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Vaginal Birth After C-Section: How Safe Is It?

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What’s the best route to this happy outcome?

Doctors used to insist “once a C-section, always a C-section.” Today it is standard practice to allow vaginal births after C-section (VBAC) for appropriately selected patients. The American Congress of Obstetricians and Gynecologists (ACOG) has issued a Practice Bulletin to guide obstetricians in determining which patients are appropriate candidates for VBAC.

We frequently hear criticisms of practice guidelines like these. The doctors who write the guidelines are accused of conflict of interest, turf protection, and biased evaluation of the evidence. For those who believe doctors put profits before patients, this should be an eye-opener. It would presumably be in the best financial interests of obstetricians to do as many C-sections as possible, since they can charge more for them than for vaginal births. It would have been easy for the ACOG to put a spin on the data to make repeat C-sections look like a better choice. The fact that they offer VBACs despite their conflict of interest makes me think that their evaluation of the evidence was probably fair and unbiased.

So just how safe is VBAC? What are the pros and cons? What does the evidence say? (more…)

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Home birth tragedies lead to changes in Oregon

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Oregon Health Plan (OHP), the state’s Medicaid insurer, will no longer cover planned home and birth center births for women whose pregnancies aren’t classified as low risk, based on newly-established criteria. The Health Evidence Review Commission (HERC), a group of experts designated by the state, came up with criteria that will exclude women with a substantial list of conditions, such as high blood pressure, diabetes, previous cesarean section, multiple gestation (more than one fetus), and various complications in previous pregnancies. Feelings ran high on both sides of the issue, which was described as the most contentious ever to come before the HERC.

The HERC’s decision was based on an exhaustive 100-page evidence review; a review, according to them, hampered by the low quality of the evidence on the safety of planned out-of-hospital births. Actually, there is a paucity of evidence altogether. Studies and statistics from other countries, like the Netherlands, were of limited utility because those countries have more stringent midwifery education and training requirements and non-hospital births are better integrated into the health care system.

Most planned out-of-hospital births in Oregon are attended by what are known as direct-entry midwives (DEM), as opposed to nurse midwives, and a few naturopathic doctors. (We’ll look at the many variations of midwifery in a minute.) Since OHP pays for 23% of Oregon births, the economic impact on direct-entry midwives could be substantial. This effect will be amplified when other insurers, who are expected to follow OHP’s new criteria, change their own coverage rules. (more…)

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Are Prenatal Ultrasounds Dangerous?

Several questionable sources are spreading alarms about the possible dangers of prenatal ultrasound exams (sonograms). An example is Christine Anderson’s article on the ExpertClick website. In the heading, it says she “Never Liked Ultrasound Technology.”

[She] has never been sold on the safety using Ultrasounds for checking on the fetuses of pregnant women, and for the last decade her fears have been confirmed with a series of studies pointing to possible brain damage to the babies from this technology.

Should We Believe Her?

Should we avoid ultrasounds because Anderson never liked them? Should we trust her judgment that her fears have been confirmed by studies? Who is she?

“Dr.” Christine Anderson is a pediatric chiropractor in Hollywood who believes a lot of things that are not supported by science or reason. Her website mission statement includes

We acknowledge the devastating effects of the vertebral subluxation on human health and therefore recognize that the spines of all children need to be checked soon after birth, so they may grow up healthy.

It also states that “drugs interfere… and weaken the mind, body, and spirit.” Anderson is a homeopath, a craniosacral practitioner, a vegan, and a yoga teacher. She advises her pregnant patients to avoid toxins by only drinking filtered water and only eating organic foods. She sells her own yoga DVD. (more…)

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Birth Day

So many of the posts on this blog are critical and deal with examples of poor science or other problems. I’d like to offer a breath of fresh air in the form of a book by Mark Sloan, MD: Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth.

It is a very positive book. Sloan has attended over 3000 deliveries but he has not lost his sense of wonder. He tells us what life is like in the womb – how much the fetus can see and hear – and smell! He explains the labor process. He explains how a fetus has to rapidly adapt to life outside the womb with a number of physiologic changes. He reflects the joy of bringing a new life into a family, and the experience of becoming a father. He delves into the history of childbirth, with fascinating anecdotes about “salting” newborns, Queen Victoria’s influence on obstetric analgesia, and the attempt to keep forceps a proprietary secret of one family.

He shows the many contributions science has made to childbirth, some of the mistakes it made along the way, and how it corrected those mistakes. (more…)

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The Business of Being Born

One of our readers asked for a critique of the movie “The Business of Being Born.” I guess my sex and specialty make me the best qualified to comment. I delivered over 200 babies as a family physician. I had two babies of my own (at age 37 and 39), one with intervention (forceps) and one 9-pounder who almost “fell” out before the obstetrician was ready.

“The Business of Being Born” is a movie about midwives, home births, and hospital births in America. It’s a sort of kinder, gentler “Sicko” with onscreen births, gooey, bloody newborns and fat naked women. The message of the movie is that for an uncomplicated pregnancy, natural home births with midwives are better and safer than medicalized hospital births with obstetricians. It’s strong on sound bites, emotional appeals, and superficial arguments, but weak on substance, depth, and scientific evidence for its claims.
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