Jan 14 2010
Is breech vaginal delivery safe?
Between 3-4% of babies begin labor in the breech (bottom first) position, increasing the risk of neonatal morbidity and mortality. Pre-emptive C-section has become the preferred method of delivery for breech babies, but now some are questioning this recommendation. The controversy is fueled by differing appraisals of the danger and by differing assessments of the whether any risk of neonatal death can be justified in the age of the safe Cesarean.
The best conducted and most important study comparing breech vaginal delivery with elective C-section is the Term Breech Trial (TBT) conducted by Mary Hannah and colleagues. It is the only randomized control trial of its kind.
… [W]e found that the fetuses of women allocated planned caesarean section were significantly less likely to die or to experience poor outcomes in the immediate neonatal period than the fetuses of women allocated planned vaginal birth. Although some of the deaths in the planned vaginal birth group were related to difficulty with vaginal breech delivery, others were clearly associated with problems during labour. Thus the avoidance of labour and vaginal breech delivery could have contributed to better outcomes with planned caesarean section…
A more recent trial, the PREMODA (PREsentation et MODe d’Accouchement: presentation and mode of delivery) study produced different findings and as a result, some obstetricians have been calling for a re-evaluation of the standard recommendation for C-section delivery of a breech baby.
The groups [planned vaginal delivery vs. planned C-section] did not differ significantly for the combined outcome of fetal or neonatal mortality or serious morbidity (odds ratio [OR] = 1.10, 95% CI [0.75-1.61]. Of the criteria included in this combined variable, only a 5-minute Apgar score less than 4 was significantly more frequent in the planned vaginal group (n = 4 vs n = 1, OR = 8.9, 95% CI [1.00-79.8]). Of the other individual outcomes, the following were significantly more frequent in the planned vaginal than in the planned cesarean group: 5-minute Apgar score less than 7 (OR = 3.2, 95% CI [1.9-5.3]), total injuries (OR = 3.9, 95% CI [2.4-6.3]), and intubation (OR = 1.8, 95% CI [1.08-3.1]).
The authors of the PREMODA study acknowledge that their trial was not randomized and that the results must applied with caution. Nonetheless, the authors concluded:
In centers where planned vaginal delivery remains a widespread practice and in complying with rigorous conditions before and during labor, we did not find a significant excess risk associated with planned vaginal delivery compared with planned cesarean for women with a singleton fetus in breech presentation at term. There may be a slightly higher neonatal risk associated with planned vaginal delivery but it is very different from that reported in the only published large randomized trial….
In light of the PREMODA study, some obstetricians have been calling for a return to breech vaginal delivery. The NNT to prevent neonatal death from breech is 111. That translates to 110 unnecessary (in retrospect) C-sections for every baby saved. What are the risks of those C-sections? They include hemorrhage, transfusion and possible hysterectomy. Maternal mortality after elective C-section is so rare that many contemporary studies of C-section focus exclusively on morbidity.
So why not simply explain the controversy to patients, as well as the differing findings and let them choose? Putting aside the issue of the magnitude of the risk, are patients capable of giving informed consent to a procedure that will, if widely offered, lead to preventable neonatal deaths? Obviously consent ultimately rests with the patient, but can it be truly informed consent?
Let’s assume for the moment that The Term Breech Trial is correct and the excess risk of neonatal mortality in breech vaginal delivery is 9/1000. That sounds like a small number and many women will reason that the number is so small that they need not worry that their babies will die.
However, 9/1000 means that approximately 9 babies per 1000 WILL die. In the US approximately 140,000 babies each year present as breech at the onset of labor. Not all will meet the eligibility criteria for vaginal delivery (approximately 35% of breech babies are in an unfavorable position for vaginal delivery, and others will exceed the weight criteria or have other contraindications), but even if only half were eligible, that would mean 70,000 attempted breech vaginal deliveries. At an excess rate of neonatal mortality of 9/1000, we could expect that 630 babies would die from preventable neonatal deaths each year.
This is a relatively small number. Indeed, it would barely impact overall neonatal mortality figures (approximately 18,000 neonatal deaths per year), since the bulk of neonatal mortality is due to prematurity and congenital anomalies. On the other hand, that is quadruple the number of deaths we would expect in an otherwise low risk group. Most importantly, that number represents 630 sets of bereaved parents who would have had a healthy baby had they opted for elective C-section. Would those parents accept a preventable death philosophically, or would they be shocked and bewildered that the baby actually died? Would they simply try again or will they look for someone to blame?
Can the excess risk of neonatal mortality can be reduced somewhat by making the eligibility criteria more strict as the authors of the PREMODA study suggest? Only a randomized trial can provide that information, and unless the excess neonatal mortality rate could be reduced dramatically, we would still anticipate the preventable death of hundreds of babies per year.
C-section is not a trivial procedure, but it is an extremely safe surgery, reducing risk to the baby and only slightly elevating risk to the mother. Even though the risk of breech vaginal delivery is small, the outcome can be catastrophic. A lot of unnecessary (in retrospect) C-sections are being done. Do we think that is too high a price to pay to save several hundred babies each year?
184 Responses to “Is breech vaginal delivery safe?”
It sounds wrong.
Surely it should be “vaginal breech delivery”.
I googled it:
“breech vaginal delivery”: 156,000 hits
“vaginal breech delivery”: 404,000 hits
Also your first quote contains “vaginal breech delivery” twice
I win.
But seriously….
There are two questions here:
1) Can mothers really give informed consent?
2) How should you present the information.
I think these two questions are related.
If the information is presented in the wrong way, the legitimacy of the informed consent will be compromised.
Telling the mother that every year 630 mothers in America who choose vaginal instead of C-section in her circumstances end up with a dead baby would be the wrong way to present the information.
Telling the mother that if she chooses vaginal delivery there is a 110 in 111 chance that her baby will survive and a 1 in 111 chance that her baby will not survive would be the correct way to present the information.
The risks of C-section would need to be put in similar terms for her to make a proper risk-benefit assessment.
Finally, if the patient defers to the obstetrician’s opinion, the obstetrician must be ready and prepared to offer her advice.
So, Dr. Amy, what would you advise your patient in this scenario?
“There are two questions here:”
There are a few more. The threshold questions are:
1. What is the true magnitude of the additional risk? (I lean in the direction of the Hannah study showing excess risk in the range of 9/1000).
2. What is the real world risk? It’s possibly even higher because the both studies were conducted in conditions that would be difficult to recreate in the real world, and because even the strictest criteria depend on subjective estimates like fetal weight.
“Telling the mother that every year 630 mothers in America who choose vaginal instead of C-section in her circumstances end up with a dead baby would be the wrong way to present the information.
Telling the mother that if she chooses vaginal delivery there is a 110 in 111 chance that her baby will survive and a 1 in 111 chance that her baby will not survive would be the correct way to present the information.”
I strongly disagree. The information should be presented BOTH ways.
The goal of informed consent is that the information be presented in a way that the patient can understanding the options she has before her.
Telling the mother that 110/111 C-sections will be unnecessary is important, but telling the mother that 630 babies WILL die and that one of those babies might be hers is equally important.
As a general matter, lay people have trouble quantifying risk. They often conclude that low risk is the same as no risk, and that is entirely untrue. It is critically important that a mother choosing a very real, though low risk of neonatal death understands that the baby really could die.
In areas where C-sections are already routine, there may be nobody experienced in delivering breech babies vaginally, while other areas may have much more experience. I imagine that the degree of experience that obstetricians or midwives have with vaginal delivery of breech babies would have a significant impact on outcomes. Could this be a factor in the difference between the two studies cited above? (If so, that would complicate any attempt to merge them in a meta-analysis.)
If the difference is largely due to practitioner experience, the next question is this: Do we spend money trying to give people expertise in vaginal breech deliveries (in order to facilitate patient choice), or do we spend that money making C-sections as safe as possible?
“Could this be a factor in the difference between the two studies cited above?”
No, all the births in both studies were attended by providers experienced in delivering breech babies.
An uncomplicated breech vaginal delivery requires very little experience. The provider should support the bottom of the baby (so it won’t hand down between the mother’s legs) and let the mother’s body do all the work. Experience is only necessary when the head does not deliver spontaneously and the baby’s life is in danger. Even then, if there is a significant mismatch between the size of the baby’s head and the largest diameter of the mother’s bony pelvis, the baby will be long dead before it has been freed.
“Do we spend money trying to give people expertise in vaginal breech deliveries ”
The issue is not money. The issue is a mother’s willing to have a vaginal breech delivery. You can’t get experience unless you attend a fair number of breech deliveries with serious complications. But every one of those babies is at significant risk of dying and some definitely will die. How many infant lives is it acceptable to sacrifice in order to reduce the number of C-sections?
“Telling the mother that 110/111 C-sections will be unnecessary is important, but telling the mother that 630 babies WILL die and that one of those babies might be hers is equally important.”
That’s not exactly what I said though.
I said that the correct way to deliver the information is to tell her that there is a 110 in 111 chance that her baby will survive and a 1 in 111 chance that her baby will not survive.
She needs to know the risk to her child right?
How does telling her that there is a 1 in 111 chance of her child not surviving not accurately convey that risk?
Seems to me that saying 630 babies will die and that one of them may be hers is a way of almost guaranteeing that she’ll opt for the C-section.
I imagine there must be situations when the mother is unable to decide and defers to your opinion. What would you recommend in that situation?
“Seems to me that saying 630 babies will die and that one of them may be hers is a way of almost guaranteeing that she’ll opt for the C-section.”
But isn’t that the truth? Doesn’t she need to understand that 630 babies will die and one of them really might be hers?
“I imagine there must be situations when the mother is unable to decide and defers to your opinion. What would you recommend in that situation?”
It rarely happened when I was practicing. Most women immediately opted for a C-section. But if there is any doubt, I would want to be absolutely, completely sure that the mother understood the fact that some babies will die and that one of them could be hers.
Most women simply cannot fathom the idea of a healthy baby dying in childbirth. It is so rare nowadays that women have never seen it and may have never heard of it. Then when it happens, mothers are shocked and outraged; they never envisioned it as a real possibility.
“Putting aside the issue of the magnitude of the risk, are patients capable of giving informed consent to a procedure that will, if widely offered, lead to preventable neonatal deaths?”
Why would patients not be capable of giving informed consent? Patients give consent every day to procedures that are far more arcane than C-sections.
And how can one “put aside the issue of the magnitude of the risk” is assessing whether or not to give consent?
The primary difficulty, it seems to me, is weighing the risk of neonatlal mortality versus maternal morbidity when choosing section.
I also question how the French study reported the neonatal outcomes of failed vaginal deliveries. If the baby was in sufficient distress during vaginal to require emergency section and subsequently expired, I suspect that the French (results simply reported by mail) study would count that as a C-section mortality thereby giving a quite distorted picture as the baby might well have lived had the section been elective.
What about other complications for breech? I mean, what would scare me away from a c/s is the sutures/staples, recovery time, etc. That would factor heavily in my decision. I don’t mean that to imply that my comfort takes precedence over a dead baby…..but I would hate for women to opt for the vaginal breech, thinking that the recovery will be as easy as a traditional vaginal delivery, when in fact there may be additional risks such as severe tears, greater chance for uterine/bladder prolapse, etc. What are those additional risks, are there any?
What about turning? What situations preclude moms from not being candidates for turning the baby? Although I understand this is not a comfortable procedure.
“Why would patients not be capable of giving informed consent?”
Obviously, the mother is the only person able to give consent, informed or not. The question I am raising is based on my personal experience (and that of many other obstetricians) that patients don’t seem to understand that a low risk of catastrophic outcome means that the catastrophic outcome may very well happen to them.
Obstetrics has become so successful at handling the inherent dangers of childbirth that parents assume that a baby that starts labor perfectly healthy will be perfectly healthy when it is is born. More importantly, if it isn’t perfectly healthy, they often think that it must be someone else’s fault.
In reality, an approximately 1% risk of death of an otherwise health baby is actually a large risk, not a small risk. Yet lay people tend to view even a 1% risk as something not likely to happen.
I think BillyJoe’s comments illustrate that point, by suggesting that the risk is not that high, and that the information should be presented so as to emphasize the fact that most babies won’t die. However, in the US today, the death of any otherwise healthy baby is considered virtually inexcusable. If a mother believes that the chances of death are so small as to be negligible, is she really giving an informed consent?
“If the baby was in sufficient distress during vaginal to require emergency section and subsequently expired, I suspect that the French (results simply reported by mail) study would count that as a C-section mortality thereby giving a quite distorted picture as the baby might well have lived had the section been elective.”
The authors said they used an “intention to treat” analysis, which means that groups were assigned based on the intended mode of delivery at the start of labor.
I’m not clear where you get 9/1000. Might not the result of perinatal/neonatal mortality of 3/511 cases with “low national perinatal mortality rate” be the one to talk about from the Lancet (TBT) paper? (Unless you are advising a person from a random country.)
I really don’t see how, after that estimated risk is given, that the figure of 630 deaths/year adds any information about the risk.
Instead, I would think that one should be obliged to say something about the uncertainty of the point estimate of the risk, and mention what other studies find, if you consider them any good.
From that Lancet paper, it seems rather likely that experience of the doctors really does matter. The paper failed to perform the statistical tests of that – which I found interesting. It fails to give the summary for mortality alone, but they do present tests for mortality + morbidity, and there the difference between C-section and vaginal intended birth gets smaller and smaller as they look at the more experienced subsets of docs. They only get p=.03 when they reduce to docs with 20 years experience. I suspect that for mortality alone they failed to get p<.05 for those docs (difference small, sample size getting small), which may be why they don't present that. That may have resulted from the usual troubles with getting competent reviews. Is the data-set actually available is another question to be ask of studies that we might actually want to act on – it did not fall in my lap, and I finally gave up trying to find it. Is it acceptable to not cough up the data here?
As informed as most consent, I’d say. How often do patients really understand the risks in any field of medicine? “A 1% chance couldn’t happen to me” is not unique to this situation, or even this field.
A very worthy discussion to have, certainly – but IMO it’s a much bigger discussion than is immediately evident, because this situation is but one example of a much broader issue.
But isn’t that the truth? Doesn’t she need to understand that 630 babies will die and one of them really might be hers?
No, it is not the truth, it is a point estimate based on extrapolation of a single number (number of births per year). This number will change, obviously.
While using the 1 in 111 is a statistical probability.
Also, as I have not read the study, no mention is made about types of breech.
(and Billy is correct, it is vaginal breech delivery, not breech vaginal delivery. The vagina isn’t breech, the delivery is).
“A 1% chance couldn’t happen to me” is not unique to this situation, or even this field.”
I would argue that it is, for a number of reasons, but most importantly because of expectations.
If you tell someone that the chance of death from brain surgery is 1%, he or she expects that brain surgery is dangerous and takes that 1% number seriously. On the other hand, because people believe (erroneously) that childbirth is not dangerous, they will discount the chance of 1% that a baby will die.
We know that lay people have a very difficult time assessing risk. People “feel” that flying on an airplane is more dangerous than driving in a car even though all available data shows that auto travel is far more dangerous.
A lot of unnecessary (in retrospect) C-sections are being done. Do we think that is too high a price to pay to save several hundred babies each year?
Reverse it: how many babies are we willing to kill to decrease the C-section rate for breech position deliveries?
Decreasing the C-section rate to 0 would kill ____?
And, I think presenting it as 1 of 111 mothers who choses this option buries her baby gets the statistics to a graspable figure.
The main problem with the informed consent question is that the mother may need to make the decision at a very difficult time. My last baby was breech, and we did a c-section. My situation was a little different, in that it was intended initially to go for TOLAC. My first baby had been an emergency c-section due to fetal distress. What is the risk of vaginal breech delivery after a prior c-section? Hard to say, and in the end, even the c-section ended up being difficult — she got stuck in the bottom of the uterus, forcing the doctor to make a lengthwise incision. If I ever get pregnant again, attempted vaginal delivery is now out of the question.
More relevant to this discussion, my baby had been vertex during an exam just a couple of days before. She’d been turning a lot during the last month. It was quite a surprise, therefore, when after my water broke and I went to the hospital, the OB nurse reached in and found a foot. I wasn’t in active labor yet; contractions had started, but were not at all organized. Had I been in active labor, would I have been in the best frame of mind to objectively analyze the situation and give truly informed consent? Hard to say. But that’s probably the best we’re gonna get. It’s probably something that should be discussed with patients about a month before the due date, so they can process the information outside the heat of the moment.
Medical science tends to be very risk-averse when it comes to delivering babies. That’s not a bad thing, really; nobody wants to hurt moms or babies. But it has restricted science from critically examining whether our fears are well-founded or not, and whether we’re really taking the path of least risk. I’m not sure how to change that situation, because I wouldn’t want to hurt moms and babies either.
I had to make this decision, actually. I don’t remember how the risks were presented, exactly — I recall that we discussed that C-section was very safe and that complications were a bigger concern than death; that breech delivery was only slightly less safe but carried a risk of emergency C-section, which would be less controlled than a scheduled C. I don’t think there were numbers, but I don’t think I asked for them. I did ask what “most” women did, and my doctor gave me percentage estimates for his patients.
I did try CEV (turning the baby from the outside), which didn’t work; he was quite stuck (see below). I think this *slightly* influenced my decision to have a scheduled C section; I felt like I’d done “everything I could” to create an uncomplicated vaginal delivery so I was more comfortable choosing the C section. What was a much larger impact was that delivery breech would have required going to my non-preferred hospital. My preferred hospital was very small, intimate, friendly; the other hospital handled high-risk cases but was much more medicalized and assembly-line. I’m sure it would have been fine, but I was emotionally prepared to deliver in the Small Hospital and had done my classes there and everything there; switching to Big Hospital at 38 weeks seemed very, very stressful and emotional.
In retrospect the C-section was a good idea; the baby was wedged in my pelvis (with adorable little bruises on his little butt) and wouldn’t have delivered. I think after the attempted CEV the doctors had an idea he wouldn’t deliver, but they couldn’t be sure, of course. (They couldn’t be sure he wouldn’t just flip on his own anyway.)
Anyway, when I finally made the decision, which was very emotional, particularly because I have an absolute horror of surgery (and being AWAKE for it — that struck me as unimaginably horrific), I made it because I was convinced the C-section would be much safer for my baby and I was afraid of what might happen to him if I tried to labor and it went wrong. I was fairly irrationally afraid that I would die from the surgery; I knew it was irrational, but I was still very frightened. However, I felt like I made the best decision for my baby.
Now, I teach medical ethics, and we talk a lot about informed consent (of course); was my decision process informed consent? I was certainly informed; I was certainly legally able to consent; but I was also certainly deeply emotionally influenced, and certainly very irrational about surgery. I also didn’t have every study and all the numbers in front of me (though I’ve done that from time to time), and I relied heavily on the expertise of my trusted ob/gyn. It’s a much more complicated issue than just presenting the statistics.
Telling the mother that if she chooses vaginal delivery there is a 110 in 111 chance that her baby will survive and a 1 in 111 chance that her baby will not survive would be the correct way to present the information.
Have you ever had a 1-in-100 condition, and if so, how did you feel about it? If someone had told you before you’d gotten sick that you were at a 1:100 risk, would you have considered it as a likely possibility?
About two years ago, one of my daughters developed ITP, a blood disorder that occurs in children at a rate of 1/20,000. I’m a math person and computer scientist, so I KNOW that even 1/20,000 is not trivial across a large population, but on the drive to the children’s cancer center, I still felt like we’d been hit with the proverbial lightning strike. When we got there, the staff told me they had two other kids there for ITP treatment and followup, and it immediately made me feel like it was a lot less unusual. When I calmed down and did the math that about 200 kids a year in the US get ITP, it again made me realize that while ITP is unusual, it does happen to a non-negligible number of kids.
It was all completely psychological, but it shows that even someone who has some formal and professional experience with risk assessment can make an incorrect evaluation in their own personal situation.
A year after that, a pregnancy ultrasound revealed my son had a potential marker for a fatal genetic condition, and the quad-screen bloodwork came back showing a 1:100 risk. My OB was a little puzzled when I completely freaked out on her — “there’s a 99% chance he will be just fine!”. Fortunately, he was, but that time I understood the magnitude of the risk at a more visceral level. If I’d been just an ordinary parent, though, without my professional background or my prior experience with K’s ITP, I think I would have been a lot more cavalier, and correspondingly more surprised and devastated if A had been affected.
The problem is all of pregnancy and labor is about statistical probability. Starting with Down’s Syndrome testing. Every first time mother I know freaked out when they got a “positive” back which really could have translated for some of them to a 1 in 500 risk rather than 1 in 1000. And then when the second test came back with proof it wasn’t the case you begin to question everything that involves probability.
After my test came back with increased risk an ultrasound was done that showed no Down’s Syndrome but an increased risk that dd would be a dwarf. Unfortunately the table that led to this only had 50 kids in it and wasn’t very statistically viable. One doctor said it was something to watch and I went back for ultrasounds every 2-3 weeks. Another OB decided it meant dd wouldn’t survive outside of the womb. It became apparent very quickly that medicine is less of a definite science in some ways than I had thought and we were overwhelmed with information that no one knew what to do with or even how to truly assess the risk.
In the end it was that the umbilical cord was attached to the side of the placenta. DD is fine and not a dwarf. None of it was discovered until after dd was born. According to the chart I was shown I think dd had at least a 5% risk of being a dwarf with her foreshortened limbs with no other markers for dwarfism.
DD wasn’t breech but after going through the emotional rollercoaster of statistical probability for most of my pregnancy if any OB had told me I needed to have a c-section b/c dd was breech b/c of a less than 1% chance of her dying I probably would have strangled that OB. I probably would have decided to have the c-section anyway but I was so tired of absolutes being presented that weren’t actually anywhere near absolutes when I asked questions about them that I just wanted dd out.
OBs would do well to find a better way to present information and explain risks to expectant mothers and make them a partner with what’s going on and respect them. To me, that’s the better way to combat woo. Telling a woman 630 babies will die from the choice they’re making and theirs could be one of the 630 is not the way to do it.
OBs would do well to find a better way to present information
I don’t think it is limited to OB, this is something all HCP’s struggle with And actually, IMO, it leads to a larger discussion of healthy literacy, and maybe even a uniform way of describing risk.
I think that people sometimes forget that the ultimate goal of pregnancy is a healthy living baby.
When c-sections were not an option (or where they are still not really an option), so many more babies and mothers were dying in labor. Modern obstetrics has increased happy outcomes and reduced tragic ones.
@provaxmom: “What about turning? What situations preclude moms from not being candidates for turning the baby? Although I understand this is not a comfortable procedure.”
I had cephalic external version done, where they attempt to turn the baby by manipulating the belly (as opposed to reaching in via the birth canal, which I guess is DURING delivery?). This is done some time in advance of delivery in the hopes the baby will then stay head down. (And you stay in the hospital for a couple hours after to make sure there’s no distress to the fetus and it doesn’t need to be delivered immediately.) Mine was done at 38 weeks, which is when the little twit turned sunny side up, so there wasn’t a lot of room to move him.
It was literally the most painful thing I have ever experienced in my life, and I’m including the entire C-section recovery.
I’m not sorry I did it, and I would do it again for my baby, but uncomfortable definitely understates it! And I would certainly understand a woman choosing a C-section rather than turning the baby with CEV (even if, let us imagine, she had foreknowledge that the turning would work). It was utterly excruciating … and of course carried its own risks to the fetus.
I imagine it’s less painful a little earlier (36 weeks, say), or if it’s a second baby and the uterus is more stretchy, or if you’re taller than me, or whatever, but even “somewhat less painful” would still be “worst pain ever” for me!
[...] just finished reading an interesting paper on Science Based Medicine. I enjoyed the article and the comments at the bottom. I find that when Dr. Amy Tuteur posts on [...]
@Provaxmom: cephalic version can be successful, but, as Kylara points out, is usually very uncomfortable/painful to the mom, and you still risk the baby going back to breech. I have seen it done several times. Most of the time, if there is enough room and the umbilical cord is free (not wrapped around baby anywhere), it works. However, the room to turn the baby also means they have the room to turn back. And, of course, it doesn’t always work – the doc can’t rotate the baby, trying to rotate the baby causes fetal distress, or mom can’t tolerate the pain.
Usually, in the cases I saw, it was most successful when the mom went in to labor soon afterwards. Height of the mother, size of the baby, etc all do effect the ability to do the version.
@Kylara: you are again correct, that internal version is done to rotate a baby from breech to vertex during delivery, with the provider inserting their hand into the uterus to rotate the baby. Again, VERY painful to the mother. I’ve seen it done only once, with preterm twins (twin 2 went from breech to lateral, decided to crash his heartrate and the doc pulled him out quickly because we didn’t have in house OR staff for a stat section. He did fine, except for the usual premature baby issues.)
“…based on my personal experience (and that of many other obstetricians) that patients don’t seem to understand that a low risk of catastrophic outcome means that the catastrophic outcome may very well happen to them.”
Well, you’ve just summed up a fundamental problem with human beings in general. I think that’s a big part of what caused the current financial crisis.
There’s many ways to say it; take your pick:
Low risk is not risk free.
Low risk is not no risk.
Low risk is not zero risk.
Low risk still means risk.
Things can still go very, very badly in a low risk situation.
A situation can go from low risk to SHTF in the blink of an eye.
etc…
People play the lottery every day with far lower odds of winning in the belief that they have some realistic chance of winning.
Some of it does have to do with framing, such as how you present the information. Some of it also has to do with what the person wants to believe. We want to believe we will win the lottery, but we also want to believe our babies will be fine.
“telling the mother that 630 babies WILL die and that one of those babies might be hers is equally important.”
I don’t disagree that it would be important to stress that babies DO die from vaginal breech delivery in order to make consent as informed as possible; however, shouldn’t we also have a denominator in that statement? Not being an obgyn, I have no idea how many babies are born each year (i’m sure my guess would be off by an order of magnitude, at least), nor what percentage of those are breech. Without those values as well, it seems like simply saying 630 babies die each year is bordering on scaremongering at an already stressful time.
“I would hate for women to opt for the vaginal breech, thinking that the recovery will be as easy as a traditional vaginal delivery, when in fact there may be additional risks”
A successful breech vaginal delivery does not have additional risks compared to a successful vertex (head first) delivery, so mothers don’t need to worry about that.
“as opposed to reaching in via the birth canal, which I guess is DURING delivery?”
Although it sounds similar, an internal version is very different from an external version and is used in an entirely different situation.
External version is used to turn a breech baby to the vertex (head first position). Internal version is for delivery of a second twin high in the pelvis after the first twin is born. It involves turning a floating baby by the feet to the double footling breech position (feet first) and extracting the baby.
“Medical science tends to be very risk-averse when it comes to delivering babies.”
Doctors are merely responding to patient expectations. Patients expect (rightly or wrongly) that any baby who starts labor perfectly healthy should be perfectly healthy at birth. It is this belief that drives the skyrocketing C-section rate for breech and for all other indications. It is simply unacceptable to deliver a dead baby.
“I have no idea how many babies are born each year”
Approximately 4 million.
Dr. Auteur.
“But isn’t that the truth? Doesn’t she need to understand that 630 babies will die and one of them really might be hers?”
It is the truth, yes, but what I’m saying is that it is not the information on which she should base her decision. She needs to know what the risk is for her. That risk is 1 in 111.
if you were “not completely sure that the mother understood the fact that some babies will die and that one of them could be hers”, then the more honest response would be to say that the risk is 1 in 111 and that her child could be that 1 child in 111.
“It rarely happened when I was practicing. Most women immediately opted for a C-section.”
I imagine they would have with the information you provided.
“Most women simply cannot fathom the idea of a healthy baby dying in childbirth. It is so rare nowadays that women have never seen it and may have never heard of it. Then when it happens, mothers are shocked and outraged; they never envisioned it as a real possibility”.
That gets back to the question of whether the mother can really give informed consent.
In my opinion, the way you present the information you have practically guaranteed that the mother will have a C-section. The question is, is this informed consent?
“I think BillyJoe’s comments illustrate that point, by suggesting that the risk is not that high, and that the information should be presented so as to emphasize the fact that most babies won’t die.”
Actually no. I think the 1 in 111 risk IS high, but I’m concerned about how this risk is presented. My underlying theme is actually the question of informed consent. In my opinion, if you want informed consent you must present the information that gives the true risk for the patient. That risk is 1 in 111. Or, if you want to use the 630 figure you would have to put it in terms of 630 out of a total of 70,000, which brings us back to the more manageable and honest figure of 1 in 111.
If you don’t think there should be informed consent in this situation – in other words, if you think the mother should have a C-section – it would be more honest to say something along the lines of “your baby is breech, so we need to do a C-section” and then prepare her for surgery. Her signing of the consent form would then be mere formality.
It seems to me that effectively is what’s happening in any case.
regards,
BillyJoe
BillyJoe,
I completely understand what you’re saying. In mathematical terms, a numerator without a denominator tells us nothing.
The problem is that most people are terrible at math. Trying to communicate the meaning of a number as well as the number itself is a challenge in informed consent.
Many women will translate 1/111 as “1/111th of a baby,” which is meaningless. Giving the absolute number of 630 makes the point that these are real babies, whole babies, and they aren’t flukes.
I think one of the things that obstetricians struggle with is communicating what statistics mean for them. Obstetricians deliver many babies, so something that is a “1 in 100″ event for an individual mother could be a yearly event for her doctor. And if the “event” we’re talking about is a dead baby, the doctor will be extremely distressed about it. Trying to ethically and accurately communicate “Yes this really could happen, in fact it happens every day, and if it did it would be really terrible” to someone who is thinking “1/111th of a baby – somebody else’s problem” must be frustrating.
Just one brief observation for Amy. As I scanned the comments, I found 4 or 5 instances in which she says “lay people have trouble understanding risk” or the like. The fact is that ALL HUMANS struggle with it, not just the laity, as I think all these comments will testify.
Alison,
“Obstetricians deliver many babies, so something that is a “1 in 100″ event for an individual mother could be a yearly event for her doctor. And if the “event” we’re talking about is a dead baby, the doctor will be extremely distressed about it.”
Yes, I haven’t been looking at this from the point of view of the obstetrician. But lets see how that actually works out:
The average obstetrician performs 150 deliveries per year.
The breech rate is about 1 in 25, which is 6 per year per obstetrician.
The death rate for vaginal breech delivery is 1 in 111
So, if obstetricians delivered all breech births vaginally, they would see one death roughly every 18 years.
So this is not a yearly event for the obstetrician, but something that occurs every 18 years on average.
I’m not saying that’s acceptable, but I think we need to get the statistics right.
“I think one of the things that obstetricians struggle with is communicating what statistics mean….”
That may be, but I don’t think the way to do that is to distort the statistics. Are patients (or obstetricians, or anyone) capable of understanding them? I think it must be at least possible. The one thing for certain is that you won’t increase their understanding of statistics by distorting them.
Dr. Tuteur:
Where did you get this number? It was not in TBT, at least I didn’t see it. Not arguing, just curious what I missed.
Interesting question. What is the alternative? Court orders for c-section?
Where did you get this number? What section or table (I didn’t look at all the tables)?
Dr. Tuteur:
Yes, I agree with Billy Joe and Edgar. This number is irrelevant without a denominator. It’s also another way of saying the same thing, except it is designed to elicit a reaction- a scare tactic. I’m all for more information, so you could also report the number of babies that would be alive (69,370) as well. Reminiscent of the mammography guidelines and everybody going nuts about risks with little understanding that the alternative has risk as well.
The study also reported that maternal mortality and morbidity were not different for c-section and vaginal either. However, the p value was something like .3, not significant. 2000 births is not a big enough group to look for maternal mortality. My main concerns with c-sections (in general, not necessarily breech) were breathing problems in my baby, as well as risks to future pregnancies. Avoiding unnecessary c-sections is not about the “experience,” contrary to popular belief.
Tim Mills:
No, that is a major criticism levied against the TBT, if you read the medical literature. All of the births were not attended by experienced breech providers. But you wouldn’t know that just by reading the abstract. They also weren’t double blinded, and the vaginal birthers were also subjected to certain interventions that can lead to iatrogenic complications.
Money is an issue, particularly in resource poor countries who may not have the facilities for cesarean section. In fact, there are many issues in the TBT regarding this very topic and how money and resources (or lack thereof) in certain countries could have influenced the results.
Calli Arcale:
Aren’t you contradicting yourself here? Are patients risk averse or are they incapable of calculating risk? Or is it only pregnant women (who disagree with you) who may not be giving informed consent?
Allison Cummins:
Not likely. An OB would have to do 2775 (or 53/week) deliveries/year to get one breech baby death as delivered vaginally (if Dr. Tuteur’s numbers are correct). Or 111 breech deliveries in a year. Some people tend to underestimate risk, definitely, but some also tend to overestimate it. The truth is somewhere in the middle.
There is probably some magnitude of increased risk to vaginal breech delivery… I’m not sure how much based on my very cursory glancing at the studies tonight. If I were in that position, I’d read a lot more, but would probably elect for a c-section.
In case anybody else is interested:
1.
Andrew Kotaska
Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery
BMJ 2004; 329: 1039-1042 [Full text]
http://www.bmj.com/cgi/reprint/329/7473/1039
Rapid response (love this part of the BMJ- very interesting!)
http://www.bmj.com/cgi/eletters/329/7473/1039
2.
RESULTS: Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies. CONCLUSION: The original term breech trial recommendations should be withdrawn.
Citation:
Five years to the term breech trial: the rise and fall of a randomized controlled trial.
Glezerman M – Am J Obstet Gynecol – 01-JAN-2006; 194(1): 20-5
(Sorry! No idea how to embed a link).
http://www.mdconsult.com/das/citation/body/178380796-2/jorg=journal&source=&sp=15934583&sid=0/N/15934583/1.html?issn=0002-9378&issue_id=18187
3.The TBT after two years (same authors):
Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial.
Whyte H, Hannah ME, …
CONCLUSION: Planned cesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age.
http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Search&term=Am%20J%20Obstet%20GynecolJour+AND+191Volume+AND+864page
I’m sorry, I should have been clearer. My own quick-and-dirty math had an obstetrician attending the vaginal births of one or two dead breech babies per career. But I had to make too many guesses to get there, so I gave up on trying to invent a number.
Instead, I just put the problem in general terms, because the problem of frequency is not restricted to breech births.
“Obstetricians deliver many babies, so something that is a “1 in 100″ event for an individual mother could be a yearly event for her doctor. And if the “event” we’re talking about is a dead baby, the doctor will be extremely distressed about it.″
If something is a “1 in 100 event″ for all deliveries – something like, I don’t know, a breech presentation, or twins, or an extra finger – then an obstetrician will see a lot of them. (One piece of advice I heard was never to accept an obstetrician who attends fewer than 50 births a month. Rates clearly vary.)
The “1 in 111 event″ we’re talking about here only applies to the 1 in 28 breech births, and then only to those women who are eligible and then only to those who choose it. Once we get into subsets of subsets, even a busy doctor won’t see that many.
Still, even one is traumatizing for the doctor. It’s not routine for them.
A few things on this…
Firstly, this trial was designed to compare outcomes between planned caesarean section and planned vaginal delivery for breech. It does not tell us, directly, what to do when someone arrives in advanced labour with a previously undiagnosed breech on board. The results of the Hannah trial have been extrapolated to this situation, though the outcomes may be different (because caesarean in advanced labour had different risks from elective caesarean, and because good labour progress may be associated with better outcomes.
Secondly, the trial protocols themselves may have biased the trial towards those providers who regarded these particular protocols as safe (and therefore ethical). Several centres in Europe with experience in vaginal breech delivery chose not to participate in the trial either because they were not equipoise about the research question (that is, there own audits had found their practice to be safe and they saw no reason to change it) and/or because they felt the trail protocols were unsafe with regard to selection criteria or labour management (in particular, the rate of 0.5cm dilatation/hour in first stage, length of second stage deemed acceptable, and the possibility augmentation). As a result, the study did not include centres with different approaches to vaginal breech delivery, which may have had better outcomes.
Thirdly, many providers had to massively increase their rate of vaginal breech delivery in order to participate in the trial. This would have been achieved by changing their normal (i.e. pre-trial) selection criteria and hence practising outside their experience and comfort zone.
Fourthly, some trial participants were outside the trial selection criteria, including participants whose babies died.
Finally (for now), the outcome measures were combined (grouping mortality and morbidity) and short-term, which exaggerated the effect. At two years out from the trial the differences in neonatal morbidity found in the initial outcomes were no longer statistically significant.
These are all well known criticisms of the Hannah trial in the obstetric literature, for example by Marek Glezerman, who was one of the trial centre leads. Dr Tuteur should at least have mentioned the concerns that have been raised about the trial, if only to refute them.
Plonit,
Thanks for the information you provided on the drawbacks of this trial.
There is also the Premoda Study mentioned by Dr. Auteur which “did not find a significant excess risk associated with planned vaginal delivery compared with planned cesarean” (though they acknowledge that the results must be applied with caution because it was not randomised.
Of course that feeds into the problem of informed consent which has been my focus here. How could you possibly present all this to the patient in such a way that she could make an informed choice?
I think there is a lot of disingenuity on the question of informed choice. If I was the obstetrician and had come to a conclusion about what should be done in any particular situation based on the available evidence, I’d make pretty sure in the way I presented the information, that the patient would reach the same conclusion.
Of course, the next problem is that the patient cannot make an informed choice of obstetrician. What on Earth would she base decision on? Where would she get the relevant information?
Perhaps, unless we are prepared to do a whole lot of work and develop some expertise ourselves (is that even possible?), we have no choice but to trust the professionalism of the various specialists that become involved in our medical care to do what is in out best interests.
Alison:
Thank you as well.
I missed your contribution before.
Dr Auteur:
Scary isn’t it.
We’ve not done a thorough search for all the available information and have come to the wrong conclusion and then we misuse statistics to get the patient to agree!!!
There has to be a lesson in there somewhere.
(And what did I just say about trusting specialists to do what is in our best interests!!! – Only joking of course. We’re all human and we all make mistakes, but I’m sure we all try to do the best we can)
regards,
BillyJoe
Zoe237:
“Where did you get this number?”
By dividing. If the excess rate of neonatal death is 9/1000, you must treat 111 women to avoid one death.
“This number is irrelevant without a denominator.”
Irrelevant to what? We’re trying to make sure that a woman understands that her baby could die.
Even better is TsuDoNihm’s formulation up thread of “presenting it as 1 of 111 mothers who choses this option buries her baby.”
“that is a major criticism levied against the TBT, if you read the medical literature. All of the births were not attended by experienced breech providers.”
No, the criticism is that not all the births were attended by obstetricians. Some of the providers were midwives who had equivalent experience delivering breech babies. If the criterion is experience, I don’t see why midwives should be excluded.
“Are patients risk averse or are they incapable of calculating risk?”
Patients are implacably opposed to any neonatal deaths, AND they often do not understand the true magnitude of the risk of neonatal death.
“An OB would have to do 2775 (or 53/week) deliveries/year to get one breech baby death as delivered vaginally (if Dr. Tuteur’s numbers are correct).”
And that’s why the concept of an “experienced” practitioner is wishful thinking. Some obstetricians are more experienced than others but even obstetricians who deliver breech babies have very, very little experience dealing with a complicated breech delivery.
In the “old days” obstetricians would gain experience by practicing on patients who didn’t need the maneuvers. For example, an older doctor might teach a younger doctor how to apply Piper forceps to an after-coming head (used to extract a trapped head) of a breech baby who wasn’t stuck. You can’t do that nowadays (thankfully), so an obstetrician can practice for a decade or decades without every having put Piper forceps on. The only time he or she will be called to do so is in the midst of a life threatening emergency.
There is one area in which experience is valuable. A hasty practitioner can actually CAUSE complications by trying to rush the delivery of the baby once the breech is out. Doing lots of breech deliveries teaches the best way to avoid complications.
It is almost impossible, however, to get much, if any, experience managing those complications if you make sure they are very rare.
Zoe237:
“Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery”
Dr. Kotaska has always been an enthusiastic proponent of vaginal breech delivery and the results of various studies have been accepted or rejected by him based on whether they supported the safety of vaginal breech delivery.
His criticism of RCTs falls into that category. Of course RCTs have important limitations, but that doesn’t make non-randomized trials superior.
“Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies.”
Yes, but the most severely injured babies were already dead, and therefore were not included in a study of outcomes at 2 years of age.
“These are all well known criticisms of the Hannah trial in the obstetric literature”
Yes, they are, and they have been addressed by Mary Hannah and others.
It is important to keep in mind that the supposed “safety” of vaginal delivery applies to only a small group. Even in the PREMODA study, the non-randomized trial with the best results, only 23% of patients with a breech baby went on to have a vaginal delivery. The vast majority were excluded based on the very stringent criteria and others had intrapartum C-sections for failure to progress (etc.)
So the issue is not whether vaginal breech deliveries are safe. For most cases, they are not. The only outstanding issue is whether deaths can be kept to a minimum by utilizing extremely stringent eligibility criteria.
I get that Alison- that makes more sense.
Be nice to see Plonit’s (and forks) points addressed- Dr. Tuteur would rather argue about philosophy about informed consent rather than the actual science.
“By dividing. If the excess rate of neonatal death is 9/1000, you must treat 111 women to avoid one death.”
Where does the 9/1000 come from? You chose to ignore that question. I also saw no NNT or excess rate in the study- just from the TBT, it is actually much lower than that, as far as I can tell. But I’m no expert.
“Even better is TsuDoNihm’s formulation up thread of “presenting it as 1 of 111 mothers who choses this option buries her baby.””
You seriously don’t know why a denominator might be needed to give informed consent, and why emotional language like “buries her baby” is intended to scare rather than inform? Oh well. Thank goodness you retired. Btw, the thinking on breech does seem to have changed since the 2000 study- ACOG has changed their policy from no breech vaginal to “it is an option for EXPERIENCED providers” in 2006. Absolutely it is dependent on stingent criteria- nobody is arguing that it isn’t.
“No, the criticism is that not all the births were attended by obstetricians. Some of the providers were midwives who had equivalent experience delivering breech babies. If the criterion is experience, I don’t see why midwives should be excluded.”
I suggest you read the Glezerman review I posted in AJOG. Hilarious you jump to that though (midwives vs. obstetricians), but I’ll explain it you. The key issue in breech in a provider who has delivered a certain number of breech babies and has practiced a certain number of years. These providers often have very stringent criteria for what women should attempt vaginal breech birth. Part of having that experience is NOT JUST the complicated obstetrical maneuvers required in case of head entrapment, but also the *selection* of good candidates for a TOL through the use of u/s and other skills to avoid complications to begin with. There are serious questions in the study that the requirements lead to more breech vaginal births than should have been done, as well as obstetricians claiming they were experienced who might not have been. As you mention, level of experience is difficult to acquire and judge.
Be nice if you could address Kotaska’s points rather than saying he supports breech vaginal birth, therefore his opinions are worthless. Same with Plonit’s points- yes Hannah has responded, and I read those responses. They’re not all that cogent on some criticisms. Like I said above, you would rather argue about philosophy about informed consent than actual science. Understandable, I suppose.
More counterpoints to Dr. Tuteur’s view of informed consent, patient choice, and breech birth and VBAC(with rapid response):
http://www.annfammed.org/cgi/content/full/4/3/265
Amy Tuteur:
I’m not quite sure what you’re getting at here. I wasn’t intending to imply that it was any particular party’s *fault* that medical science is risk-averse in obstetrics. If there is a fault (and I’m not sure there is; there are good reasons for being risk-averse in this area), then I’d say it’s society as a whole. That includes not just patients but also their families, doctors, nurses, hospitals, lawyers, policy-makers, insurance companies…. It’s everybody. I think very few people alive, in any context, want to risk a dead baby or a dead mother.
I do agree that many patients aren’t clear on the risks of labor and delivery. If the baby was fine before labor, why was he born dead? Lots of reasons, and most of them, there really isn’t a good person to point the finger at. I suppose it’s a bit like the autism thing; they want to blame somebody, even if there’s really no fair basis for that. I think this is what you’re alluding to — that obstetricians are risk-averse because of the fear of lawsuits. This is true, but is smaller than what I had in mind.
Medical science as a whole is risk-averse when it comes to mothers and babies, and this has profound influences on the whole process that go beyond an OB deciding to do a c-section just in case. In particular, this risk aversion makes it harder to do scientific research because it’s tough to answer some of the critical questions in ways which will satisfy an ethics IRB. Pharmaceuticals are seldom tested in pregnant women and small children for this reason. There’s good reason for this — nobody wants to hurt a kid. But it means that doctors and pharmacists have to extrapolate from inferior data when deciding how to treat pregnant women and newborn babies. And it means that you have to do other, less rigorous types of research if you want to improve risk estimates for obstetric procedures. This means that the estimates for the risk of c-section are probably not accurate, and neither are the estimates for the risk of breech delivery. It’s something we all have to live with — these are the best estimates we have. But we can’t know how close they are to reality, and that can be disquieting, especially in a high-stakes situation like pregnancy and birth.
So to cut a long story short, the risk-aversion in medical science goes far beyond simply OBs afraid of being sued for delivering a dead or injured baby. We’ll never know how many c-sections were really unnecessary, nor how many breech deliveries were unnecessary — we have an estimated NNT, but that’s not exactly the same thing. It’s close; closest we can get in science, probably. But not the same, and the existence of uncertainty will inevitably make a lot of people nervous.
(BTW, for the record, I favor c-section over vaginal breech delivery, even in a woman with no prior c-sections. But I’m a software engineer, so take that opinion for what it’s worth.)
Thankyou Zoe237. Those pointers were excellent!
The Kotaska article was a good read. I am also quibbling about the actual facts rather than the theory of consent, and some might find that quibbling uninteresting by comparison, sorry.
Perhaps Kotaska has an agenda, but that doesn’t make what was written wrong. Plonit’s summary (above) of Kotaska didn’t point out that in that half of the data that were for countries with low perinatal mortality, that intended vaginal deliveries gave death 3/511 times, and this was not significantly more than zero (of about 500) in the C-section group. It questions one of those 3 deaths as well. Kotaska (surprisingly) doesn’t point to the fact that even in the Hannah data there seems to be a strong experience effect, which Hannah also essentially weasels out of, as I mentioned earlier.
So perhaps 2-3 out of 500 seems like more realistic risks around my area, assuming semi-aggressive inclusion criteria, and that the doc is merely as good as the average from this study. Docs informing the patient of their skill and experience seems important.
PS: I advocate better math education in my particular country (U.S.), and much better math/stats education for docs (I have horror stories both as a patient, and a researcher). This blog is helping I hope. Thanks for that.
Dr, Tuteur,
This post seems to have a hidden agenda, as do most of your posts, but it is difficult to tease it out. Here are the points I’ve gathered so far:
-The risks of vaginal breech delivery may be lower than we thought, but are not zero.
-Laboring women, like the rest of us, can’t comprehend risk very well, and therefore can’t give truly informed consent.
-C section for breech babies lowers the risk of neonatal complications
-Doctors are only responding to patient demand when they recommend C section for breech births
You seem to feel that C section IS a better choice for breech births, so why not come right out and say it – “If a baby is in breech position I would recommend a C section.”?
Or are there cases where you would recommend a vaginal birth? If not, is it you who is risk averse, or is it the patient?
You say that people look for someone to blame when something goes wrong during delivery, and I don’t doubt that for a moment. But I’m hearing a bit of the same here – if a patient chooses the riskier procedure, well, it’s their fault if something goes wrong.
Many universities are introducing courses for prospective scientists in how to present complicated research findings to the public. While doctors already have instruction in talking to patients, I’ve long wondered if a course specifically in how to present statistics and risks to patients would be beneficial to the medical community.
Statistics are confusing, particularly when they’re mixed up in emotions. Creative and effective ways to present them to laypeople would be a very useful thing.
Dacks,
“I advocate better math education in my particular country (U.S.), and much better math/stats education for docs (I have horror stories both as a patient, and a researcher)”
I take it that you mean that denominators are important.
How about the dispassionate presentation of the facts?
And I would love to hear some of your “horror stories” (provided they are also instructional).
BillyJoe,
That was rork, not me.
There are women who claim to be fine with the risk. I read a first-person account of a UC delivery in Mothering magazine… maybe ten or twenty years ago. The baby was born limp, apparently infected, and died within a couple of days. I was fascinated to realize that her logic was completely consistent. She didn’t use birth control, this was her fifth child, her next oldest was only about a year old, and she was exhausted. Maybe this baby dying wasn’t the end of the world. She was living a life in which she allowed nature to take its course. That meant that when she was too spent to carry a healthy pregnancy to term that she allowed the baby to die as nature intended,* instead of actively seeking care to ensure the baby lived. (Reading between the lines, if the baby was born infected, presumably she’d been bleeding quite some time before labour started and she didn’t seek medical care.) If she was too drained to deliver a healthy baby, she was too drained to raise the child.
While this isn’t the logic I would use to make my choices, I have to respect the internal consistency. I can completely imagine this woman fully appreciating the risk that a breech baby would die and finding that risk acceptable on the grounds that if it didn’t live then it wasn’t supposed to.
*Yes I am perfectly aware that nature doesn’t “intend” anything.
*** *** ***
On another note, have we all read Atul Gawande’s classic New Yorker piece on the place of c-section in modern obstetric practice?
http://www.newyorker.com/archive/2006/10/09/061009fa_fact
There’s also a related nice little blog post by an obstetrician talking about her mission to learn to use forceps in an age of c-sections.
http://mwwak.blogspot.com/2007/08/forceps-are-your-friends.html
… and about what it’s like to deliver a breech baby. http://mwwak.blogspot.com/2006/11/do-or-do-not-there-is-no-try.html
None of these articles address the science, but I thought that people who are enjoying this exchange might also enjoy these other ones. If they don’t already know them.
“You seem to feel that C section IS a better choice for breech births, so why not come right out and say it – “If a baby is in breech position I would recommend a C section.”?”
It would be more accurate to say that if a baby is in the breech position I feel compelled to recommend a C-section and to emphasize the dangers. Basically I’m expressing the frustration that most obstetricians feel with the current situation.
Obstetricians are held to an impossible standard: any baby that starts labor healthy must be healthy when delivered. We dropped the neonatal mortality rate approximately 90% in the past 100 years (and the maternal mortality rate 99%), yet perfection is the standard.
As the neonatal mortality rate has dropped to a very low level, the pressure exists to save the few babies who still will die. Therefore, the indications for C-section keep growing; first it was for all breech babies, now it’s for all women with a previous C-section.
It seems that the law of diminishing returns applies in obstetrics. As we asymptotically approach the lowest possible neonatal mortality rates, we are doing more and more C-sections to save fewer and fewer babies. But, I for one, don’t see any alternative.
I find the debate on the safety of vaginal breech delivery (as well as the debate on the safety of VBAC) to be disingenuous in the extreme. Those who are promoting vaginal breech delivery and a liberal VBAC policy are not honest about the fact that some babies WILL die. Unless patients understand that, they cannot make an informed decision.
I personally am in favor of vaginal breech delivery with strict criteria, and VBAC for any woman who wants one, BUT it is only a feasible policy if women understand and ACCEPT that some babies WILL die as a result.
Horror stories.
Here’s one that happened at a homebirth. It might not have happened in the hospital since the patient would have been counseled emphatically to have a vaginal delivery, but it gives people a sense of the situation. A trapped breech is horrific in the extreme.
This account is from the Oregon Register-Guardian:
“The call to paramedics came at 8:10 p.m., the instant midwife Anita Rojas realized the head of the breech baby she was delivering was stuck.
Twenty-one-year-old Kelsie Koberstein was swept up by medics in a blur of pain and fear.
Rojas rode in the front of the ambulance, with Koberstein’s mother and best friend rushing behind in their car…
On her back, her legs pushed up as high as they could go, she clutched the hand of a paramedic as if he were her only anchor to reality.
Those minutes, so frantic for so many, ticked by slowly for her. As paramedics tried to wrest the baby out, Koberstein said she could sense the small life, still partially within her, beginning to fade. She began “letting him go, in a way.”
At Sacred Heart Medical Center, the on-call emergency room obstetrician-gynecologists, Drs. Elizabeth McCorkle and Brant Cooper, wasted no time…
When medics pulled up to the doors, the doctors leapt into the back, refusing to squander precious seconds bringing Koberstein inside. The doctors had to turn Lucian’s head 180 degrees in order to free him, a move that took at least 20 minutes.
By then it was too late.
The infant was dead.”
Zoe,
http://www.annfammed.org/cgi/content/full/4/3/265
“The American College of Obstetricians and Gynecologists has released a formal opinion supporting obstetricians who perform elective primary cesarean delivery, citing the ethical premise of patient autonomy and informed consent”
“[The authors of this article] are pleased at the emphasis on preserving women’s medical choices”
Is it the “ethical premise of patient autonomy and informed consent” and the “preservation of women’s medical choices”? Or is it the abrogation of responsibility by the specialist collleges and their members?
“The primary investigator of the TBT has stated that a woman’s choice for vaginal breech delivery should be respected”
“opinions from professional societies in Australia and the United Kingdom acknowledge a woman’s right to choose vaginal breech delivery”
Is this “respect for patient choice” and the “patient’s right to choose” or a surrogate for “don’t blame me. you made the choice”
Patients even have the right to choose a PRIMARY caesarean section – in other words, for no medical reason at all!
The irony is that the point of this paper is that women seem not to have the choice any more of delivering vaginally with a breech presentation or after previous C-section because obstetricians are no longer prepared to give that choice to the patient.
Patient choice and autonomy indeed!
Dr Tuteur,
Thank you for clarifying your position. Your frustration with the current state of affairs is certainly understandable. We are a risk averse society, and that is nowhere more true than when it comes to our children. Yet it is hard to make the case that we should take more risks.
Dr. Auteur,
Thank you for your continued reponses in the face of strong opposition (and the occasional gratuitous insult). You sound like a true professional in that regard, so thank you (and I know you cannot resppond to everyone).
I appreciate the frank summary of your views on VBAC and vaginal breech delivery in the second last post above as well as for this perpective”
“As we asymptotically approach the lowest possible neonatal mortality rates, we are doing more and more C-sections to save fewer and fewer babies. But, I for one, don’t see any alternative.”
I think, though, that we must be certain that more lives ARE being saved as we approach that asymptotic point.
I am interested in your view on patient autonomy and informed choice but perhaps that is for a future article?
regards,
BillyJoe
This is very true, and gets to another area that I’ve always had some unease about: the heroic efforts to save very ill newborns and the increase in high-risk pregnancies which, in retrospect, could probably have been avoided. (Higher order multiples during fertility treatment, for instance.) You’ve talked of how there is an expectation that a healthy fetus should be delivered as a healthy baby; what about unhealthy fetuses, and high-risk pregnancies? Though it’s wonderful to save a baby’s life, I admit to some discomfort when I hear about new records set in smallest baby to survive, or youngest. Second-trimester preemies, nursed back to life at great expense and often great pain, with a tendency (at least in the media and the public eye) to consider “mortality” the only significant factor for these babies. Are we trying *too* hard to save some babies? A thorny question indeed; it’s sort of the flip side of the abortion debate, but far less commonly discussed — we discuss whether it’s always okay to kill a fetus, but we don’t discuss whether it’s always okay to save one, because our instinct screams “hell yes”.
I would be interested to someday hear your thoughts on that, though I bet that would be another thread that would get an excruciatingly long comment section.
“You’ve talked of how there is an expectation that a healthy fetus should be delivered as a healthy baby; what about unhealthy fetuses, and high-risk pregnancies?”
Those situations raise very serious ethical issues, although different issues. In the case of high risk pregnancies, those mothers are desperate for any baby, and it doesn’t have to be healthy. Plus, in the past two decades the age of viability has been dropping constantly, giving people hope that even the most hopeless cases can work out… I’ve been surprised on a couple of occasions.
It is extraordinarily difficult to counsel patients appropriately in those situations since there are times when no one really knows what what the odds are.
Here is an point of view I can relate to:
http://www.annfammed.org/cgi/eletters/4/3/265#4003
“Cesarean Delivery: a choice, a demand, or a request?
A mother may request [as opposed to "choose" or, god forbid, "demand"] a cesarean, but it is the caregiver who must use their knowledge of medicine and the patient to provide guidance. The decision should respect both the patient’s autonomy and the provider’s obligation to optimize the health of both the mother and the fetus”
Thank you for covering this topic.
I was persistent breech, even after attempted external version. Even if my group was still doing elective breech deliveries, I would have not been a good candidate as a primapara (an elderly one, at that).
I have seen one (1) elective breech delivery; it was done in the OR, with anesthesia (me) in the room throughout to provide for emergency uterine relaxation or crash c-section if needed. Given the amount of sphincter tone associated with this elective delivery, I can understand the reluctance to go with a vaginal birth over a c-section.
However, there always will be “surprise” breech births that must be managed– how are OBs going to gain experience in this? I would not advocate resuming elective vaginal breech births just for the experience, but if the main determinant of a safe(er) breech delivery is the experience of the OB (and the anesthetist), how can we train the next generation? It seems to be an extreme of the “elective forceps” problem.
I would argue that most patients can NOT give informed consent regarding this issue– phrases like “head entrapment” (baby can’t breathe and the cord is compressed in the birth canal against its body= asphyxia) give me the screaming willies. Unless a practicioner can create the kind of visceral fear that is appropriate in that scenario, I don’t think “informed” consent is possible.
Just the fact that some women feel that delivering a breech infant with a midwife at home is OK would imply that there is a serious gap in understanding.
Rork, thanks.
BillyJoe:
http://www.annfammed.org/cgi/content/full/4/3/265
Yep. The recommendation in 2000 after the TBT was NO breech delivery, patient choice be damned. After further studies came out, particularly those finding no difference at two years in TBT, the recommendation was revised (2006) to allow women the option of breech delivery vaginally. I believe there is ONE provider about an hour north of me willing to do breeches, and has many years of experience. Many other OBs don’t have the skills and are extremely risk averse. Obviously their lack of confidence/experience/skill should not be tested, and these patients should be referred to another doctor.
Alison, THANKS for those links to midwife with a knife (yes, she’s an ob for those not familiar)- I had never read that one before. As I’ve been reading Dr. T’s stuff on here for a few months, and newly reading a bit on the online blog world, I’m pleasantly suprised to be coming across many OBs who realize c-sections have risks, mothers ARE capable of informed consent (as much as any other human being anyway), and that obstetrics should be based on evidence not emotion. Oh, not to mention that midwives are an underutilized resource, not evil witches!
http://mwwak.blogspot.com/
Baloney. Every OB and FP who promotes those (a significant number) acknowledge the risks to VBAC and vaginal breech delivery. In fact, it seems to me it is you who is incapable of acknowledging the risks of (unnecessary) c-sections to mother and neonate.
This is the exact reasoning promoted by those against the mammography guidelines, and they are correct. If we don’t screen every mother between the ages of 40-49, some WILL die of undetected breast cancer. This simplistic evaluation of risk ignores other factors- resource allocation, cancer statistics, and risks of biopsies, etc. The anti-vaccine camp uses a similar risk analysis- a one in a million risk of encephalopathy is catastrophic (and yes, some babies WILL die from vaccination), never mind the millions of lives saved. Doctors are also often not very good at making statistical inferences- they see many anecdotes and assume that every case must be too risky to allow few interventions. Like 630 vs. 69,000.
There are the OBs who are honest about the fact that med mal *forces* them to be more risk averse than they would otherwise be. Then there are the OBs who truly believe, in a religion like way, that mothers are stupid and any neonatal risk is too be avoided, and that iatrogenic complications don’t exist.
The complete (desire of) avoidance of risk, paricularly when it comes to children in general, is a very new phenomenon (and definitely moreso in the U.S.) Interesting to consider the ethical implications as we expand and extend the human life span. How we are born and how we die are the big question marks on this. Even if increasingly complex technology allows us to extend life, at what point is it not worth it/ too painful? Should we be saving micropreemies who will need 24-7 care for the rest of their lives? How about the capacity for IVF and giving birth to eight babies? I have no idea what the answers are, but I do know that they are not simplistic and that we HAVE to allow people to make their own decisions with informed consent, even if we don’t like/agree with the risk analysis.
Ugh, must work on being concise!
“The recommendation in 2000 after the TBT was NO breech delivery, patient choice be damned.”
And what about those 630 babies? What do you say to the parents who exercised “patient choice” and their babies are now dead after a truly horrific disaster in the delivery room, one that has emotionally scarred them for life, not to mention the grief of losing a baby who would otherwise be healthy and flourishing?
It is easy, oh so easy, to pontificate about patient choice. Try counseling parents who have buried a baby and then get back to me about the relative value of “patient choice” vs. a live baby.
Note that mwwak can offer a forceps-assisted vaginal delivery as an alternative to a c-section: when an intervention of some kind is needed to deliver the baby safely, she has a wider armamentarium than many. Forceps are very difficult to use safely without hurting the baby and she happened to be very motivated to learn to master them.
She also acknowledges the risk.
“It is easy, oh so easy, to pontificate about patient choice. Try counseling parents who have buried a baby and then get back to me about the relative value of “patient choice” vs. a live baby.”
Gee, Dr. Tuteur, I thought you supported patient choice for vbac and vaginal breech delivery if the patient understood the risks (both ways). I thought we were pretty much in agreement. Risky choice, varied study outcomes, dependent on provider experience, should be available with *truly* informed consent. You sound a little bit hysterical, although I can understand why if you’ve been an ob to mothers who’ve lost their neonates to head entrapment in a breech delivery. Anecdotes can be very powerful.
“I thought you supported patient choice for vbac and vaginal breech delivery if the patient understood the risks ”
But anyone who is cavalier about the babies who will die doesn’t understand the risk. That’s been my point all along.
Amy’s hysterical finger-pointing approach on this topic and several others does not help the call for rational, science-based medicine. Giving birth has risks, and in the U.S. those risks are among the lowest in the world, even for home-births, and parents who decline the muscular medical interventions Amy is pushing so hard in this article and others. Babies die in hospitals too, and sometimes because of medical mistakes. My son’s hospital birth was far from perfect: nurses whisked him away because they said his O2 levels were low. When I tried to follow they informed me it was against the rules. I ignored them. They put him under a mask with lots of tubes and sensors, and to my amazement, as these women chattered and laughed, his O2 levels kept dropping. Finally I realized they hadn’t connected a large blue tube that delivered O2. When I pointed it out, they just laughed and connected the tube, and went back to their conversation. God knows what damage was done, but I’m sure this was recorded this as another successful hospital birth with no complications. The vitamin K injection, severe jaundice, heel puncture, and relentless unwelcome demands to circumcise him added insult to injury. At least he got out with all his penis intact. Not a very good advertisement for the medical industry.
I’m jealous of my friend who has given birth to two healthy sons at home, with no beeping monitors, c-section pushing doctors, circumcisers, injections, O2 machines that did more damage than good, and careless nurses.
-John Kuehne, Ph.D.
Dr Tuteur – “Try counseling parents who have buried a baby and then get back to me about the relative value of “patient choice” vs. a live baby.”
Do you equally inform mothers about the dangers of c-sections? And the differences between a vaginal birth and c-section? Do you advise against elective c-sections? I’m certainly not against c-sections and they can be life saving for both mother and child, once again I question your neutrality on this issue Dr Tuteur (and how you’ve chosen a controversial topic – c-sections – and yet again seem to be trying to use science merely to prop up a personal position).
Dr Tuteur, you seem to be making this about you and your feelings, which is fertile ground for personal bias to creep in. While I’m sure that delivering healthy babies (and being given full credit and praise for doing so) is more satisfying than the more difficult aspects of your job, dealing with the hard parts of being an OB/GYN is also part of your job. Some women do have hard choices to make about keeping a baby or ending a pregnancy (due to both physical or life complications and birth defects). Women do lose babies – both during pregnancy and childbirth, and after birth as well.
An upset parent may not be very rational, even if they were properly informed about benefits vs risks of a procedure, but that doesn’t mean you should be taking away the opportunity for parents to assess risks and make their own choices simply because you find it hard to deal with a distraught parent who may blame you after the fact (or even sue you). All one has to say is “the risks are 1 in whatever, that may not seem too bad but remember that you may be that one in whatever”. It really isn’t nearly as complicated as you make out to get people to understand risk. There’s no need for the emotional manipulations and fear mongering approach you seem to prefer, a simple personalization works very well to personalize risk without manipulative dramatics. In fact, by being emotionally manipulative you’re making it harder for parent to make a rational decision about a highly emotionally charged matter.
It’s interesting that you chose to approach a generally controversial topic – c-sections – from this angle and are making an argument from emotion that you’re dressing up as SBM. An interesting article about the controversial topic of unnecessary c-sections (slightly off topic but relevant considering the high rate of elective c-sections in the US)…
http://www.scientificamerican.com/blog/post.cfm?id=elective-cesarean-sections-are-too-2010-01-11
Funny thing about the WHO study you referenced: the authors were so anxious to condemn elective C-sections that they ignored the fact that THEIR study showed that the safest form of delivery (for babies and mothers) is elective C-section WITHOUT medical indications. Their data show it to be safer than vaginal delivery!
This may be my last comment here but I have to agree with Zoe on the question of emotionally laden information:
If you are going to present information on which a patient is to make an “informed choice”, it must be a dispassionate presentation of the facts.
Once emotional content is added, the patient is no longer making an “informed choice” but a “forced choice”. Yes, that is an oxymoron – you are effectively telling the patient what to do.
I do understand that a mother with a dead baby is necessarily an extremely emotional situation for both the mother and her doctor, but that is no excuse for an unscientific approach to this question.
The best summary I have seen is this (slightly paraphrased):
“A mother may request a caesarean, but it is the doctor who must use her knowledge of medicine and the patient to provide guidance. The decision should respect both the patient’s autonomy and the doctor’s obligation to optimize the health of both the mother and her baby”
“Do you equally inform mothers about the dangers of c-sections?”
Of course I do; that’s part of my job. Interestingly, women seem to have a much better grasp of the risks and consequences of surgery than they do of the risks of neonatal death. I suspect that is because most people think of surgery as inherently dangerous and (erroneously) think of childbirth as inherently safe.
“once again I question your neutrality on this issue”
Neutrality on what issue? I am decidedly not neutral on the subject of neonatal death. I am unabashedly committed to the notion that it is a tragedy of major proportions and that all reasonable measure should be taken to prevent it.
The key criterion of informed consent is being informed. Anyone who dismisses the possibility of neonatal death out of hand or as too negligible to consider seriously cannot possibly make an informed decision.
Those who are commenting in this thread supporting the notion of patient choice refuse to make the acknowledgment that would justify their support of such choice. They need to acknowledge that they find it acceptable that some babies will die needlessly in order for other women to avoid surgery that was unnecessary in retrospect.
I am all in favor of patient choice, but I can tell you as an obstetrician that it is extraordinarily difficult to obtain informed consent in the current climate when women are told that obstetricians merely want to rob them of their “birth experience” and make extra money (they don’t make extra money) on promoting C-sections instead of blissful, “empowering” vaginal births.
I always found it much easier to obtain informed consent for hysterectomies and other GYN procedures than to obtain informed consent for obstetric procedures where a baby’s life may be placed at risk, because it often seemed to me that patients discounted the possibility of neonatal death.
I’m assuming you are pro-life Dr. Tuteur? That is the only reason I can see for putting a fetus’ life ahead of a woman’s right to informed consent?
I am probably in the politically incorrect minority, but not only am I pro-choice, I also would not sacrifice my own life for my fetus’s. If an ob told me, it’s your life or your 38 week fetus, I would say “save mine.” I have other children to take care of.
Again, I have said repeatedly that I realize neonates are at risk of dying with a vaginal breech birth (630 of them every year, if I believe your numbers, which the more you refuse to give a source for them, the more I doubt them). They are also at risk every time we put them in the car. Mothers and grandmothers are at risk of death from cancer every time we scan every other year rather than every year. We could also probably cut down on neonatal death if we put women in the hospital for their entire pregnancies. And yes, I believe the risks of breech are probably more significant than these examples, but so are the risks of surgery.
I also stated that I myself would most likely choose a cesarean for breech. But I realize that women are smart, diverse, and capable of making their own decisions, with their own risk analyses.
You are no different than those who seek to limit a woman’s right to choose elective cesarean section, saying they don’t “truly” understand the risks.
Anyone who dismisses the possibility of neonatal death out of hand or as too negligible to consider seriously cannot possibly make an informed decision.
I hope Dr. Tuteur remembers to inform her patients when discussing or before doing a circumcision that every year some boys die from the complications of this surgery and that this circumcision might be the next death. Seems in her recent circumcision post she forgot to mention the possibility, or thought it too negligible to consider seriously.
This whole thread is surreal: millions of women in the U.S., and most of the women on earth, can’t even afford to buy a C-section. It’s only a choice for the wealthy, or those who are fortunate to be covered by that peculiar social medicine known as Health Insurance. There’s no obligation for a hospital to perform a C-section that patients elect to have but can’t pay for. There’s no legal obligation for a hospital to do a C-section at all unless the woman or baby are in the process of dying.
“This whole thread is surreal: millions of women in the U.S., and most of the women on earth, can’t even afford to buy a C-section. It’s only a choice for the wealthy, or those who are fortunate to be covered by that peculiar social medicine known as Health Insurance. There’s no obligation for a hospital to perform a C-section that patients elect to have but can’t pay for. There’s no legal obligation for a hospital to do a C-section at all unless the woman or baby are in the process of dying.”
That’s because your health system is ******
And it’s all because of ideology.
What do you call it? Libertarianism?
Hey, people are more important than ideology.
And there’s finally been a chance to fix it but you missed it.
In some parts of the world, it doesn’t depend on whether you are wealthy or not, if you need a caesarean you get one.
“I’m assuming you are pro-life Dr. Tuteur? That is the only reason I can see for putting a fetus’ life ahead of a woman’s right to informed consent?”
Your assumption is wrong.
Moreover, I’m not putting a fetus’ life ahead of a woman’s right to refuse a C-section. I’m saying that refusing to acknowledge the risk or minimizing the risk makes it impossible for a woman for to give consent that is informed.
When someone says to me (and it has happened): I’d rather take the risks that the baby dies than to do X, they’ve acknowledged that risk. I am both legally and ethically obligated to accept the patient’s decision even if the baby does die, which did happen in one case.
The issue of informed consent for procedures that put the baby at risk extend far beyond the issue of breech delivery. The assumption that every baby who starts labor healthy will be healthy at birth drives the rising C-section rate.
Americans say to obstetricians, “Give me a perfect baby or I will try to destroy you professionally and economically by suing you” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.
If we wish to control the rising C-section rate, we must confront the expectations of patients, including those who refuse to acknowledge that liberal policies for vaginal breech delivery or VBAC will mean that some babies will die.
“That’s because your health system is ******
And it’s all because of ideology.
What do you call it? Libertarianism?
Hey, people are more important than ideology.
And there’s finally been a chance to fix it but you missed it.
In some parts of the world, it doesn’t depend on whether you are wealthy or not, if you need a caesarean you get one.”
That’s right. If a hypothetical person truly cares about babies, they’d work on lobbying for universal health care. Poverty issues, race issues, and prematurity for social reasons is what is ***killing*** babies in this country. Not the very rare woman opting for vaginal breech delivery or homebirth.
“Americans say to obstetricians, “Give me a perfect baby or I will try to destroy you professionally and economically by suing you” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.”
Is that where your passion comes from and why you retired? There are some who wonder why you’ve gone off the deep end on this subject.
Dr Tuteur – “Neutrality on what issue? I am decidedly not neutral on the subject of neonatal death. I am unabashedly committed to the notion that it is a tragedy of major proportions and that all reasonable measure should be taken to prevent it.”
Neutrality about c-sections, of course, since that’s the issue being discussed. Not only are you erecting a strawman by making it all about neonatal death, you’re once again doing so by making a potentially inflammatory emotional appeal (and once again in a way that invokes a very inflammatory subject in the US, though a woman’s right to choose isn’t controversial in Canada, Australia or Europe).
Dr Tuteur – “The key criterion of informed consent is being informed. Anyone who dismisses the possibility of neonatal death out of hand or as too negligible to consider seriously cannot possibly make an informed decision.”
You’re erecting another emotionally laden strawman, nobody here is dismissing the possibility of death out of hand or pretending babies don’t die. What you’ve been called on is using unnecessarily emotionally loaded language when relating the risks/benefits of c-sections and not actually presenting the evidence in a neutral manner (others have called you out on misrepresenting the statistical risk, not being a statistician I don’t know about that – however I do know about communication and you clearly try to use emotionally charged language to manipulate both patients and readers of your posts here).
Dr Tuteur – “I am all in favor of patient choice, but I can tell you as an obstetrician that it is extraordinarily difficult to obtain informed consent in the current climate when women are told that obstetricians merely want to rob them of their “birth experience” and make extra money (they don’t make extra money) on promoting C-sections instead of blissful, “empowering” vaginal births.”
Ahhh, so it’s all about you and your personal ideological battles again and not actually about SBM. I’m confused – are you actually a working OB/Gyn or retired? You seem to have a personal resentment that some women choose other options and once again are just grinding some ax rather than actually discussing this as SBM. You seem to have some kind of weird resentment against vaginal birth. For someone who keeps claiming to have an interest in science, you don’t seem at all interested in some of the current research that’s being done. It’s not conclusive by any means, and only a beginning, but it does point out a lack of knowledge in this area and something that mothers should potentially be aware of if they’re going to make a truly informed choice. Now, clearly c-sections can save both babies and mothers lives when they’re truly necessary and no one here seems to be disputing that, what is being disputed is your emotionally charged language and your very obvious personal bias in this matter which you’re trying to float as SBM. The other thing you seem to be totally ignoring is just
The inconclusive but interesting first forays into the neurobiology of childbirth.
http://sciencebasedparenting.com/2008/09/13/vaginal-birth-vs-c-section-the-interview/
Just so you know, I’m sympathetic to just how difficult it can be for doctors to practice medicine in the anti-medicine climate (both my parents are doctors). However, your tactic of personalizing and using emotionally loaded language (and admitted desire to be sensationalist to get attention) serves neither SBM nor women’s health. In fact, it makes you appear to be an ideologue and someone willing to use emotional bullying and abuse professional power/authority, not to mention willing to abuse science, to enact your own personal/ideological agenda.
Dr Tuteur – “Americans say to obstetricians, “Give me a perfect baby or I will try to destroy you professionally and economically by suing you” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.”
You are aware that there’s a whole world beyond America and you’re writing on the internet? Once again, it’s not all about you. Of course I’m shocked that a physician would put their own economic well being before their patient’s health, it’s highly unethical! I find it interesting that you don’t take issue with this. Trying to blame patients for your actions is pretty unethical too. This constant refrain of yours – that doctors are being victimized (particularly American doctors since you seem to disregard the rest of the world, except when ideologically useful) – is a bit pathetic. Having a c-section is no guarantee someone will have a perfect baby, do you tell your patients this as a means to encourage c-sections? All this “perfect baby” nonsense seems to be coming from you and some of your American colleagues. It’s interesting that you even use this terminology – “perfect” – when one would hope the goal is to have a healthy baby and mother.
I rather think that you are proving my point for me.
I’ve presented the scientific evidence that shows that vaginal breech delivery involves real risk of neonatal death and have made the argument that those who promote vaginal breech delivery ignore or elide that risk.
And in this thread those who are promoting vaginal breech delivery ignore or elide the risk to babies. I don’t notice anyone saying what must be said: The preventable deaths of 630 babies is worth it to reduce tens of thousands of unnecessary (in retrospect) C-sections.
If you think it is worth it, then say so. If you are not willing to say so, then you are ignoring the real risks.
“The inconclusive but interesting first forays into the neurobiology of childbirth.”
http://sciencebasedparenting.com/2008/09/13/vaginal-birth-vs-c-section-the-interview/
Thanks for the link.The study author is Dr. Swain, MD, PhD, a Yale psychiatrist with a neuroscience Ph.D. Sample size 12.
I’m skeptical of the findings that c-section moms may show less response to crying in their brains from MRIs. But I know almost nothing about MRI research either.
But I do think Dr. Tuteur glosses over the risks of c-sections because of her ideological war.
Dr Tuteur – “If you think it is worth it, then say so. If you are not willing to say so, then you are ignoring the real risks.”
Once again you erect a strawman because all you can do is think in black and white terms (a la “you’re either for me or against me” and that anyone who actually calls you on something must be an advocate of whatever you’re against…it’s a telltale sign of an ideologue that you can’t get beyond binary thinking). I’m for informed consent and think it should be the mother’s choice (with input from her partner when appropriate) – not mine, not your’s…do you understand this? What you’re being called out on here is promoting your own personal agenda using emotionally loaded language rather than presenting the information in a neutral way. You’re using exactly the same tactics as the people you’re all up in arms about. All that a mother needs to be told is what the information is and reminded that even though the odds may seem good that she may be the unlucky one in however many. For myself and my baby, that’s a decision I’d make at the time and according to the evidence and my particular situation, not due to some predetermined ideological position. I respect the right of other women to make their own choices, particularly without being emotionally bullied or having the evidence misrepresented by someone in a position of power.
Zoe – I totally agree that it’s a small sample size and not at all definitive. My point was to prove anything, it’s that we don’t know and more research needs to be done. Clearly all the repercussions of having a c-section instead of a natural birth aren’t known yet (and even if natural childbirth does end up being preferable it doesn’t mean that c-sections won’t need to be done, I’m not anti-c-section, I’m anti-emotional rhetoric and ideological positioning trying to pass itself off as SBM). And, obviously, c-sections aren’t risk free for the mother (even if they do reduce the risk of being sued for doctors in America).
This is an interesting article that looks at ways to reduce the need for c-sections and the role of technology in the increase. Since the rates have been rising astronomically around the world, it’s worth considering why and if this is really in the mother and child’s best interests. There are some very interesting discussions to be had around this issue, particularly if we look at this rationally and not from an emotionally charged and ideological starting place.
http://www.research.utoronto.ca/behind_the_headlines/what%E2%80%99s-behind-canada%E2%80%99s-rising-c-section-rate/
That was meant to read…
“My point WASN’T to prove anything, it’s that we don’t know and more research needs to be done.”
Actually, I guess my point was to prove that there are still many unknowns and things to be considered and that c-sections aren’t a simple black and white issue.
If anyone is interested, the official position of Canadian OB/GYNs is that c-sections shouldn’t automatically be done for breech births.
[excerpt]
“No more automatic C-section for breech births, says Ob/Gyn Society
Halifax – June 17, 2009 – Physicians should no longer automatically opt for caesarean sections in the event of breech birth, according to new guidelines for Canadian health professionals released today by the Society of Obstetricians and Gynaecologists of Canada.
The guidelines are based on a comprehensive review of research and clinical evidence regarding the safety and outcomes of vaginal breech births compared with that of caesarean sections.”
http://www.sogc.org/media/advisories-20090617a_e.asp
On Tuteur’s point that “the most severely injured babies were already dead, and therefore were not included in a study of outcomes at 2 years of age.”
It should be noted that in subgroup analysis, for low-perinatal mortality countries, there was no statistically significant difference in perintatal mortality between the planned vaginal and planned caesarean delivery groups.
In the low-perinatal mortality countries, the recommendation of planned caesarean over planned vaginal delivery was therefore based entirely on the difference in morbidity, either alone or when aggregated with a non-significant difference in perinatal mortality. In the two-year follow-up, the difference had disappeared calling into question the initial definitions and judgments about serious morbidities (as well as the fact that paediatricians were not blinded as to which group – vaginal or CS – the neonates they assessed belonged).
Plonit,
“It should be noted that in subgroup analysis, for low-perinatal mortality countries, there was no statistically significant difference in perintatal mortality between the planned vaginal and planned caesarean delivery groups. ”
If that is true, then the actual information that Dr Auteur gives her patients is actually false.
This is another reason to present the information in a neutral manner: if the information you have presented to the patient is false, flawed, or incomplete, you won’t have unnecessarily aggravated your error by driving the patients decision in the wrong direction.
Dr Auteur,
“If we wish to control the rising C-section rate, we must confront the expectations of patients, including those who refuse to acknowledge that liberal policies for vaginal breech delivery or VBAC will mean that some babies will die.”
You seem to be in two minds about C-section. You both blame patient expectation of a perfect baby for the rising C-section rate and, at the same time, you are advocating more C-sections to reduce the infant death rate.
So, which is it, are there too many C-sections because of unrealistic patient expectation or do there need to ber more C-sections to reduce the infant death rate?
Dr. Amy, I couldn’t agree more with your prudent approach to breech deliveries. When things go wrong in obstetrics, it happens rapidly. And not only that, there are 2 patients at risk, not just one. I personally was glad not to be recovering from abdominal surgery while caring for my newborn. But why risk the baby getting “stuck” in the middle of delivery? Breech doesn’t just mean bottom first. It can be a footling or even worse, a shoulder presentation (which if I remember, is impossible to deliver vaginally).
Post C/S, the number of patients is decreased back to one, the post-op mother. Most complications, should they arise, post-op are generally of lower acuity. Infection or other complications to healing, can often be managed thru homehealth nursing care, even though care may need to be initiated in a hospital setting. Yes, in a perfect world, babies would gently emerge despite which end comes first. But once the body is delivered and the head is stuck, it’s too late to then op for a C/S.
It seems your blog attracts women who’s ideology trumps practicality. Big Birth is another medical conspiracy to earn $, and the dirty little secret is that child birth is a completely natural and safe occurrence. Human beings are at physical disadvantage compared to other animals. If the fontanels were closed, the head would not fit thru the birth canal. If our female pelvises were any wider, we could not walk upright. Considering all the amazing advantages our species is endowed with, it’s a fair trade off, IMO.
I don’t recall you ever mentioning the horrible reality of litigation. Any poor outcome for the neonate, means a lawsuit. Not to imply that dr’s perform C/S just to cover their butts. But people don’t realize how devastating an impact a neonatal death makes on the attending md. It just seems plain reckless to run the incredible risk of attempting a vaginal breech delivery. The patient may completely assume the potential for serious problems, but a dead child is automatically be the doctor’s fault.
“I’m assuming you are pro-life Dr. Tuteur? That is the only reason I can see for putting a fetus’ life ahead of a woman’s right to informed consent?”
This is just so wrong on so many levels. The woman who has carried her child to term, not only chose life, but is counting on it.
This comment is clearly not about appropriate medical care, but a battle of ideology.
The whole point of labor and delivery is a healthy, living child. It’s horrifying to imagine conceiving a child (not easily for many), enduring 9+ months of pregnancy, the intense pain of labor, and during the middle of delivery, you helplessly see your baby die.
Bang that feminista drum on a political blog, not a medical one.
“It should be noted that in subgroup analysis, for low-perinatal mortality countries, there was no statistically significant difference in perintatal mortality between the planned vaginal and planned caesarean delivery groups. ”
Do you mean in the TBT at two years? I’m looking at the tables now for the first one, and Plonit is correct. The bulk of the mortality/morbidity in low PMR countries comes from morbidity. IOW, it was only by combining the two that they got statistically significant results, probably because of lower sample size. I initially accepted Dr. Tuteur’s “630 babies will die” but now I’m starting to wonder if that’s correct. particularly in the U.S.
Fifi, I know you weren’t trying to prove anything. Those were just my disjointed thoughts as I read the link. I totally agree on binary thinking being a sign of an idealogue. Some natural child birth advocates do it, and Dr. T definitely does it.
While I’m on the subject, can I ask a question, Dr T?
Isn’t the standard of care to deliver the baby prematurely in the 3rd trimester if the mother’s health is threatened as opposed to a late term abortion?
I developed what appeared to pre-eclampsia during my 2nd pregnancy. When protein was detected in my urine, I gained 7lbs of water-weight in one week, my ankles and feet were too swollen to wear shoes, and my blood work revealed a elevated alk phos, my OB admitted me for MgSo4 gtt and an insertion of Cytotec. Early the next am, Pitocin gtt was started. By 3:30 pm, I was holding my son. Granted his gestation age assessment indicated 38 weeks. I recall doing a C/S for a woman with toxemia/severe eclampsia at just 26 wks. I’m an OR RN, and because of the acuity of the patient, anesthesia insisted on doing the case in Surgery, rather than OB (those nurses aren’t experienced at assisting an anesthesiologist). The NICU team was present to manage the infant, who was immediately intubated. Even though she was a micro-preemie, the overall prognosis was good and she was eventually discharged to home with her mother (several weeks in NICU).
When late term abortion is discussed in reference to saving the mother’s life, how often does this occur in reality? Note, the viability of the infant is a separate, but obviously significant issue-meaning I see no ethical conflict with a late term abortion for fetal demise, anacephaloly, etc.
“I don’t recall you ever mentioning the horrible reality of litigation. Any poor outcome for the neonate, means a lawsuit. Not to imply that dr’s perform C/S just to cover their butts. But people don’t realize how devastating an impact a neonatal death makes on the attending md. It just seems plain reckless to run the incredible risk of attempting a vaginal breech delivery. The patient may completely assume the potential for serious problems, but a dead child is automatically be the doctor’s fault.”
Actually Dr Tuteur did mention litigation as a defense for her position, while also blaming her patients for having unrealistic expectations (though it can be easily argued that the commercial nature of American medicine – and the almost pathologically heroic way commercial medicine is often practiced – is at least partially responsible for creating those unrealistic expectations). She did acknowledge that in the US doctors perform c-sections to cover their butts financially (while simultaneously claiming there’s no commercial/monetary interest informing the frequency of c-sections). And, really, it’s not about the MDs feelings when they lose a patient (not to trivialize how sad death can be) and putting patients through procedures to spare the MDs feelings. Most MDs will lose patients over the course of their careers (both my parents are doctors), it comes with the territory. It’s unrealistic for an MD, including an OB/Gyn, to think they’ll never lose a patient so I’d suggest, once again, that some of the unrealistic thinking that patients end up with actually originates with doctors who have unrealistic heroic visions of themselves.
As it stands, I’m an advocate for informed choice and not ideologically against c-sections. What I object to is the emotionally charged language Dr Tuteur uses to persuade women towards what she prefers and the pretense that doing so is somehow SBM. Each woman should be able to decide for herself without being bullied in that way, and it’s something that should be discussed well before a woman starts giving birth. Women should know that childbirth carries risks, as well as the potential complications from c-sections and potential risks for future pregnancies if you have a c-section. Trying to scare women about natural childbirth OR c-sections with emotionally charged language is emotional bullying and manipulation, it’s not practicing SBM.
A c-section can be a necessary and lifesaving procedure for both mother and child. However, to routinely do c-sections so a doctor can protect him or herself from being sued is highly unethical (and seemingly a particularly American thing to do). That this has twice been used as a defense of routinely doing c-sections doesn’t do much to dispel accusations that it’s about money in the US. In other countries with non-commercial medical systems the rising rates of c-sections are due to other factors (so it didn’t actually occur to me that it was about money).
I’ll continue to look to policies in Canada, Australia and Europe to inform and guide my own decisions about any medical treatment I may require simply because of the commercial nature of American medical practice and the lack of focus on SBM and rational public health policies.
@ laursaurus
“Breech doesn’t just mean bottom first. It can be a footling or even worse, a shoulder presentation (which if I remember, is impossible to deliver vaginally).”
You are right, not possible to deliver vaginally with shoulder presentation, but the TBT was not about this presentation – and no one is doing planned vaginal deliveries with shoulder presentation.
“But once the body is delivered and the head is stuck, it’s too late to then op for a C/S.”
That’s true. It is also true that once the head is delivered and the shoulders are stuck (shoulder dystocia), it’s really too late to then opt for a CS. But we don’t use that argument as the basis to institute 100% CS, because as you rightly point out there is maternal health to consider also.
Head entrapment is operating more as spectre than science in this debate – from the discussion you would think that the deaths in the TBT were mostly caused by this very rare complication of breech, which is simply not true. In fact, some of the deaths – I forget what proportion, and don’t have access to the paper right now to check – were not caused directly by the mode of delivery. At least one baby in the planned vaginal delivery died before onset of labour, so the death was certainly not due to head entrapment or any other complication of the delivery itself. TBT was intention to treat analysis, so it is right to include these sorts of death – especially as planned CS were inevitably delivered earlier (on average) and this may have some effect on outcome regardless of presentation.
Do you mean in the TBT at two years?
++++++++
I mean that in the initial findings, there is no statistically significant difference in perinatal mortality alone in the low perinatal mortality countries. However, in the low-perinatal mortality countries there was a statistically significant difference in what was termed “serious” neonatal morbidity. The aggregated mortality+morbidity also showed statistically significanct difference.
At two-year follow-up, in the low perinatal mortality countries, there was no longer any statisically significant difference in morbidity. There was still no difference in perinatal mortality, because there never had been. Aggregated, the mortality and morbidity in low-perinatal mortality countries showed no difference at two years.
Fifi, “What I object to is the emotionally charged language Dr Tuteur uses to persuade women towards what she prefers and the pretense that doing so is somehow SBM. Each woman should be able to decide for herself without being bullied in that way, and it’s something that should be discussed well before a woman starts giving birth.”
Fifi, “Beauty is in the eye of the beholder.” Maybe emotion is in the ear of the reader because I find your posts to be full of “emotionally charged language”. I definitely agree that people should be able to decide for themselves what is best and in this instance it goes for patients and their doctors. Neither should be able to force the other to do something they are not comfortable with.
I also think people should be able to stand up to bullies and that they should prepare themselves ahead of time for life’s major events – like childbirth. Most people know when they are quite young whether or not they want to have children. If they do, they should start educating themselves early on about the procedure and start looking for practitioners they feel comfortable and compatible with, be that a witch doctor, a practitioner of evidence-based medicine or anyone in between, so that when the hour arrives, they are well prepared.
Fifi, “Actually Dr Tuteur did mention litigation as a defense for her position, while also blaming her patients for having unrealistic expectations (though it can be easily argued that the commercial nature of American medicine – and the almost pathologically heroic way commercial medicine is often practiced – is at least partially responsible for creating those unrealistic expectations).”
“Blaming her patients” for unrealistic expectations” or stating that people in the society where she has practiced have unrealistic expectations? I most certainly believe that that the majority of people today have very unrealistic expectations about medicine and that the main reason is that given the improved health care that we enjoy, compared with that of even our parents or grandparents, very few people today ever experience serious illness or death until, often quite late in life, they or someone they love are afflicted. At that point they do not have the experience necessary to deal emotionally with it in an appropriate way. And please don’t tell me that these things don’t have to be experienced that they can be taught from a book or a lecture.
It may be quite easy to argue about the commercial nature of American medicine and about American culture as compared to the practice of medicine in other countries, but it is very hard to get evidence to support those arguments that can’t be refuted with evidence from the opposing side simply because of the great complexity of the problem. If you want to trade anecdotes, you can also find many supporting each of the opposing positions. I lived in Quebec for 10 years and was on your system and now live in Vermont 1.5 miles south of the border. I’ve also lived, worked and studied in Italy, Germany, Mexico and Spain.
You may look to health policies in Western countries other than the US to help you make informed medical decisions. I look at the scientific evidence.
I would guess that there are very few people in any western society, even doctors, who face, and I do mean face as look in the eye, the life and death decisions that obstetricians face on a regular basis. In their field things can go very bad very fast. It is very emotional for them and for their patients. So much so that I find it amazing that there are still people willing to practice in the field and it astonishes me to hear the way so many people here who never are in those situations attack Dr. Tuteur.
I would guess that there are very few people in any western society, even doctors, who face, and I do mean face as look in the eye, the life and death decisions that obstetricians face on a regular basis. In their field things can go very bad very fast. It is very emotional for them and for their patients. So much so that I find it amazing that there are still people willing to practice in the field and it astonishes me to hear the way so many people here who never are in those situations attack Dr. Tuteur.
+++++++++++++
I don’t think anyone is attacking Dr Tuteur. Her presentation of the issues is being questioned.
Also, I agree with you that obstetricians and midwives have more of their fair share of looking death in the face – and it is emotional. However, the issue is not whether childbirth presents dangers (it is a given that it does) but whether interventions (such as CS) can reduce those dangers. This is one of the things need science-based medicine for: to overcome our emotional drive to do “something” regardless of the efficacy of that intervention. In the findings of the TBT, in countries with already low perinatal mortality, CS for breech at term did not reduce perinatal mortality, and intitially large differences in neonatal morbidity were not sustained over time.
Thanks for the explanation Plonit. That was my take as well, but it does seem to invalidate every argument Dr. Tuteur has made thus far, at least the fact based ones. That’s informed consent… how?
“If they do, they should start educating themselves early on about the procedure and start looking for practitioners they feel comfortable and compatible with, be that a witch doctor, a practitioner of evidence-based medicine or anyone in between, so that when the hour arrives, they are well prepared.”
Rosemary, I agree with you. I also do not agree with Fifi that *some* doctors are promoting c-sections for financial reasons. Medical mal being what it is, these doctors are simply trying to continue practicing. I know way too many good obs who have gone out of practice because of the insurance rates. For their education level, OBs don’t seem to be raking in the dough either. So the financial argument may be valid, but only on a system wide level, not an individual OB level.
My own OB was very honest that a lot of hospital policies were CYA and not evidence based, and that she was perfectly willing to let me labor without intervention. I trusted this OB that when she said (hypothetically speaking) I needed a c-section, it was for a damn good reason, not just because the baby was 10 pounds or I’d been laboring for 24 hours. (CPD and Friedman’s curve). I also asked for her rates- and they were around 15%, despite her fairly high high risk caseload. Because you really do need that trust- if you are in the middle of pushing, doing extremely hard work, it’s rather hard to give informed consent, stop the episiotomy, or refuse a c-section.
Then there are the obs who are defending the system and asserting that c-section for everything is justified by the evidence. Which it’s not. Just because the technology is there doesn’t mean it’s beneficial in every circumstance. Some obs, out of idealogy, fear, or emotion, assume that their interventions are always necessary. But it is not that simple, and research has reflected that. Again, that false dichotomy.
The Term Breech Trial and the PREMODA study are not the only two papers on the subject. I chose to present them because they represent the two poles of the debate.
Since the publication of the TBT study, there have several large studies of breech vaginal delivery in real world populations.
Rietberg et al., The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35 453 term breech infants, BJOG 2005;112:205–9):
“Within two months after publication of the Term Breech Trial, the overall caesarean rate increased from 50% to 80% and has remained stable thereafter. In the group of infants less than or equal to 4000g this was associated with a significant decrease of perinatal mortality from 0.35% to 0.18%, a decrease of the incidence of 5-minute Apgar score less than 7 from 2.4% to 1.1% and a decrease of birth trauma from 0.29% to 0.08%. In the (small) group of infants greater than 4000g a similar trend was observed.”
Gilbert et al., Vaginal versus cesarean delivery for breech presentation in California: a population-based study. Obstet Gynecol 2003;102:911-17:
“More than 3.2 million singleton term newborns were identified during the study period, with 100,667 (3%) in breech presentation at the time of delivery. Of these, 4952 women (4.9%) had vaginal breech delivery, whereas 60,418 women delivered by cesarean without labor, and 35,297 women underwent cesarean in labor. Breech vaginal delivery in nulliparous women was associated with increased neonatal mortality (odds ratio [OR] 9.2, 95% confidence interval [CI] 3.3, 25.6) and morbidity (asphyxia: OR 5.7, 95% CI 4.5, 7.3; brachial plexus injury: OR 33.9, 95% CI 15.2, 76.1; and birth trauma: OR 5.8, 95% CI 4.7, 7.1) compared with breech delivery by prelabor cesarean in nulliparous women. In breech-presenting women with one prior vaginal delivery, neonatal mortality was not different between groups, but morbidities (asphyxia: OR 3.9, 95% CI 3.0, 5.1; brachial plexus injury: OR 22.4, 95% CI 9.9, 50.5; and birth trauma: OR 4.2, 95% CI 3.4, 5.3) remained increased for vaginal compared with cesarean delivery. CONCLUSION: The “normal” term breech fetus, when delivered vaginally, had significantly increased neonatal mortality (in nulliparous women) and morbidity (all breech deliveries), when compared with the breech fetus delivered by cesarean, which suggests that these patients might best be delivered by cesarean to avoid these adverse outcomes.”
Collaborative Breech Study Group. Term breech delivery in Sweden: mortality relative to fetal presentation and planned mode of delivery. Acta Obstet Gynecol Scand 2005;84:593–601:
“The study comprised two parts. Study A is a national cohort study for the period 1991–2001, including 22 549 breech presentations and 875 249 cephalic presentations born at ≥38 completed weeks. Study B is a case–control study, including all 164 breech deliveries with perinatal or 1-year infant death (during 1991–1999 in Sweden) and controls.
Results. Study A: Among non-malformed infants, the total mortality rate was 0.46% in breech and 0.28% in cephalic presentations [adjusted odds ratio (OR) 1.6; 95% confidence interval 1.3–1.9]. Non-malformed breech babies were at an increased risk of antenatal death (breech versus cephalic hazard ratio: 2.7, 2.1–3.6). The infant mortality among non-malformed breech deliveries was higher in vaginal birth than in delivery by CS before labor (OR 2.5, 1.2–5.3). The perinatal + infant mortality among non-malformed breech babies was higher at delivery after 39 completed weeks than at CS delivery at 38 weeks (0.53% versus 0.14%; OR 3.5, 1.9–6.4). The estimated needed number of CS to avoid one death was 400. Study B: In breech presentations without malformations, OR for perinatal or infant death was 3.1 (1.7–5.8) at planned vaginal delivery compared with planned CS delivery, and when breech presentations not diagnosed at 37 gestational weeks were excluded, OR was 3.7 (1.6–9.2).
Conclusions. These large population-based and case‐control studies both show a significant reduction of perinatal and infant mortality with planned CS in term breech pregnancy.”
Even the authors of the PREMODA study acknowledge that vaginal breech delivery leads to an increased risk of death. They merely claim that the risk can be reduced by limiting eligibility with very strict criteria.
In other words, claiming or implying that vaginal breech delivery can be extended to tens of thousands of women without resulting in preventable neonatal deaths is simply false. If we wish to consider a policy of promoting vaginal breech delivery, we inform women of the risk and make sure they understand that their babies could die and some will die.
Rosemary – “I would guess that there are very few people in any western society, even doctors, who face, and I do mean face as look in the eye, the life and death decisions that obstetricians face on a regular basis.”
We actually agree about more than we disagree about Rosemary – where we mainly disagree are our opinions of how Dr Tutuer presents her arguments on both this topic and others she’s written about here, and on how heroic OB/GYNs are in relation to other doctors and people. You are aware that Dr Tuteur tries to be inflammatory on purpose and has said so?
Sorry but your guess is not a particularly good guess. Anyone who works in an ER/trauma/emergency medicine faces life and death decisions frequently, as do lots of surgeons. Many other doctors deal with these kinds of decisions and even harder ones (as do nurses – while for obvious reasons there aren’t good statistics, voluntary/requested euthanasia and assisted-suicide aren’t as rare as the general public tends to think). Psychiatrists also face life and death decisions all the time – perhaps just not in a form you’d considered. You seem to be forgetting that a great deal of medicine is about treating dying and suffering people. The main reason why so many people think having a baby doesn’t hold many dangers anymore is because the risks actually have been greatly reduced. Nothing is risk free, of course, and people do have a tendency to believe that medicine can fix anything and is magic (and that bad things won’t happen to them and to blame their doctors when they do, this isn’t an area where OB/GYNs get singled out).
As for making decisions purely on the science…that’s a snappy answer but you’re a fool if you think you have the expertise and don’t need any input from a doctor. I mean, sure I’m quite well informed, I read up on things and grew up around medicine and research but I’m not a doctor, let alone a specialist. Even doctors rely upon other doctors who are specialists, they don’t presume to be specialists in every field (and it’s generally not a great idea for doctors to be treating themselves for anything but minor ailments, it’s a little matter of appropriate detachment).
Even if someone can weigh the evidence on their own, specialists have clinical experience as well as specialized education and can also judge each of our cases based on who we are as individuals. Studies are great but at the end of the day we’re all an N of 1. I ask my parents – who are doctors – for their opinions if it’s their field but they’re wise enough to refer me to a specialist when it’s outside of their field of expertise (or inappropriate for them to be treating me). I go to see a specialist because, if I have found them trustworthy, I value their opinion and expertise – specialists exist for a reason. If a doctor is trying to impose either their personal ideology or morality on me – and I have had this happen – I simply find another doctor. Not everyone is equipped to do this though and many people see doctors as authorities they can’t question or aren’t comfortable enough with science to even start weighing the evidence. The fact remains that many people rely upon their doctors to help them make decisions. Adding emotional content to sway a patient one way or the other is unethical, particularly if it’s under the pretense of being neutral and simply SBM. Offering a professional opinion, which can most definitely include the physician’s biases, is an entirely different thing than pretending to be merely presenting the scientific facts (particularly if not all the facts are being presented due to a professional/personal bias).
zoe – “I also do not agree with Fifi that *some* doctors are promoting c-sections for financial reasons.’
I didn’t originally make this claim and I highly doubt it’s relevant anywhere but in America. It was Dr Tuteur who said that doctors were making decisions to perform c-sections for fear of being sued and brought the idea of the “perfect baby” into the conversation (I’d think the goal would be a healthy baby AND mother). The financial incentive didn’t even occur to me until Dr Tuteur brought it up in defense of c-sections, it seems to be something specific to America. I’m still unclear why she believes that people shouldn’t be shocked or dismayed by her assertion.
Dr Tuteur – “Americans say to obstetricians, “Give me a perfect baby or I will try to destroy you professionally and economically by suing you” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.”
Amy said, “In other words, claiming or implying that vaginal breech delivery can be extended to tens of thousands of women without resulting in preventable neonatal deaths is simply false. If we wish to consider a policy of promoting vaginal breech delivery, we inform women of the risk and make sure they understand that their babies could die and some will die.”
Yes, this is fair to say. However, for many women, especially those in a first pregnancy, avoiding a c-section is an important consideration for future fertility, healthy pregnancies and births. What are the stats about the risks of c-section for mothers, babies and future reproduction? Currently in an increasing number of US hospitals, one c-section means all future births must be c-section. Do you think that these other factors should be factored in when parents are deciding to risk their baby being that 1 in 111 that doesn’t survive a vaginal breech birth?
Informed choice again.
Rosemary,
“I also think people…should prepare themselves ahead of time for life’s major events – like childbirth. Most people know when they are quite young whether or not they want to have children. If they do, they should start educating themselves early on about the procedure and start looking for practitioners they feel comfortable and compatible with…so that when the hour arrives, they are well prepared.”
You’re living in cloud cuckoo land!
What percentage of woman, when they decide they will have children, have the inclination, intelligence, wisdom, and investigative skill to do this. My estimate is <10%
Of those, what percentage could attain a level of knowledge to be able to effectively argue against what their obstetrician recommends. Again, my estimate is <10%
So we effectively have <1% of mothers who have anything that could reasonably be called "informed choice".
BillyJoe, if your estimates about women are correct, and if the other side of the coin is also correct, that doctors are highly intelligent almost always right superior beings, then in the interest of society, I think we had better return immediately to the old paternalistic society of our ancestors.
If your estimates about women are correct, but you do not believe that doctors are all knowing, then I think instead of fighting with doctors and demanding that they hand feed and take responsibility for the total education of their patients as I feel people here are doing, I think we should just give up on women and let them suffer the consequences of their inferiority.
Plonit, I disagree with you about people attacking Dr. Teuter personally. I have the impression that they do. In comments on another topic they even attacked her writing style.
I agree with you about the need to objectively review the evidence. In my glancing at comments it seems to me that that is what you have been doing, but you are in the minority.
@Fifi “And, really, it’s not about the MDs feelings when they lose a patient (not to trivialize how sad death can be) and putting patients through procedures to spare the MDs feelings. Most MDs will lose patients over the course of their careers (both my parents are doctors), it comes with the territory. It’s unrealistic for an MD, including an OB/Gyn, to think they’ll never lose a patient so I’d suggest, once again, that some of the unrealistic thinking that patients end up with actually originates with doctors who have unrealistic heroic visions of themselves.”
The tragedy of losing a baby is a much more horrific event than losing an adult for everyone involved. The father, siblings, grand parents are devastated. It really is not comparable to other deaths. For months, the family is anticipating one of the most joyful events of their lives. Child birth is the only happy occasion to visit the hospital (if I had a nickel for everytime a visitor mumbled, “I hate hospitals!”)…. As I said before, I was an OR nurse for many years. The patients I actually witnessed dying on the table, arrived already with a grave prognosis. A somber cloud envelopes the room the moment of death. These are tragic. But the most upsetting occurrence of my career was an emergency C/S for fetal demise. Even knowing the baby was already dead, seeing the blue, lifeless body of an otherwise normal, 7+lb baby boy, was indescribable. Things got even worse, as the patient went into DIC needing an emergency hysterectomy to save her life. There was no time to grieve when the nursing supervisor had to get verbal consent for an emergency hysterectomy from the husband/father. (She had general anesthesia). Post-op, she went into renal failure and was very lucky to survive.
Dad requested to see the baby (which is considered a healthy reaction) So one of the OB nurses wrapped up the beautiful, lifeless bundle.This was his only child (she had one from a previous marriage).
Although this scenario is completely different from a vaginal breech delivery gone bad, it exemplifies the profoundly different impact a neonate’s death has. The news spread quickly through the hospital nursing staff. Colleagues sympathetically inquired the nurses who cared for her(this was decades before the HIPPA regulations, where you are strictly forbidden to discuss personal health info with colleagues unless they’re directly involved in that pt’s care). I think the eventual admitting diagnosis was determined to be abruptio placenta.
In the event of a perinatal death, the feelings of the staff are much further down on the scale. Witnessing the immense pain and grief that the pt and her family had to endure was heart-breaking. When in the case of a breech presentation, a C/S seems like a no-brainer to completely avoid a well-known, significant risk. If a pt had appendicitis, cholecystitis, bowel obstruction, or even a benigh tumor, surgical intervention is medically necessary, usually on an elective basis. According to the studies Dr. Tuteur cites, C/S’s are life-saving surgical interventions. When parents refuse or neglect to seek medical treatment for religious or ideological reasons, society takes legal action in the interest of the child who doesn’t have the authority or ability to informed consent. If a mother refuses a C/S for a breech delivery, it is a practically identical situation. There is no opportunity for legal action of behalf of the child. So it’s up to the OB dr to explicitly explain that insisting on a vaginal delivery for a breech presentation is accepting a lethal risk. Where is the distinction between merely the mother’s preference and refusing medical treatment for the child? It’s ridiculous to consider the doctor’s legitimate deep concern for the infant’s survival as “bullying”.
When a child of Jehovah’s Witness’ survival requires a blood transfusion, is it “bullying” for the pediatrician to state she’ll obtain a judicial order if they refuse? How about the 13 year old boy who was to have court-ordered chemotherapy? The mother took off with her son and a nation-wide manhunt ensued. She had decided chemo was “poison” and faith-healing/prayer was the cure. Eventually, she was caught. The boy had chemo and his cancer went into remission.
Fifi, “You are aware that Dr Tuteur tries to be inflammatory on purpose and has said so?”
Fifi, I missed that but it would not change what I’ve said. I sympathize with Dr. T because I too am very passionate when I try to communicate about a topic that I feel strongly about. I think emotions are valuable and should be used effectively rather than suppressed. I think that denying that they exist or believing that anything, especially anything as personal as medicine, can or should be practiced in a cultural vacuum is at best unrealistic. I also believe that different cultures and different individuals react to what they perceive to be a display of emotion differently. Some believe that an emotional display demonstrates a lack of rationality. Others believe it demonstrates a lack of caring.
I know that there are people who I infuriate with my displays of emotion, but I also know that there are many, and many who are diametrically opposed to my positions, who respect me for them and conclude that I hold my positions because I really do care about human beings and many of them even agree that in spite of my passion I am rational. One quack site has actually stated that I do not go beyond the evidence regarding the dangers of silver supplements.
I’ve had many experiences that lead me to this conclusion about how my emotional approach to communication is viewed including a confirmed alt who repeatedly tried sending me a $75 Christmas present because even though she disagreed with me and we had exchanged some very heated words, she concluded that I care very deeply and truly believe what I had stated. (She kept sending the money to my Pay Pal account. I don’t have Pay Pal account and only accept homeopathic money which can be shaken and sent on the airwaves.)
Fifi, “As for making decisions purely on the science…that’s a snappy answer but you’re a fool if you think you have the expertise and don’t need any input from a doctor.”
I didn’t say that I don’t think there is a need to consult and listen to the opinion of an expert. I was responding to your comment about basing your personal medical decisions on the written policies of medical boards (not sure those are the right words) in western nations other than the US.
Fifi, “The fact remains that many people rely upon their doctors to help them make decisions.”
Please don’t blame doctors for that. And yes I agree that many people either cannot or do not want to review medical evidence for themselves just like I have no desire to learn about computers or software and choose to rely on others for relevant information in those fields, but in doing so, I also accept the consequences. IMO, people who are for whatever reason unable or unwilling to locate and evaluate medical evidence for themselves should familiarize themselves with reputable websites like that of the Mayo Clinic and set themselves up with doctors they trust and feel comfortable with before an emergency hits. I know not everyone can do this but believe that certainly the vast majority of those in western societies at least can.
I am very aware of the fact that people working in ERs, surgery, internal medicine, oncology and even psychiatry deal in life and death decisions. However, I think there is usually a difference in that most patients wheeled into the ER look very sick or badly injured so that if the staff can “save them”, they appear to be saviors to the general public and certainly are not often accused of causing deaths or permanent injuries to their patients when they fail to revive them. While some surgical patients are healthy going in for what seem to be minor procedures and die on the table or are seriously injured, I believe that is rather rare and quite a different experience from that of a surgeon operating on a patient everyone knows to be very sick for whom it is believed that the odds of a good outcome are not high. With other branches of medicine, aside from OS, bad things do happen, but they aren’t usually dramatic and immediate or considered unavoidable by anyone, including laypeople, watching. That is often even true for psychiatry where most observers believe that even though the patient killed himself in spite of the efforts of his therapist that he would have done so even without the intervention. None of that is true when delivering the majority of babies.
Rosemary – “Fifi, I missed that but it would not change what I’ve said. I sympathize with Dr. T because I too am very passionate when I try to communicate about a topic that I feel strongly about. I think emotions are valuable and should be used effectively rather than suppressed. I think that denying that they exist or believing that anything, especially anything as personal as medicine, can or should be practiced in a cultural vacuum is at best unrealistic. I also believe that different cultures and different individuals react to what they perceive to be a display of emotion differently. Some believe that an emotional display demonstrates a lack of rationality. Others believe it demonstrates a lack of caring.”
Yes but the point is that she’s blogging at SBM and pretending her passionate stance is purely rational (while accusing others of being emotional and irrational). That’s what I take issue with. Just so you know, I have no prejudice against emotions or passion. Quite the opposite in fact. I work in the arts because I value emotion and I have a deep appreciation for the biology and science around emotion (hence the interest in the neurobiology of pregnancy and childbirth). I’m actually passionate and curious enough about emotions that I ended up working in a pain clinic helping people understand the connection between mind/body/emotions/pain and am very highly aware of the cultural aspects of communicating about these subjects since I did it in two languages with a culturally diverse group of people. (It was a very basic education and education – based in the science and not woo! – that provided tools to help patients manage their pain and depression. I was part of a multidisciplinary team.)
My point is that Dr Tuteur’s personal passions shouldn’t be imposed upon her patients, nor should she be trying to pass them off as SBM. If she’s emotionally attached to a certain position, she’s prone to confirmation bias. If she’s denying that she has a confirmation bias or is emotionally invested in a certain idea, she’s doing exactly what she accuses others of doing (being ideologues and not respecting SBM).
Fifi, “The fact remains that many people rely upon their doctors to help them make decisions.”
Rosemary – “Please don’t blame doctors for that.”
I’m not “blaming” anyone, I’m merely talking about the reality of the doctor/patient relationship. People should be able to rely upon their doctors to help them make complicated medical decisions, that’s part of a doctors job! They should be able to rely upon their doctors to give them science-based advice that isn’t distorted by the doctor’s personal passions or ideologies – that’s the whole point of standing up for SBM so that patients truly can make informed decisions! At the very least, Dr Tuteur should be honest about her biases so that a patient can take that into consideration and decide whether she’s an appropriate doctor for them and be aware that she’s using science to support her passions or emotional bias.
You seem to be doing a lot of special pleading for Dr Tuteur and OB/BYNs in general. You’re really off the mark if you don’t think doctors in other fields don’t get blamed when things go wrong (or dying patients aren’t saved) just as much as OB/GYNs do. To be anecdotal, it seems lots of people blame oncologists for not curing their or their loved one’s cancer (and there’s even more unrealistic expectations regarding cancer because of the anti-science propaganda and lurid promises of miracle cures). Really, I think you may be being blinded by a personal bias here. Nothing wrong with being passionate or having a bias, as long as you’re honest about it and not trying to pass it off as SBM or as being purely rational.
Thanks, Dr. Amy, for pointers to those other studies.
I did not read them carefully, but maybe mortality risks for two of them look closer to 1/200 or even 1/300 deaths, eh? Small detail, I grant.
Plonit’s (and others) summary along the lines of “In the findings of the TBT, in countries with already low perinatal mortality, CS for breech at term did not reduce perinatal mortality” is not quite fair. CS did give less mortality, about 0/500 vs 3/500, it is just that this did not give p.05, barely).
Anyway, it seems possible to quantify those risks somewhat accurately ( though experience of the docs might be hard to model without a ton of data), and those risks are comparatively easy to communicate.
It seems a much harder part is quantifying the CS risks, and then trying to judge if for some people they will ever outweigh the mortality risks of vaginal breech birth attempts. I am open-minded (ignorant). Even with perfect knowledge, that trade-off may get very difficult to communicate (presuming it gets to be a close call for some).
Best wishes to moms and docs out there in the trenches, you are more in my thoughts now.
“The tragedy of losing a baby is a much more horrific event than losing an adult for everyone involved. The father, siblings, grand parents are devastated. It really is not comparable to other deaths.”
Um, you’re the only one comparing deaths here and claiming one is more tragic than another. All untimely death is tragic and can be traumatic, whether it’s a baby dying during childbirth, a five year old dying of cancer, a ten year old hit by a bus, a fifteen year old dying of anorexia, a 20 year old dying of AIDS, a 35 year old mother dying of ovarian cancer, a 40 year old father dying in a car crash, etc. People have plans and look forward to enjoying time with their loved ones at all ages. Having dreams and hopes that die with your child or a loved one is tragic at any age. It’s a bit callous of you to presume to compare suffering and loss in the way you have, and to privilege one over the other.
Crap, had editing troubles it appears:
CS did give less mortality, about 0/500 vs 3/500, it is just that this did not give p.05, barely).
Hells, bells, still not working.
I was trying to say there that I actually get p=.2 for two-sided fisher’s exact, and that 500 v 500 is not enough to expect a small p. Repeat after me: Failing to get small p does not show no difference.
No, it does not show no difference. However, it also does not show a statistically significant difference and it was the decision of the trial leads to stop the study earlier than planned. Vaginal birth is the physiological default (i.e. it is what will happen without intervention), it is for proponents of intervention to show that those interventions do more good than harm, on the basis of as robust evidence as possible. This goes for maneouvres to expedite delivery in vaginal birth, as well as for caesarean section. Some of these comparisons cannot feasibly and ethically be compared by RCT, but some possibly could be (burns-marshall vs. mauriceau-smellie-veit vs. forceps?) (maternal upright position vs. all fours vs. lithotomy?) and many other variables.
The term breech trial was an opportunity to show lower perinatal mortality, but did not have sufficient power to demonstrate this in already low perinatal mortality countries, nor lower neonatal morbidity at two years. We cannot presume that had it been bigger, it would have shown a significant difference. As a result, you could say that the most honest position is ‘equipoise’ on the best mode of delivery for breech babies. But since caesarean section is the more significant intervention, you could argue that it is CS which has to make the stronger case. (The counter argument is that usual practice for vaginal breech delivery is already highly interventive, so we are really comparing to types of intervention).
“Vaginal birth is the physiological default (i.e. it is what will happen without intervention), it is for proponents of intervention to show that those interventions do more good than harm”
Proponents of vaginal breech delivery like to pretend that the PREMODA study is the last word on breech vaginal delivery, but it is just one data set among many. As I pointed out, there is copious data that show that breech vaginal delivery increases the neonatal death rate. It is disingenuous at best, and deceitful at worst to suggest that vaginal breech delivery is as safe as C-section. Even the authors of the PREMODA study acknowledge that.
So Plonit, how many dead babies are acceptable to reduced C-sections for breech? One in a million? One in a hundred thousand? More? The refusal of vaginal breech proponents to address this issue is inexcusable.
“The tragedy of losing a baby is a much more horrific event than losing an adult for everyone involved. The father, siblings, grand parents are devastated. It really is not comparable to other deaths.”
Really? Come on Rosemary. The loss of a young healthy adult or an older child is devastating too. I don’t think you can compare.
Rork is correct. The difference was not statistically significant, but only because the sample sizes weren’t large enough. I got p= .3 for the low PMR countries and perinatal mortality. However, Dr. Tuteur was the one who offered it as “proof” of her position. The onus is on her.
It is very difficult to glean further information from Dr. Tuteur based on the evidence, because she would rather discuss anecdotes and informed consent theory (which was her response to the criticism that the providers may not have been experienced enough and that the study encouraged docs to get their breech rates up past 40% to get enough of a sample size, despite the fact that safe vaginal breech birth rates might be around 20%). In addition, she has erected a strawman claiming that VBD advocates don’t acknowledge the risk. She has admitted her non-neutrality on the subject, which I appreciate.
The *rational* truth is that 630 dead babies means absolutely nothing without context, a denominator, how many babies die from other causes in pregnancy and birth, NNT, and a risk analysis of the alternatives. Dr. Tuteur refuses to have such a conversation, so it really leaves me with nothing more to say.
“Vaginal birth is the physiological default (i.e. it is what will happen without intervention), it is for proponents of intervention to show that those interventions do more good than harm”
++++++++
That statement has nothing to do with the PREMODA trial, or any particular trial. It is more a philosophical position with regard to evidence-based, science-based maternity care. Wherever we make a claim that intervention X has more benefits than harms, let’s be reasonably certain that is the case. The Term Breech Trial didn’t show this in the context of low perinatal mortality countries, though one can extrapolate from high perinatal mortality countries, or from the trend (‘nearly statistically significant’ – as rork points out), if you wish.
To point out that there is uncertainty surrounding mode of delivery for breech birth, dependent on context ,doesn’t make one a “proponent of breech birth”. What you’re asking of me (which is that I state my own personal judgment about an acceptable NNT/NNH for perinatal mortality) is really irrelevant, since I don’t have a breech baby on board, and I don’t have to make that choice. The choice is one to be made by women who have their own values, own attitudes to risk (more tolerant or more averse to risk), own reproductive future plans – and to that end we should provide the data that exists, including being honest about uncertainty on the question.
Zoe, “‘The tragedy of losing a baby is a much more horrific event than losing an adult for everyone involved. The father, siblings, grand parents are devastated. It really is not comparable to other deaths.’
Really? Come on Rosemary. The loss of a young healthy adult or an older child is devastating too. I don’t think you can compare.”
Zoe, I did not say that. Laursaurus did. I believe she was talking about conclusions she had drawn from her years of experience as an OR nurse. In other words she was reporting the effect such events had on her, her colleagues, and the families involved. I do not know but assume that she is talking about large numbers of people.
Until I see evidence to the contrary, I will continue to believe that experiencing a quick, unexpected death is something most humans find very difficult to deal with emotionally, far more so for most people than experiencing the death of a person, no matter what his age, who is obviously sick and suffering. In such cases, many including the patient often consider the death “a blessing” even though the survivors miss the person and feel very sad. IMO, there is no comparison on a visceral level between that kind of death and the experience of the sudden, unexpected death of a healthy neonate.
Healthy young people don’t usually die suddenly except in accidents and accidents are considered just that “accidents” which is quite different than the situation in which a healthy woman is giving birth to a healthy fetus when something suddenly goes very wrong which requires those attending to make instant life and death decisions that people with no experience in such things then proceed to second guess. In other words, while one has to evaluate the evidence constantly to set policies, when you are on the front line, you don’t have the luxury to spend a lot of time considering options.
One of the points I am trying to make is that doctors are not patients’ servants. They are their partners. Both have responsibilities and obligations. Part of a doctor’s job is patient education, but part of a patient’s job is educating himself, preparing himself and finding a doctor he is comfortable with before a crisis occurs. Another point is that it is very easy to second guess people who are in professions that regularly require them to make instant life and death decisions, but you know the saying about Monday morning quarterbacking. I am a very strong proponent of evidence based medicine. However, I believe that “real world” evidence and not just the academic kind has to be considered to get the entire picture.
Sorry Rosemary.
“What you’re asking of me (which is that I state my own personal judgment about an acceptable NNT/NNH for perinatal mortality) is really irrelevant, since I don’t have a breech baby on board, and I don’t have to make that choice.”
What? Aren’t you a midwife? What do you counsel your patients about the risk?
It is one thing to *provide* information about the absolute and relative risks, the NNT, NNH (insofar as they can be calculated) and so forth, based on the current evidence – and to express this as a range, given uncertainty. This is surely within the remit of a midwife. It is even more firmly within the remit of the obstetrician to whom the midwife refers the woman (after ultrasound scan to confirm breech presentation).
It is a different thing altogether to substitute the midwife’s or obstetrician’s judgment about what is an acceptable level of risk (in this context) for the woman’s. It is in this sense that any personal judgment about what is acceptable “One in a million? One in a hundred thousand?” (the question you put to me) is irrelevant.
We (by which I mean the maternity care service comprising midwives and obstetricians of which I am a part) offer caesarean section for all women carrying a breech baby at term – in line with the findings of the TBT. We also ensure that women are aware that vaginal breech delivery is a genuine choice. We recommend CS most strongly where women are obviously poor candidates for vaginal delivery (explaining the reasons), and are happier to support vaginal breech delivery where women are good candidates, in line with the PREMODA study and our local audit results. These complex issues are communicated to women, supported with RCOG and hospital literature.
So, Plonit, when a woman asks you to quantify the risk of a baby dying or being injured during a breech vaginal delivery, what do you tell her?
At what point would the decision to attempt a breech delivery be reckless endangerment? We have strict laws enforcing child restraint car seats. I guess the difference would be that a C/S involves surgery on the mother’s body. If you’d donate a kidney to save your child, what’s the big deal with a C/S?
When it comes to the life of the child, one preventable death is too many.
Yes, this is an emotional appeal supported by the studies cited in this article.
Just a few months ago, a government-funded study found that routine mammograms for women under 50 resulted in far too many unnecessary procedures (breast biopsies) compared to the rare occasion when a woman’s life was saved because cancer was diagnosed early. They also found that monthly self-exam was producing the same outcomes. People went absolutely nuts for purely emotional reasons. If you happen to be that 1 in whatever woman who’s life was saved, that was all that mattered.
How would morbidity rate for breech vaginal delivery compare? Clearly, as women, our emotions and ideology carry a lot more influence than the statistics. Is it because there is a sentiment that a “real” woman delivers her baby without any intervention a more noble pursuit compared with accepting appropriate medical intervention to ensure a healthy, live baby? Why accept any risk of potential death?
“Why accept any risk of potential death?”
The issue, though, is that proponents of vaginal breech delivery are not honest about the risk of neonatal death. Within the comment thread there has not been one person willing to quantify the risk or explain how they might counsel a patient about the risk she faces. They’d prefer to be vague about the risk and emphasize a woman’s right to make an informed decision.
Of course every woman has the right to make her own decision, but it can’t be an informed decision if no one will honestly inform her of the risks.
Laursaurus, do you believe that c-sections are risk free? Or do you understand that there is also a risk of complications both during the operation and long term for future pregnancies?
Dr Tuteur – “Of course every woman has the right to make her own decision, but it can’t be an informed decision if no one will honestly inform her of the risks.”
Agreed, the issue here has been whether you’re actually doing that or are instead operating from a personal and emotional bias in both the way you present the risks of vaginal breech birth and the way you have avoided discussing the risks of c-sections. Honestly informing women of the risks of having a c-section is just as much part of any honest, evidence based discussion regarding this issue. And, obviously, while statistics are nice we’re all an N of 1 and the risk is going to be different depending on the specifics of each woman’s situation.
Plonit – Sounds like a very sane and respectful approach, that actually gives women an informed choice without pressuring them. But, then again, it sounds like you work somewhere where it’s not about promoting an ideology or some ego driven midwives vs doctors competition.
“Agreed, the issue here has been whether you’re actually doing that or are instead operating from a personal and emotional bias in both the way you present the risks of vaginal breech birth and the way you have avoided discussing the risks of c-sections.”
What has bias got to do with it? Vaginal breech delivery increases the risk of neonatal death. You may not like that; you make wish it weren’t so; you may try to pretend that the risk is so small that it doesn’t count. None of that changes the fact that there is a real risk and it is difficult to communicate that risk to women.
I haven’t noticed anyone offering alternate figures. Indeed I haven’t noticed anyone willing to address the fact that promoting vaginal breech delivery means consigning some babies to a preventable death. That doesn’t mean that women shouldn’t be offered the choice, but it does mean that we need to be explicit about the dangers.
As far as the risks of C-section are concerned, they pale in comparison to the risk of death from vaginal breech delivery. C-section is almost always safer than vaginal delivery for the baby, and it is an remarkably safe procedure for the mother (not perfect, but remarkably safe).
All childbirth is inherently dangerous. The risk can be apportioned between mother and child in differing ways, but the overall risk remains. A C-section shifts more of the risk onto the mother. A vaginal delivery shifts more of the risk onto the baby.
In breech delivery of any kind, the total risk is increased over that of a vertex delivery. There’s no questions about that. The only question is how to apportion that increased risk.
Dr Tuteur – Once again you’re erecting strawmen, I’ve never been promoting vaginal breech birth, I’ve been promoting the right of women to be properly informed about their choices and the consequences of those choices so they can make up their own mind. My objection is to your pretense that you’re practicing SBM when you’re actually using science to promote a personal bias. The fact that you have talked so much about how it effects you and how victimized you feel is an indicator of how personal this is for you. As is the fact that you seem to think everyone who doesn’t fall into lockstep behind your highly emotionally charged bias is promoting vaginal breech birth. It’s not having a personal bias that’s the problem here, it’s that you’re not being honest about it and pretending that you’re simply promoting SBM (and have been called out by others more into statistics than me about the statistics).
It’s pretty clear that your bias means you minimize and apparently totally ignore some of the consequences of having a c-section can have for future pregnancies. You obviously didn’t include it in your initial blog and haven’t actually said you do inform patients about these risks. Not that I expect much from someone who wants the authority of being under the SBM umbrella but who consciously tries to be as inflammatory as possible and cherry picks evidence about controversial topics. Seriously, for those of us from countries where these things are publicly discussed quite rationally (and women’s health issues are a bit more advanced and much less controversial than in the US), you’re coming off as an attention seeking ideologue and not someone who actually cares about SBM or women’s health and freedom to choose.
Fifi,
I must say, this is not the discussion I was anticipating when I wrote the post. I was anticipating a discussion of the relative merits of the studies, and a comparison of the risks of breech vaginal delivery vs. the maternal risks of C-sections. In other words, I was anticipating a relatively dispassionate discussion of the facts.
Instead the discussion has recapitulated the typical discussions with patients who don’t understand the risks.
Breech vaginal delivery increases the risk of neonatal death. If that is acceptable, then all those who favor a more liberal policy toward breech vaginal delivery merely need to acknowledge that a few hundred preventable neonatal deaths is an acceptable exchange for tens of thousands of fewer C-sections. I certainly could accept that argument.
Instead, I’ve gotten all the usual accusations and evasiveness that one typically hears from patients who are convinced that vaginal breech delivery is safe and those evil obstetricians merely want to deprive women of their empowering “birth experience.”
We’ve seen the entire gamut including:
You ought to minimize the risk when counseling patients;
Telling a woman that her baby has a nearly 1% chancy of dying is too scary and manipulative to boot;
Obstetricians just want to protect themselves;
Obstetricians value the life of the baby over the life of the mother;
And so on …
Everyone refuses to confront the real issue: some babies will die.
It’s a cop-out to kick the can down the road to the mother. Obviously it is her decision and no one else’s. However, from a policy point of view, we are obligated to recognize when people have difficulty understanding scientific information and giving informed consent. Everyone is hiding from that issue either by pretending that the risk is too small to matter, or that we don’t need to think about it because it’s the mother’s decision, or hoping that no babies will die and we then don’t need to think about it at all.
In my view, it bears a lot of similarities to counseling patients about vaccinating their children. Sure, it’s ultimately the parents’ decision, but we know that people who are choosing not to vaccinate their children don’t really understand the risks. In some cases it is because they are literally unaware of the risks. In other cases it is because they have difficulty evaluating relative risk.
We don’t simply throw up our hands and say: “just give them a description of the data, without any bias toward vaccination, and let them decide.” Why don’t we do that? Because more is at stake than exercising personal freedom to make parenting decisions. The health of children is at stake and that means we need to make our best efforts to insure that parents understand.
If you think it is biased and overly emotional to feel strongly about preventing neonatal deaths than I am proudly guilty as charged. That doesn’t mean that I wouldn’t step back and let a mother take steps that might or even will kill her baby, as long as she understands what’s at stake. Indeed, I have gone along with a patient who refused pregnancy interventions to save the baby because she was ambivalent about the pregnancy and wanted the baby to die. It’s her right to make that choice, and I have no ethical or legal basis to stop her.
On the other hand, I have seen patients make decisions that they have been told are dangerous and then observed the tragic outcome. In not one case have parents accepted responsibility for their own decisions. Zip, zero, nada. Every single time the parents cried out in their grief: “I didn’t understand that this could happen.” Women who chose homebirth, women who refused induction for medical indications, women who refused to comply with medical advice, all responded in exactly the same way when confronted with the ultimate loss: “I didn’t understand. I didn’t realize. I never knew this could happen.”
Doctors know, and most patients realize, that there is more at stake than a dispassionate discussion of the data and the exercise of personal autonomy. Real lives are at stake and that requires taking all steps necessary to insure that decisions are informed.
[quote]I hope Dr. Tuteur remembers to inform her patients when discussing or before doing a circumcision that every year some boys die from the complications of this surgery and that this circumcision might be the next death. Seems in her recent circumcision post she forgot to mention the possibility, or thought it too negligible to consider seriously.[/quote]
I too found Dr. Tuteur’s whole stance on here completely contradictory to what she was espousing when it came to circumcision. With circumcision, she poo poos the risks of death, infection and other complications as being rare and not worthy of discussion. If you bring it up, you’re fear mongering, or a foreskin fetishists. But here, Dr. Tuteur launches into the details of the INHERENT RISKS, even though she admits they’re rare.
In this case I actually agree with, patients should be informed that if they choose vaginal birth, their child may not make it. Likewise for circumcision. As Dr. Tuteur astutely pointed out, when you tell parents that complications are “rare” or less than 1 percent, no one ever imagines their child being that rare case.
“That doesn’t mean that I wouldn’t step back and let a mother take steps that might or even will kill her baby, as long as she understands what’s at stake. ”
Oops, Dr. Tuteur must not have gotten enough “hits” on this particular blog post, so she’s again pulling out the “mothers/ care providers/ commenters who choose vaginal breech delivery (or believe in informed consent) are baby killers.” She would also like to shift the burden of proof on non-obs to quantify the risks, after a sound criticism of her “630 babies will die.” Surprise, surprise.
We recommend caesarean section for breech at my hospital and discuss the option of vaginal breech delivery. We discuss the risks and benefits of each and, as I’ve said before on several occasions, we are honest about the uncertainty that exists.
The excess risk can’t be easily quantified in a single headline figure because a) our knowledge is inadequate (due to inadequacies with the largest trial, and counterveiling information from other sources) and because every woman’s situation is individual (parity, estimated fetal weight, type of breech, previous obstetric history, and so on).
So, we share and discuss the information that exists, which includes the TBT and Cochrane review as well as the Premoda trial and others. The RCOG green top guidelines are very useful for framing this discussion.
rosemary,
“BillyJoe, if your estimates about women are correct, and if the other side of the coin is also correct, that doctors are highly intelligent almost always right superior beings…”
The problem, rosemary, is that you think you are average. Or that all obstetric patients are as informed amd motivated as you are. The average obstetric patient is far less motivated, far less intelligent, and far less attuned to the evidence and what it means than the average ostetrician, and by a large margin. If that is not so, there is something wrong with the education of our obstetricians.
“then in the interest of society, I think we had better return immediately to the old paternalistic society of our ancestors.”
That’s such an obvious strawman I’m surprised you made it.
You might hope to get a great deal of information via the iternet, but what you cannot get is expertise. Sorry, democracy has its limits.
“If your estimates about women are correct, but you do not believe that doctors are all knowing, then I think instead of fighting with doctors and demanding that they hand feed and take responsibility for the total education of their patients as I feel people here are doing, I think we should just give up on women and let them suffer the consequences of their inferiority.”
Goddamn, I count about three strawmen here.
rosemary,
“I am a very strong proponent of evidence based medicine. However, I believe that “real world” evidence and not just the academic kind has to be considered to get the entire picture.”
What exactly is “real world” evidence?
“The RCOG green top guidelines are very useful for framing this discussion.”
Here’s what the guidelines say:
“Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.”
“Women should be advised that planned caesarean section for breech presentation carries a small increase in serious immediate complications for them compared with planned vaginal birth.”
Regarding the criticism of the Term Breech Trial, the RCOG guideline states:
“However, multiple subgroup analyses failed to identify any group for which the benefit of planned caesarean section was eliminated.”
“I hope Dr. Tuteur remembers to inform her patients when discussing or before doing a circumcision that every year some boys die from the complications of this surgery”
This is what I mean about lay people having trouble understanding relative risk.
The death rate from breech vaginal delivery is 1/110. The death rate for circumcision is 1/500,000. So the death rate from breech vaginal delivery is 5000 times higher.
In the case of breech vaginal delivery, neonatal death is common. In the case of circumcision, neonatal death is rare. That doesn’t change the need to include it in obtaining informed consent, but the risks aren’t remotely comparable.
On the RCOG guidelines…your quotes are accurate but do not adequately represent the careful discussion of the issues in the document overall, I would suggest that people read for themselves
http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT20bManagement_ofBreechPresentation.pdf
By the way, did I mention that we *recommend* caesarean section for breech at my hospital and discuss the option of vaginal breech delivery.
You did mention it.
Amy just wants you to tell your clients “630 babies will die if birthed vaginally. 630. 630.”
“DID YOU HEAR ME? 630!”
630!!!!!
Unless you are doing this exactly as written, you are negligent!
“DID YOU HEAR ME? 630!”
Do you think hundreds of dead babies is some sort of joke worthy of your contempt? I can assure you they’re not.
Of course not, but your ham handed attempt at ‘informed consent’ is.
Plonit has a good approach.
The RCOG guidelines seem very reasonable, no mention of 630 dead babies. Not only do they support the option of planned vaginal birth, but if the facility OBs are not experienced enough, they recommend referral to another. Also, they mention the risk to mothers and future pregnancies.
Btw, are baby killers worse or the same as Nazis? Pretty common tactic for those without a leg to stand on fact wise. Just curious.
You are the one using the inflammatory language to further your own ideological agenda, not any obstetrical organization in the world. You have a long history of *using* the tragedy of the death of an infant to further your own position. Some find this tactic reprehensible.
“The RCOG guidelines seem very reasonable, no mention of 630 dead babies.”
That’s hardly surprising since the 630 deaths would occur in the US. The UK has a much lower number of births. If 50% of women with breech babies opted for vaginal delivery, the number of deaths would be 117.
I did notice that RCOG also elided the issue of quantifying the risk. How can women make an informed decision if they don’t know the magnitude of the risk?
“In the case of breech vaginal delivery, neonatal death is common. In the case of circumcision, neonatal death is rare. That doesn’t change the need to include it in obtaining informed consent, but the risks aren’t remotely comparable.”
Neither are the benefits remotely comparable in low HIV/AIDS prevalence areas. Any risk needs to be weighed against a benefit; any benefit needs to be weighed against the risk.
This conversation could be better grounded if you could quote a common “natural birth” reference that obscures the risk of neonatal death in vaginal breech delivery. You attack Plonit, who recommends cesarian delivery for breech presentations. Is your goal to attack people who recommend cesarian delivery for breech presentations? Or is your goal to attack people who do not? Perhaps you could identify these other people and explain what is wrong with what they are saying?
I was also shocked that the RCOG document did not seem to be offering advice quantifying the absolute risk of breech deliveries.
So I’m agreeing with Tuteur that that’s bad, though I am probably not agreeing about the estimate of the risk to give exactly. I also agree not much has been said about the breech vaginal delivery benefits – I do not think Tuteur is obliged to spoon feed me that, though I wish someone would have, and if I were a patient I hope you would feel so obliged. The RCOG did give me some idea about that.
Missionary work: I sure hope docs do get quantitative when the patients can follow it and not just act as if “patients do not understand probabilities” (Mayer,D “Evidence-based medicine”, Epilepsia, Vol 47). I live in a college town. For just a few of us, there is concern about 1) whether our doctors really understand the evidence, and 2) if they understand decision theory.
“not just act as if “patients do not understand probabilities”
I’m not sure why this is such a controversial point. My point is not that probabilities should be omitted from counseling. Patients have a right to know. My point is that providers must be aware that a straightforwardly quoting statistics is not enough to ensure that the patient understands.
Similarly, patients don’t understand medical terminology, so telling a patient that the risks of C-section include a subsequent increased risk of placenta accreta would not be a valid way to obtain informed consent for a C-section. It is the provider’s obligation to present the information in a way that the average person can understand it.
Patients are not incapable of understanding probabilities, just like they are not incapable of understanding medical terminology. Nonetheless, the provider is still obligated to explain risks in a way that the average person can understand and to be sure that the patient understands it.
BillyJoe, if you want me to comment about my 3 strawmen, please define the term for me. Yes. I did learn it in philosophy class about 40 or so years ago but have forgotten it although I know that Skeptics use it often. And no I’m not going to look it up for the simple reason that I strongly believe discussions like these opened to the general public should speak the vernacular rather than using terms only Skeptics and academics are likely to understand. (When discussing medicine with the general public, I think that part of the discussion should include teaching the medical terms relevant to the discussion.)
I made statements that you call strawmen in response to your statement, “What percentage of woman, when they decide they will have children, have the inclination, intelligence, wisdom, and investigative skill to do this. My estimate is <10%
Of those, what percentage could attain a level of knowledge to be able to effectively argue against what their obstetrician recommends. Again, my estimate is <10%
So we effectively have <1% of mothers who have anything that could reasonably be called 'informed choice'."
Perhaps I should have asked if you think that the same percentages apply to men understanding medical information given by a doctor.
I find your figures incredible, but that is based on my personal experience, which includes translating for illiterate people. Without knowing where you got your figures, or if they are based on personal experience, what that experience is, I don't really have a clue which one of us is correct. However, if you are a doctor and use terms like strawmen when talking to patients, I believe that may be part of the comprehension problem you are speaking about.
But really if in fact less than 1% of patients are incapable of understanding well enough to make an informed choice, do you really believe that trying to provide them with the relevant information required to make those choices makes any sense? Don't you think that if that is the case, the health care practitioner should be able to quickly determine if he is talking to one of the rare creatures capable of doing it and only bother to give the relevant information to that person?
IMO, people including patients have to take responsibility for themselves or else accept the consequences. To put it another way, if you aren't going to try to learn the risks involved in a specific procedure and find a doctor you are comfortable with before you need him, then if things go wrong, don't simply blame the doctor. At the very least, share the blame.
BillyJoe, "You might hope to get a great deal of information via the iternet, but what you cannot get is expertise."
I didn't say that you can get expertise from the Internet. I said, "IMO, people who are for whatever reason unable or unwilling to locate and evaluate medical evidence for themselves should familiarize themselves with reputable websites like that of the Mayo Clinic…" I meant that is the very least they should do and I think it is something that the majority of people can do.
You asked what I mean by "real world evidence". That actually touches on expertise. I find that many academics and intellectuals, highly educated people, are very critical of Dr. Tuteur. They sound as if they are brilliant and caring, but they also sound, to me at least, as if they have no practical experience, just "book knowledge", and some sound as if they would faint at the sight of blood and oppose, or at least be very leery of, any surgical intervention no matter what the benefits and risks.
I don't think "book knowledge" alone is sufficient to evaluate the safety and efficacy of drugs or therapies. I think to do that also requires hands on experience or at least close observations. I think that is true when it comes to educating laypeople about medicine too. I think that both high quality studies and experience have to be weighed although I do realize that I am walking a thin line between subjective and objective evidence. However, I think it is a line that always has to be walked when treating real people in the real world.
Now let me try to explain with examples, I was asked to present testimony to an FDA advisory committee on pharmacy compounding. The pharmacists wanted Mild Silver Protein put on the list of bulk drugs they could compound. It was to be used in ophthalmology. I know a great deal about silver and have almost all the Eng. lit on it. I wrote up my report based on that then brought it to my mother's ophthalmologist and asked him to check it for accuracy. Another example. I have a good friend who is retired after a career developing drugs who has told me that in Scandinavian countries they do some very good research but because of the homogeneity of the population, it is impossible to extrapolate the findings to other countries. Today when it is relatively easy for laypeople to find medical journal articles someone with a PhD in English may come up with many studies showing one thing which he believes should apply in his society or to his case whereas a practitioner may have a feeling something is wrong. He may or may not know what, but I think that his feelings must be given weight.
Sorry. These examples are obviously oversimplifications, but I have no idea if I'm clearly expressing a concept that I believe is important or not, and I don't have any more time to spend trying.
Rork, that would seem to be because we don’t really know the increased absolute risk, and that it is dependent on many factors, also listed. The RCOG statement quantified the increase risk from several studies, but they varied. But yes, most moms who you handed that would look at you like you had two heads. This is unfortunate, because people like certainty. There is certainly increased risk, the question is “how much” and what are the possible benefits.
“On Tuteur’s point that “the most severely injured babies were already dead, and therefore were not included in a study of outcomes at 2 years of age.””
Is this factually true? I can’t access the study on mdconsult right now for some reason. Were the dead babies (vaginally- or c-section born) not included in the analysis at two years? That would seem to invalidate some of the results.
http://www.ajog.org/article/PIIS0002937804006568/abstract
This quote from RCOG made me question that:
“A 2-year follow-up was conducted at the Term Breech Trial centres which expected to be able to
achieve follow-up rates of about 80%.15 The primary outcome, death or neurodevelopmental delay
at age 2 years, was similar between the two groups (RR 1.09, 95% CI 0.52–2.30). The smaller
number of perinatal deaths with planned caesarean section was balanced by a greater number of
babies with neurodevelopmental delay.”
That can sound pretty scary.
http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT20bManagement_ofBreechPresentation.pdf
“A study from the Netherlands estimated that, in the 4 years following
publication of the Term Breech Trial, the increase of approximately 8500 elective caesarean sections
probably prevented 19 perinatal deaths. However, it also resulted in four maternal deaths that may
have been avoidable. It is estimated that, in future pregnancies, nine perinatal deaths can be
expected as a result of the uterine scar and 140 women will have potentially life-threatening
complications from the uterine scar.21″
This would indicate 447 c-sections for every one infant saved, not 111. And 4 maternal deaths. Like I said, uncertainty.
rosemary,
A strawman argument is one in which you mischaracterise a person’s argument by using parody or exaggeration in order to either to refute or dismiss it. It is most often done unconsciously, as in your case, but can be done deliberately.
You were effectively characterising my argument as being anti-feminist, authoritarian, and paternalistic. However, nothing in what I said could possibly indicate that those descriptions characterise my views.
I used the words “women” amd “mothers” because I consider that it is women and mothers who are being expected to make the informed choice about their pregnancies (although the father would be expected to have some input, the final decision, in my opinion, lies with the pregnant woman – so you see I am clearly no anti-feminist).
In the case of prostate cancer I would make the same comments about men. In Australia, the media has already decided that all men should have prostate tests (although the commencement age is often left unstated, as a result of which men in their 20s and 30s are fronting up for tests!). Most men who present for a test are actually blindly follow that media advice unquestioningly.
Talking generally now, my point was simply that the average person is simply not suffiuciently motivated, or intelligent, or educated to make an informed choice against the advice of experts in the field.
And, when I used the figure of <1%, I was being generous.
I am totally ignorant about cars and I am not motivated to find out. I chose a mechanic recommended by friends because of his reputed expertise and trustworthiness.
On the other hand, because my father died of prostate cancer, and because I just happened to read an interesting article on the testing and treatment of prostate cancer at the time of his death, I was sufficiently motivated to educate myself about the pros and cons of testing and had fully made up my mind about this before even seeing a GP.
I could not possibly do this for every condition from which I could possibly suffer, or in every field in which there are people with expertise.
Finally, to your point about "real world evidence":
This is more commonly known as "anecdotal evidence" or "the evidence of personal experience". It may interest you to know that it was the realisation that this sort of evidence is so unreliable as to be almost no better than a coin flip that gave rise to the scientific method and "Evidence Based Medicine" (though I also much perfer the term "Science Based Medicine").
I would stay clear of any expert who presumes to make decisions based on "personal experience" and seek out one whose decisions are based on "the evidence of properly controlled clinical trials".
regards,
BillyJoe
“Were the dead babies (vaginally- or c-section born) not included in the analysis at two years? That would seem to invalidate some of the results.”
You are correct; the dead babies were included in the subgroup analysis at 2 years.
The paper on outcomes at 2 years does not include all of the more than 2000 deliveries in the original paper. Only some centers participated in the 2 year follow up and 20% of patients in each group were not evaluated. Less than half the participants from the original study were evaluated.
There was no difference between the two group. I wouldn’t say that the smaller number of perinatal deaths was balanced by the increased number of neurodevelopmental delays, since the two outcomes are very different.
The authors acknowledge that the study at 2 years is underpowered:
“if a policy of planned cesarean birth for breech presentation at term is to have a beneficial effect on the long-term outcome of children, it is likely only through an ability to reduce the risk of perinatal asphyxia and/or trauma. The risk of cerebral palsy that is due to perinatal asphyxia is exceedingly low, probably approximately 1 in every 1000 births, which increases to approximately 1% to 7% if the Apgar score is <4 at 5 minutes.10., 11., 12. In retrospect, the Term Breech Trial had far too small a sample size to be able to assess the effect of planned cesarean birth on abnormal outcomes of children at 2 years of age."
"A study from the Netherlands"
The study is in Dutch so we can't evaluate the claims. Moreover, the authors are claiming an exceedingly high maternal death rate for C-sections. Multiple large studies with thousands of women in each arm have showed no difference in maternal deaths (indeed they have shown no maternal deaths) in C-sections done on a non-emergency basis in women without medical problems.
Interestingly, a very large Dutch study (Rietberg CC, Elferink-Stinkens PM, Visser GH. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35 453 term breech infants. BJOG 2005;112:205–9.) reported very different results, claiming that 60 lives had been saved. They calculated an NNT of 175.
Thanks Dr. Tuteur.
Dr Tuteur – “I must say, this is not the discussion I was anticipating when I wrote the post. I was anticipating a discussion of the relative merits of the studies, and a comparison of the risks of breech vaginal delivery vs. the maternal risks of C-sections. In other words, I was anticipating a relatively dispassionate discussion of the facts.”
Considering that you have stated elsewhere that your intention when writing about controversial issues is to be inflammatory, that you didn’t actually discuss the maternal risks of c-sections in your initial blog and then continued to ignore them, that you’ve consistently erected strawmen and essentially accused anyone who doesn’t agree with the way you want to deliver your message as being a pro-vaginal breech delivery baby killer, and that you’ve resorted to emotional appeals of quite a personal nature over and over again, that claim seems less than honest. (Particularly in light of your previous circumcision post.) Or you could really believe you’re engaging in a SBM discussion and just be entirely unaware of how you’re communicating and your own rather obvious and very personal biases in this and the circumcision posts. (I haven’t read any of your other ones here so I don’t know if your approach was the same in other posts.) I get it that you want to be seen as promoting SBM and undertaking a dispassionate discussion of the facts. However, how and what you actually communicate contradicts the image you’d like to promote of yourself and your stated intention.
I find it particularly silly since you’re actually alienating all kinds of very reasonable people (who want to have a rational discussion) with your presumption that anyone who doesn’t uncritically accept your position is the enemy or anti-SBM. In my case, I’m actually very sympathetic to the pressures that doctors face from anti-medicine propaganda since my mother is a doctor (hey, it’s a personal bias towards people not hurting my mom’s feelings or insulting her when she’s given so much of herself both professionally and socially). That said, since my mother is now 70 I’m also aware of the historical prejudices in medicine (and society) that were based in religion/ideology (and the historical sexism). Science, along with ethical pressure and activism, has been instrumental in making the practice of medicine more ethical and evidence-based. This is one reason I find it quite objectionable that you’ve been promoting personal beliefs/ideology/prejudices – which you may quite honestly be unaware of – using the cloak of SBM to try to claim you’re above reproach and that anyone who questions your authority or position is on the other side of the ideological fence that you seem to have erected. Why not tear down the fence, put aside your ideology and personal axe grinding (or simply be honest about your personal bias)?
SBM needs as many feet on the ground as it can get – particularly in the US where science has become an ideological battleground (as well as a corporate interest vs public health good one) – please think a bit more deeply and critically about what and how you’re communicating. The recent discussion regarding abortion was a good example of how controversial topics can be managed in a way that dampens ideological fires and supports SBM rather than simply inflaming passions (be they your own or others). There’s nothing intrinsically wrong with passion or even having an emotional bias, it’s simply not SBM and it disrespects SBM and science to use/abuse them to promote an undeclared personal bias or ideology. (And, sorry, but retreating into “just talking about the science” now when that hasn’t been what you’ve been doing from the beginning also seems a bit dishonest at this point in the discussion. To be honest, you seem to use a lot of the same communication tactics as the anti-science/medicine crowd.)
“Considering that you have stated elsewhere that your intention when writing about controversial issues is to be inflammatory”
No, I never stated anything of the kind.
“I find it particularly silly since you’re actually alienating all kinds of very reasonable people”
All kinds of people? A brief perusal of the comments on my posts in the past 3 months shows that it is the same few people who comment over and over again saying essentially the same thing.
Moreover, the people who comment are a small fraction of the people who read the posts (usually in the range of 1% of readers) and they are non-representative fraction. People are more likely to comment if they disagree than if they agree.
FIFI” I find it particularly silly since you’re actually alienating all kinds of very reasonable people (who want to have a rational discussion) with your presumption that anyone who doesn’t uncritically accept your position is the enemy or anti-SBM.”
Dr. Tutuer “Moreover, the people who comment are a small fraction of the people who read the posts (usually in the range of 1% of readers) and they are non-representative fraction. People are more likely to comment if they disagree than if they agree.”
Just want to point out the alienated people don’t necessarily continue reading or commenting so basing your estimate on how many people you alienate on repeat commenters numbers isn’t realistic.
Also, you can not expect a standard percentage of readers who agree with a writer. It is going to vary. I would estimate that David Brooks of the NYT has a much higher percentage of disagreeing readers than Peggy Noonan of WSJ. (I could be wrong, don’t know their numbers).
I myself feel that you tend to stir the pot, then act the injured party. I don’t feel I learn a lot from your posts, but I do find it interesting reading the comments. Generally the comments on SBM are quite interesting and thought provoking (if somewhat needlessly sarcastic). It’s why I keep coming back.
Dr Tuteur – Um, yes, you did indeed say that you like to stir the pot (on Open Salon not here).
http://open.salon.com/blog/amytuteurmd/2009/10/17/dr_amy_was_mean_to_me
Your assumption that you’re not alienating readers who don’t comment is silly. How can you even know that? (Not that I’m claiming to know what readers who haven’t commented think either, I’m sure there’s a diversity of opinions.) For someone who wants to claim the authority of SBM, you’re clearly reaching beyond the realm of evidence here yet again. It’s clear that you’re alienating all kinds of people who do care enough to comment, including people who support SBM and even people in this particular thread that actually do recommend c-sections for breech birth but also support informing women about vaginal breech birth. It’s just weird the way you go out of your way to write about obviously controversial topics, do so in an inflammatory and biased/ideological way, attack anyone who doesn’t automatically agree with you (and in this case paint us all as baby killers), and then claim to be being victimized when called on it. It’s certainly not indicative of someone who actually has a genuine interest in SBM. Really, it seems like attention seeking behavior and abusing science for personal/ideological ends. I find that offensive in arena that’s about SBM and damaging to rational discussion of controversial topics.
Also, your assumption that people only comment when they disagree is bogus and self serving (do you actually know what a confirmation bias is?). It may make you feel better to assume that there’s an invisible army out there that agrees with you and all negative commentary is simply because people disagree with an ideological stance you’ve taken. Is this why you’re so reactionary and automatically assume that anyone who calls you on anything is anti-SBM and your ideological opposition? All that does is indicate you’re actually arguing ideology and not actually discussing the science. I’m just as likely to comment on or defend posts here that I agree with (or that I think are presenting the science without being ideological) as I am ones that I don’t.
“Um, yes, you did indeed say that you like to stir the pot (on Open Salon not here).”
Did you read it? If so, then you would know that I was responding to people who complained that among the thousands of weekly posts on the Open Salon blog aggregator, mine were routinely chosen to be featured and had thousands of readers.
“For someone who wants to claim the authority of SBM, you’re clearly reaching beyond the realm of evidence here yet again”
With the possibly exception of the circumcision post, all my posts are the standard mainstream view of obstetricians. Indeed, a lot of what I do is explain why obstetricians practice the way they do.
I realize that this is not the received view among some lay people, but that’s why I write: Much of what “natural” childbirth advocates and some midwives criticize about modern obstetrics reflects the fact that they don’t know what the scientific evidence shows.
I did read it. I see you’re still totally focused on how much attention you get as the most important thing!
Dr Tuteur – “With the possibly exception of the circumcision post, all my posts are the standard mainstream view of obstetricians.”
That’s not at all true as evidenced by the recommendations of the Canadian professional body. It’s pretty narcissistic to claim that you’re speaking for all obstetricians when you’ve self appointed yourself in this role and professional bodies around the world clearly indicate that you don’t. Once again this seems to be more about your ego than it is about reality. Also, your claim that everyone that agrees with you is “mainstream” and inference that anyone who doesn’t is some kind of radical is the same kind of supercilious ad hominem as the way you try to paint anyone who questioned you in this thread as being pro-vaginal breech birth baby killers. It’s becoming quite clear why you’re unable to actually acknowledge or even see how your own ideological biases taint the way you use science and claims to be presenting SBM. Really, own your own opinions rather than claiming to speak for all obstetricians and various other arguments from authority (or presumed popularity).
“That’s not at all true as evidenced by the recommendations of the Canadian professional body”
The SGOC does not speak for obstetricians in any other country besides Canada, and it’s not clear that it even speaks for them. Their recommendations are new, and have not yet been tested in practice, and it isn’t even clear that obstetricians will follow them.
In the US, C-section is still the standard recommendation for breech delivery for the reasons that I have discussed.
Besides, I never claimed to speak for Canadian obstetricians or even all US obstetricians. I’m merely articulating the mainstream view of American obstetricians. You may not like it; you may disagree with it; but among obstetricians it would not be considered remotely provocative.
ACOG and RCOG also have changed their guidelines back to “vaginal breech birth should be an option.” But I agree, you do represent mainstream obstetricians (maybe not the nastiness towards people though, not sure about that). I don’t know why mainstream obstetricians don’t often agree with or follow their own trade organizations, or what the politics is there.
The RCOG guidelines also made the point that vaginal breech techniques still need to be taught and practiced because a significant minority of planned c-sections are vaginally delivered, I’m assuming because labor went too fast. It was 10% in the TBT.
Hmm, I just posted, not sure why it didn’t show up.
FWIW, ACOG (US) and RCOG (UK) also recommend that breech vaginal delivery should be an option. I seriously doubt that ACOG’s policy statement recommends informed consent as describing the population based risk of “babies killed” argument advocated here.
I agree though, Dr. T does represent mainstream obstetrical thought (maybe not the nastiness towards other people though, I don’t know). I’m not sure why mainstream obstetricians seem to often disagree or not follow their own trade organizations or their own research, or what the politics is there.
Also, RCOG points out that obs still need to be trained and practiced at breech vaginal deliveries because a significant minority of planned c-sections will be delivered vaginally, I’m assuming because the labor went too fast. 10% of planned c-sections in the TBT were vaginally born.
Dr Tuteur – The point is that you’re claiming that you speak for “mainstream obstetricians” when you haven’t been appointed to do so and have just presumed the authority to do so. It’s highly questionable if all your opinions do actually reflect what the majority of American obstetricians think or how they’d approach discussing breech birth with their patients even if they agree about c-sections. This isn’t just about your opinions regarding breech births but the way you present science and your opinions in both this post and discussion and the one regarding circumcision, which you’re now trying to make an exception so you can claim to speak for “mainstream” obstetricians.
It’s interesting how you keep trying to pretend that nowhere in the world is relevant except America when it suits your purposes – this is the internet and you were quite happy to make claims about Uganda and AIDS that were totally irrelevant to medicine in America when it served your ideological stance masquerading as SBM regarding circumcision.
Really, just have the honestly to claim your own opinion as your own instead of trying to hide behind the authority of SBM or making appeals to populist authority by claiming to speak for “mainstream obstetricians”. Your inability to identify or own your personal opinions, or recognize when you’re being ideological and not scientific, is an indication of just how blind to your personal confirmation biases you are. Really, you’re using science in exactly the same way anti-science ideologues do…to support ideological positions and confirmation biases that you refuse to recognize and continually defend by appeals to populism and manipulative emotionalism. I have no doubt you CAN do better, the question is whether you’re willing to be honest and own your own opinions so you can actually deal with the science in the detached way for you to be truly supporting SBM and not abusing it.
“The point is that you’re claiming that you speak for “mainstream obstetricians” when you haven’t been appointed to do so and have just presumed the authority to do so.”
Get a grip. I did not say that I speak for American obstetricians in an official capacity. I said that the positions I articulate are the positions of mainstream obstetricians and would not be considered remotely provocative by them.
“It’s highly questionable if all your opinions do actually reflect what the majority of American obstetricians think or how they’d approach discussing breech birth with their patients even if they agree about c-sections.”
Really? The C-section rate for breech in the US approaches 100% and ACOG recommends C-section as the preferred mode of delivery for breech.
Moreover, breech delivery is not the only topic I’ve written about. I’ve also written about homebirth, waterbirth, the C-section rate and midwifery. In all those cases, my positions are consistent with both mainstream obstetrics and ACOG (to the extent that ACOG has specific policies on these topics).
Please, stop talking about me and let’s get back to the issues at hand.
I have not read all the comments above (too many), but have a few points to mention. As a paediatrician I would point out that the end-point for research into outcomes should not just be mortality, but long-term morbidity – and significant long-term neurological impairment at that. This is a difficult area to research due to (1) long follow up required ie until 6-8 years of age, (2) what is considered “significant” impairment, & (3) a large number of infants required to be enrolled to detect small but statistically significant results.
I have unfortunately been present at difficult vaginal breech deliveries where the head is delivered after a considerable delay and the infant needs significant resuscitation… with less vaginal breech deliveries being performed the younger ObGyns have less experience and hence potentially higher complication rates.
BillyJoe, “This is more commonly known as ‘anecdotal evidence’ or “the evidence of personal experience”. It may interest you to know that it was the realisation that this sort of evidence is so unreliable as to be almost no better than a coin flip that gave rise to the scientific method and ‘Evidence Based Medicine’ (though I also much perfer the term ‘Science Based Medicine’).”
I am very aware that evaluating the safety and efficacy of a drug or therapy based on personal experience alone is useless. I am also aware that you can’t teach surgery from a book alone. To develop surgical skills, you need hands-on practice and to evaluate many published studies you need knowledge or expertise in the field being studied, the study methods used and even the equipment and what it can and cannot do to actually be able to evaluate the studies themselves.
I believe that the hands-on experience of practitioners is a part of the body of evidence that has to be weighed when trying to reach a conclusion about which drugs and therapies to use in individual cases. However, the point I was trying to make in previous posts on this thread is that I see a red flag when I notice people with no hands-on experience, no expertise in a field, using published studies alone to criticize someone with the expertise and experience.
I prefer the term “evidence-based medicine” to “science-based medicine” because I fear that people who promote SBM may be so in love with logic and science that if solid evidence is consistently presented that contradicts one of their scientific theories that they will disregard the evidence rather than their theories, something very unscientific that scientists have been known to do in the past.
While I consider this very important, it is way off topic. If anyone is interested, I’d be happy to continue the discussion privately. You can write to me here:
rosemary@rosemaryjacobs.com
Dr Tutuer – Once again you erect strawmen. You were the one claiming to speak for “mainstream obstetricians” – I pointed out that this was an appeal to populist authority.
Essentially you’ve been critiqued by a number of people for how you communicate and propose communicating with patients regarding the risks of both breech births and circumcision. In regards to breech births it is in a sensationalized way that includes fearmongering and emotional bullying to convince patients (and leaving out information of the potential long term consequences of c-sections) while claiming to be merely presenting the evidence and representing SBM. In regards to circumcision it was minimizing and ridiculing to promote an ideological position that’s really not supported by the majority of doctors around the world. Meanwhile, you accuse everyone who doesn’t support your position as being emotional, ideological and even pro-vaginal breech birth baby killers (when they’re no such thing). You’re abusing science and using SBM as a shield. I probably wouldn’t be so offended if both my parents weren’t doctors. However, because my mother is a doctor (the only woman in her graduating class and someone who fought for our right to informed choice as women), I find your abuse of science and inability to discern your own confirmation biases while using SBM as a soapbox pretty sketchy and self-serving. And, yes, fairly or not, I expect better from women – particularly women in medicine and science. That’s a personal bias I have and can freely admit.
You’re still talking about me and not the science.
Amy Tuteur, MDon 21 Jan 2010 at 6:44 pm
You’re still talking about me and not the science.
You say that like it’s a bad thing. One of the reasons there are comment boxes on blogs is so that people can voice their agreement or opposition to the writer’s approach, style OR factual content.
There are many controversies in science. Some of them are not about the science themselves. They are about how science is communicated to the public, the patient, the student.
The recent “Climategate Scandal” is an illustration of that.
Okay, trying again to post this while my other one is awaiting moderation.
FWIW, it’s not just the Canadians. ACOG (US) and RCOG (UK) also recommend that breech vaginal delivery should be an option, as a 2006 *revision* of their 2000 policy of “no vaginal breech delivery.” I seriously doubt that ACOG’s policy statement recommends informed consent as describing the population based risk of “babies killed” argument advocated here.
I agree though, Dr. T does represent mainstream obstetrical thought (maybe not in her nastiness towards other people though, I don’t know). I’m not sure why mainstream obstetricians seem to often disagree or not follow their own trade organizations or their own research, or what the politics is there.
Also, RCOG points out that obs still need to be trained and practiced at breech vaginal deliveries because a significant minority of planned c-sections will be delivered vaginally, I’m assuming because the labor went too fast. 10% of planned c-sections in the TBT were vaginally born.
Communication about science and medical issues can be a touchy thing, and obviously I’m the last one to be able to recommend how to do so. I do however know demeaning when I hear it. There are lots of OBs who can say “I can understand surgery can be really scary when you’ve not gone through it. IT’s hard to take care of a toddler (or several) when you’ve had a c-section and you don’t have a lot of help. There is an increased risk of serious maternal morbidity, as well as a possible risk to future pregnancies and deliveries. C-sections should only be done in necessary circumstances and breech is one of those circumstances, in my professional opinion. There is an XXX increased risk of neonatal mortality and/or serious morbidity, as shown by research and my experience, and it’s a significant risk. Yes, babies can and have died, and it could be yours. ACOG supports vaginal breech delivery in some very limited circumstances. Here’s some more reading you can do. Ultimately it’s your body and your choice.” (assuming ECV has failed). And referral if needed.
Rather than, “if you have this baby vaginally, you are possibly going to kill your baby!!! And if other moms do it too, you’ve killed 630 babies THIS YEAR ALONE!!! Suck it up because you are seriously selfish if you *for one second* think about your own bodily integrity *in addition to* your baby’s LIFE.” Moms are a lot more likely to trust the former OB, and not only that, but “owning” the decision no matter what the outcome. I know if my OB had talked like the latter, I’d have been out the door, even if I was scrambling to find someone at 36 weeks. I don’t like to be bullied, not even by an MD, and I’m pretty good at standing up for myself and my babies. (Didn’t have to though, because when I interviewed doctors, I asked those questions. Particularly when do you recommend c-sections and what is your philosophy regarding them.)
Since half of the original blog post was about informed consent, I think communication about that in relationship to the topic is fair game. I don’t think anything Dr. Tuteur is advocating even resembles informed consent and respect for mothers. Not to mention, maybe 10% of the time, her facts are just plain wrong. Possibly because she hates “natural” childbirth advocates so much, she goes too far to the other extreme, I honestly don’t know.
Finally, Dr. T’s blogging style has been discussed ad nauseum over on Open Salon, for years, and MUCH more nastily than on this site (by both her and her… non fans- and over on OS these non fans are not birth advocates of any kind). She’s not going to change or be kind or nuanced, so it’s kind of a waste of time. It’s more a distraction, and since reading over on OS a little bit, I regret my participation in criticism of said vitriol. There’s plenty of logical and factual errors abound without having to go into blogging style, especially since the latter is subjective. But of course comments are open and I appreciate that on SBM.
“You’re abusing science and using SBM as a shield. I probably wouldn’t be so offended if both my parents weren’t doctors. However, because my mother is a doctor (the only woman in her graduating class and someone who fought for our right to informed choice as women), I find your abuse of science and inability to discern your own confirmation biases while using SBM as a soapbox pretty sketchy and self-serving. And, yes, fairly or not, I expect better from women – particularly women in medicine and science. That’s a personal bias I have and can freely admit.”
Okay, Fifi, this is going a little far. She’s some random online blogger, not the downfall of modern medicine or women’s rights. Unfortunate SBM endorses it, but I’m still reading, so I can’t complain too much.
Now I’m done.
rosemary,
“I see a red flag when I notice people with no hands-on experience, no expertise in a field, using published studies alone to criticize someone with the expertise and experience.”
If Dr Tuteur was presenting evidence based on her personal experience of treating women with breech presentation, I would have been long gone, because that sort of evidence is almost totally unreliable and totally anaethema to “Science Based Medicine”
“I prefer the term “evidence-based medicine” to “science-based medicine” because I fear that people who promote SBM may be so in love with logic and science that if solid evidence is consistently presented that contradicts one of their scientific theories that they will disregard the evidence rather than their theories, something very unscientific that scientists have been known to do in the past”.
Okay short reply as it is off topic: “Science Based Medicine” considers BOTH prior probability AND evidence; the point being that if the prior probability is low then the evidence has to be correspondingly high; and if the prior probability is almost zero, then the evidence has to be extraordinary.
BJ
“As a paediatrician I would point out that the end-point for research into outcomes should not just be mortality, but long-term morbidity – and significant long-term neurological impairment at that. This is a difficult area to research due to (1) long follow up required ie until 6-8 years of age, (2) what is considered “significant” impairment, & (3) a large number of infants required to be enrolled to detect small but statistically significant results.”
Absolutely!
I wonder if the PREMODA team is planning to study the long term effects of vaginal breech delivery.
zoe – “Okay, Fifi, this is going a little far. She’s some random online blogger, not the downfall of modern medicine or women’s rights. Unfortunate SBM endorses it, but I’m still reading, so I can’t complain too much.
Now I’m done.”
Hmmm, well she’s not a “random blogger”, she’s being promoted here as an advocate of SBM and given the blessings/conferred authority of this collective that purports to be a superior source of science-based medical information and a defender of SBM. The other bloggers here generally do present SBM and very good discussions around SBM, the attacks on SBM by anti-science ideologues, the difference between science and pseudoscience, and so on. So, in many ways being a blogger here gives someone a certain amount of authority and credibility. Certainly I advocate a reader/buyer beware approach and for people to think critically, however that doesn’t change the fact that being supported/presented by this blog does lend the bloggers a certain amount of credibility.
I don’t think she’s about to bring down medicine or destroy women’s rights, I was simply explaining why I find her abuse of science and SBM so personally appalling and worth commenting upon (aka what my own personal bias is in this matter and why I’ve been passionate enough to keep commenting). Dr Tuteur keeps trying to paint anyone who calls her out as being some kind of ideological proponent of pseudoscience. I’m quite the opposite. I was raised by two doctors and with science as the best means to understand the world. I grew up around medical research so also understand that being able to say “we don’t know” is integral to good science. I also worked briefly in a clinical setting where a great deal of what I did was helping people understand the mind/body connection in lay terms (in two languages and with people from a very diverse range of cultures). I have a very deep respect for the scientific method as the best way to discern, explore and understand objective reality (subjective experience is another thing, there’s plenty of room for that too). I understanding confirmation bias and how ideology can interfere with science, I’m aware of my own biases and the difference between objective reality and subjective experience (and how one can inform the other and the traps our cognition can lay for us). I also understand how hurtful and insulting all the anti-medicine and anti-doctor propaganda can be for people who’ve dedicated their lives to medicine, science and helping others (once again, this is personal because it’s my mom who gets angry, hurt and frustrated).
While Dr Tuteur is just one more person abusing science for ideological/personal ends, the whole point of the SBM blogging group (supposedly anyway) is to call out people who abuse science for ideological or commercial ends. The other purpose seems to be to present good science and further understanding of science. It doesn’t seem to me that Dr Tuteur is doing either.
I had absolutely no idea who Dr Tuteur was before I ran across her here – despite her seeming previous notoriety and reading Salon sometimes. I’ll just avoid her posts from this point in (which I’m sure she’ll appreciate) but I’m pretty disappointed that the SBM blogging collective is supporting and promoting this kind of thing. Why? Because I do think the battle between science/reality-based thinking and pseudoscience/unreality-based thinking is a defining battle of our times and has all kinds of very potent real world repercussions. From my perspective, someone like Dr Tuteur does more harm than good because she makes any accusations that SBM is as equally ideological as any other group that is pseudoscientific and ideological true (and uses the same kinds of sketchy and dishonest tactics as those she claims she’s against). The very least I can do is to speak up. I’ve done that but, like trying to discuss anything with the ideologues that Dr Tutuer considers her enemy, to continue doing so is obviously fruitless because Dr Tuteur doesn’t seem to even respect science enough to be honest about her own biases. C’est la vie, but I can’t say I’m not disappointed and don’t expect better from the SBM blogging group (and, personal bias alert, women in medicine and science).
Good points Fifi, especially this, “From my perspective, someone like Dr Tuteur does more harm than good because she makes any accusations that SBM is as equally ideological as any other group that is pseudoscientific and ideological true (and uses the same kinds of sketchy and dishonest tactics as those she claims she’s against).”
I’m starting to wonder, what is the point of discussing risks stats in obstetrics and gynecology when the discussion is so limited? From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done. Anyone could be that 1 in x thousand, so everyone should accept the practices in maternity wards for their births. Parents aren’t educated enough to give informed consent and it is best left to the doctors to make decisions. The only consideration in childbirth is having a live baby, nothing else is involved in decision-making.
There we go, done and dusted!
“From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.”
I’m glad that came through to you since I have been pounding on that point in almost every post.
The canard of the moment in the “natural” childbirth community is that obstetrics is not based on scientific evidence. That claim, like so much of “natural” childbirth advocacy, is simply fabricated. Obstetric recommendations on breech birth, “natural” childbirth, homebirth, waterbirth, C-sections, etc. ARE based on the scientific evidence. It is it TRUE that the scientific evidence shows that obstetric recommendations and technology save lives.
Indeed, the fact that obstetrics is based on the scientific evidence has become obvious in some quarters of the midwifery community, much to their disappointment. As I pointed out in another post, they are clamoring for a “redefinition” of evidence so that they can justify ignoring the actual scientific evidence.
“From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.”
“I’m glad that came through to you since I have been pounding on that point in almost every post.”
I hope the SBM editors who defended Dr. Tuteur by saying “I’m sure Dr. Tuteur is not defending every practice in maternity wards” will take note. She is indeed as extreme as others have been saying all along, without the goods the back it up.
Otherwise, Dr. Tuteur might want to check the ACOG policy statements versus what is being done in maternity wards. A lot has changed since the early ’90s in terms of recommendatons.
http://www.acog.org/navbar/current/publications.cfm
See committee opinions.
Love the newest midwife dig in there at the end too.
“I hope the SBM editors who defended Dr. Tuteur by saying “I’m sure Dr. Tuteur is not defending every practice in maternity wards” will take note.”
I am not defending EVERY practice in maternity wards. I am specifically defending and explaining the practices that I write about. How about addressing what I actually say instead of erroneously insisting that I said something entirely different?
Amy,
What part of …
“‘From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.’
I’m glad that came through to you since I have been pounding on that point in almost every post.”
… did you not say? You quoted someone saying “everything.” You agree with their statement. This seems very clear to me.
“How about addressing what I actually say instead of erroneously insisting that I said something entirely different?”
Amy, you are the one who persistently says things and later complains that’s not what you meant. And that we should talk about what you mean instead of what you say.
Can you explain exactly how we are supposed to know what you mean if it’s different from what you say?
“Amy, you are the one who persistently says things and later complains that’s not what you meant”
Hardly.
I am addressing a common fallacious argument.
I present evidence that various obstetric recommendations (like C-section for breech) are based on the scientific evidence. Invariably someone claims: So you are saying every obstetrical practices that exists and ever existed is based on scientific evidence?
No, that’s not what I said, but it is ever so much easier to argue against the absurd absolute than to address what I actually said.
That’s what’s happening here and the same thing is happening on the Big Placebo thread. I said that contrary to the claims of Big Placebo, most illness and death is not caused by lifestyle factors. Of course someone immediately claimed that I was insisting the lifestyle factors never cause disease. Once again, that’s not what I said.
Amy, if someone says,
“From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.”
… and you want to communicate that this is a fallacious argument of the straw man variety, you should say something like, “No, that is a straw man. I present evidence that various obstetric recommendations (like C-section for breech) are based on the scientific evidence.”
What you said instead was, “I’m glad that came through to you since I have been pounding on that point in almost every post.”
If you want us to understand what you mean, you should say what you mean and not something else.
“you should say something like, “No, that is a straw man. I present evidence that various obstetric recommendations (like C-section for breech) are based on the scientific evidence.”
Oh, you mean I should have interpreted the “everything” in her statement “everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.’ as “everything in the history of obstetrics”? You mean I gave her more credit than she deserved since I assumed she meant “everything I wrote about” instead of “everything in the history of obstetrics.”
Alison, why do you nitpick about irrelevant details? Does it make any difference to the claims in this post? Why not address what I wrote about instead instead of anything else but?
Obviously, “everything done in maternity wards is based on scientific evidence” should be interpreted as “everything done in maternity wards is based on scientific evidence.” A plain reading of the text is called for here!
I would probably presume (in the context of the discussion) that the maternity wards being cited were contemporary US maternity wards. But I might clarify that if that were ambiguous.
I wouldn’t assume that the Zoe237 was referring to “everything in the history of obstetrics” since that is not what is written.
Statlerwaldorf: “From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.”
Dr. Tuteur: “I’m glad that came through to you since I have been pounding on that point in almost every post.”
Me: “I hope the SBM editors who defended Dr. Tuteur by saying “I’m sure Dr. Tuteur is not defending every practice in maternity wards” will take note.”
Dr. Tuteur: “I am not defending EVERY practice in maternity wards. I am specifically defending and explaining the practices that I write about. How about addressing what I actually say instead of erroneously insisting that I said something entirely different?”
_______________________________
Um, I’ll take your word for it, but for the life of me I can’t figure out why you would then agree with statlerwaldorf rather than calling her observation a strawman.
However, I’m glad you can’t defend every maternity ward practice as based on scientific evidence. Because some are not.
Amy, the point you have missed is that just because 1 death in x thousands of births may occur, it does not justify all labouring women being coerced or forced into accepting maternity practices for their individual pregnancy and taking into consideration their own bodies and future fertility.
You have presented here the statistical risk of a bad outcome when attempting vaginal breech birth. (Well, another poster gave a more reasonable way to present the stats to parents.) As anyone can see, there is risk; however, it should not be standard that all women with babies in breech position are c-sectioned (especially court-ordered!), or told that if they don’t consent to a c-section they will kill their baby. You argue that women who don’t consent to a c-section aren’t educated enough on the issue and have no concept of the risk (and brainwashed by the evil natural childbirth folks!). Maybe you think that the evidence shows that everyone should opt for the c-section, but as has been discussed here, c-sections have their own risks for mother, baby and future pregnancies and therefore parents might want to take the chance that they will not be the 1 in 111 that will see a bad outcome.
I’m wondering if one of your main unstated beliefs is that parents essentially are incapable of informed consent and all decisions should be left to the expert ob-gyn.
It’s tricky out there, on one hand you have extreme NCBers that say “Trust nature, trust birth.” and on the other hand you have some ob-gyns well versed in “You are going to kill or brain damage your baby!”. Neither side is discussing the risks adequately, nor respecting parents’ choices.
“the point you have missed is that just because 1 death in x thousands of births may occur, it does not justify all labouring women being coerced or forced into accepting maternity practices for their individual pregnancy and taking into consideration their own bodies and future fertility.”
That is a different issue entirely.
The threshold issue is: what does the scientific evidence show? After determining that, women can address how they wish to use that evidence.
It is perfectly reasonable for a woman to say that she’d rather incur a small increased risk of neonatal death than have abdominal surgery. That is something altogether different than claiming that the recommendation for C-section to deliver a breech baby is not based on the scientific evidence.
Amy,
You are starting to make a lot more sense to me (though I think you have not clarified you position on “informed choice”). Perhaps your original article should have been a lot more pointed, or a lot more detailed.
Someone complained about David Gorski’s long posts a while back, but I think that is preferable to all the misunderstanding that has occurred here.
Maybe a good compromise is a detailed article covering a sinle or a limited number of points for those keen on commenting on the subject, together with a summary at the beginning for those who don’t want so much detail and are not interested in commenting on the article.
Just a suggestion.
“I assumed she meant “everything I wrote about” instead of “everything in the history of obstetrics.””
Ok, that’s interesting and maybe very relevant to why you have so much difficulty communicating.
Why would you assume she meant everything you wrote about? She said “everything done in maternity wards is based on scientific evidence,” and I assume she meant “everything done in maternity wards.” If she wanted to say “all the practices Amy writes about,” I assume she would have written “all the practices Amy writes about.” She wrote in the present tense, so was not referring to the thousands of years of obstetric history.
There is no reason for anyone to assume that StatlerWaldorf meant anything different from what she wrote. And yet you did just that.
I assume that if you write something, you must mean it. You call that nitpicking, but I have no alternative.
“Alison, why do you nitpick about irrelevant details? Does it make any difference to the claims in this post?”
If you cannot communicate your claims, and if you cannot interpret questions and comments, then it makes a difference to whether you should be an SBM blogger. After 180 comments, BillyJoe is starting to understand what you might be talking about. It shouldn’t take 180 comments to begin to understand a post.
As I have said before, I want you to be a better writer. I want you to understand that accuracy matters.
“Why not address what I wrote about instead instead of anything else but?”
I did. I defended your use of the statistically meaningless 630 dead babies on the grounds that human beings generally have a hard time with probability.
I did mean everything done currently in maternity wards, not what was done through obstetric history.
I think Amy believes that everything done currently in maternity wards is science-based because of her writings on her own blog and here. The only thing I’ve seen her mention is episiotomy as an exception.
Amy said, “The threshold issue is: what does the scientific evidence show? After determining that, women can address how they wish to use that evidence.”
I agree. My argument is that stats on infant mortality or brain damage from head entrapment during a vaginal breech birth are not the only stats used in the decision making. It would have been interesting to see some stats on risks for baby, mother and future pregnancies after c-section to get a good picture of which stats should be more persuasive in informing women’s decisions.
Amy says, “It is perfectly reasonable for a woman to say that she’d rather incur a small increased risk of neonatal death than have abdominal surgery. That is something altogether different than claiming that the recommendation for C-section to deliver a breech baby is not based on the scientific evidence.”
I haven’t heard anyone claim that vaginal breech birth has the same risk level as vaginal vertex birth, nor that a c-section is not a valid medical recommendation. This topic is not a good example of “things NCBers say is not evidence-based”. Where is the post on continuous vs. intermittent fetal monitoring if you want to get into something juicy.
brain damage from head entrapment during a vaginal breech birth are not the only stats used in the decision making.
+++++++++
Just to be clear, no one has actually given those stats. The perinatal deaths in the Term Breech Trial were not all from difficult deliveries.
Plonit you are correct. Those would be useful stats to see.