounds and listen intently and all of that, but it's not measurable in terms of changes in behavior. Everybody's waiting for the next person to get brave."(5)""

And one of my personal heroes, Dr. Marsden Wagner- former Director of Women & Childrens Health for the World Health Organization (WHO) writes this in his article "Technology in Birth: First Do No Harm"

"There are other cascades of interventions during labour. For example, routine electronic foetal monitoring leads to more caesarean sections, which lead to babies with respiratory distress syndrome or prematurity, which leads to putting these babies into newborn intensive care units. Every one of these interventions carries risks for mother and baby! It is easy to see how the high-tec approach to birth actually creates many new problems. Rather than change their habits, however, doctors conclude that birth is quite risky, when in reality doctors have caused it to be risky....Doctors' fear of litigation is another non-medical motivation for using technology. Doctors are afraid both of having to go to court and of having to pay higher malpractice insurance premiums. Two prime examples of the unnecessary use of technology due to doctors' fear of litigation are routine electronic foetal monitoring during normal labour and caesarean section with little or no medical justification."

So, why would they change it? Why would they create a better, more reliable, less dangerous way of monitoring babies and labouring mothers? If they did, they'd loose. If they did, then maybe the public would realized that they have been duped for years and years and MAYBE the same public would demand an accounting of all the problems the medical machine has caused with their ridiculous toy. Better to stick to their guns and pretend that the problem doesn't exist. Besides.... who's going to question the all powerful all mighty medical machine? I mean, they only have our best interests at heart, right?