CHICAGO (EGMN) – The modification of the oxytocin infusion protocol at a
large university-affiliated community hospital nearly halved the number of
emergency cesarean deliveries over a 3-year period, reported Dr. Gary
Ventolini.
As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean
deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual
meeting of the American College of Obstetricians and Gynecologists.
Other birth outcomes improved as well at an 848-bed community hospital that
serves as the primary teaching hospital of the Boonshoft School of Medicine
at Wright State University in Dayton, Ohio.
These included significant declines in emergency vacuum and forceps
deliveries and a sharp reduction in neonatal ICU team mobilization for signs
of fetal distress (P = .0001 in year 3 compared with year 1).
“More and more data are showing us that we are using too much oxytocin too
often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at
the university, said in an interview.
“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units
every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,”
he said.
Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively
analyzed to determine any impact of the change in an oxytocin protocol
implemented in 2005. Patient characteristics were similar in all three
calendar years.
The most profound changes were in emergency deliveries, including caesarean
deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps
deliveries (which fell from 4% to 2.3%).
The overall cesarean section rate remained unchanged, as did the rates of
cord prolapse, preeclampsia, and abruption.
Dr. Ventolini cited a recent article in the American Journal of Obstetrics
and Gynecology that suggests guidelines for oxytocin use, including
avoidance of dose increases at intervals shorter than 30 minutes in most
situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-.e6).
Dr. Ventolini and his associates reported no financial conflicts of interest
relevant to the study.
I just received my copy of New York Magazine yesterday and noticed that it was the “Best Doctors” issue. I eagerly opened it to see if I knew any of the featured doctors, since I have worked with quite a few over the past 6 years as a labor support doula. I found that I knew one, Dr. Joan Kent OB/GYN from NY Pres-Weill Cornell. I would like to note that out of the 18 OB/GYNs listed, she - along with only one other – was not described as a “high risk, fertility specialist,” or by having any other surgical specialty.
The magazine explains that the list is compiled from peer recommendations, not from client/patient recommendations. They say: “The idea is that medical professionals are best qualified to judge other medical professionals.” I believe there is some truth to that, but it emphasizes that the medical profession (in this case, obstetrics) follows a pathological model of care. Meaning that doctors are trained to look for what is abnormal or pathological as opposed to accepting a wide range of what is normal. So does that mean, then, that there is a higher regard for doctors who know how to do the “fancy” procedures instead of those that are comfortable sitting back, observing and caring for the low-risk mother? If I was teaching a yoga class with my peers watching or judging me, would they be more impressed that I taught a challenging, difficult series of poses as opposed to a simpler, but perhaps more appropriate, basic class? I would like to stress that we do need specialists for abnormal conditions or situations, but it was shocking that out of the list of 18 OB/GYNs, only two were “average, low-risk doctors”. (I won’t even go into my distress that there was no mention of a midwife in this article.) As a low-risk woman, I would so much rather go to a doctor that has a low cesarean rate then one who has a high one. Yes, the doctor who has a high rate may be more proficient at performing that procedure since that doctor performs them more often. However, I would think that there may be a problem based on the mere fact that the doctor does perform this surgery so often.
Are we valuing technology and complicated procedures more than we value instinct and personal touch? Two years ago I went down to Summertown, Tennessee to take a week long midwifery assistant program at The Farm with Ina May Gaskin and the renowned Farm Midwives. While there, I learned how to feel for fetal position. The technique that made the most sense to me is called Leopold’s Maneuver. It consists of four distinct hands-on actions, each helping to determine the position of the fetus. I worked with some actual pregnant mamas along with teaching dolls. This technique is primarily what the Midwives use to determine fetal positions. After learning this technique relatively easily and seeing it function with good accuracy, I noticed that it is never used in hospitals!! Upon admittance to the Labor and Delivery floor, an ultrasound machine is wheeled into triage to determine whether the baby’s head is down. Why go straight for the costly technology, especially since the overuse of ultrasound is in question relative to its safety to the fetus? Why not just have the residents place their hands on the laboring mother’s abdomen? Along these same lines, why are unmedicated, laboring mothers strapped to an external fetal monitor designed to tell everyone when that mother is having a contraction. If she is indeed unmedicated, she will likely be able to tell you when she is having a contraction. If the mother does not perceive the contractions, the nurse or doctor can feel the uterus hardening since the whole belly tightens during the contractions. Another great example of toned-down technology is the fetal scope. It is an instrument used to listen to the fetus’s heart rate without exposing the baby to ultrasound waves like the doppler or ultrasound machines. The fetal scope is definitely “old school”, but that doesn’t mean it doesn’t work! Look below for a picture of it. The care provider listens like they would through a stethoscope. The horn-shaped part is at the mother’s belly and the flat part against midwife’s or doctor’s forehead. I wonder if a high risk OB/GYN walking into an “average” risk doctor’s or midwife’s office and seeing them use the fetal scope or the Leopold maneuver instead of more modern machinery would look down upon these less advanced devices.
The New York magazine article also features stories about several of the “Best Doctor” candidates talking about their first time performing procedures that were scary for them. The author explains that: “In relating the stories of their inaugural attempts to remove a brain tumor or deliver sextuplets, among other harrowing scenarios, the doctors in question display an almost superhuman ability to cure what ails us-and an altogether mortal mix of self-doubt, fallibility and compassion.” Maybe we, as a society, have put the doctor and his/her modern technology into the “superhuman” category to such an extent that we no longer look to or value the simplicity of human touch and instincts.
Take a look at the hospital sketch from Monte Python Meaning of Life. It illustrates quite humorously how impressed we are with the machine that goes PING!
FACT: The United States ranks 42nd in the WORLD for maternal mortality rates
FACT: The Centers for Disease Control (CDC) report that there has been no improvement in the maternal death rate in the United States since 1982.
FACT: The CDC estimates that more than half of the reported maternal deaths in the United States could have been prevented by early diagnosis and treatment. (1)
The difficult part of this information to digest is that the US is also one of the highest cost-per-birth countries in the world. I am dumbfounded and saddened by the statistics I continue to uncover while researching for this blog. My original idea was to focus on Ina May Gaskin’s “The Safe Motherhood Quilt Project”. Ina May’s quilt is a reaction to a growing problem in this country, a traveling and virtual quilt representing mothers that have died from pregnancy-related causes since 1982. Each square in the quilt represents the story of the mother that has died. It is similar to the AIDS Memorial Quilt. Currently the quilt has over 125 pieces.
What is maternal mortality rate? According to the World Health Organization: “A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental cause.”
Why is this happening? Well, the answer is complicated; there are several ideas about what might play a role in this issue. Many arrows continue to point back to the growing number of cesarean births as a cause of our embarrassing ranking. If we begin by considering medically unnecessary inductions, we follow a cascade effecting leading to a greater chance of a c-section. With each cesarean a woman has, her chance of complication grows. It is also important to look at the defensive practice of medicine. In the movie, “The Business of Being Born” Dr Eden Fromberg says “There was a doctor who trained me that says “They can never fault you if you just section ‘em.” Several doctors in the movie concur that it is a growing problem and litigation plays a role into the decision to perform a cesarean. The maternal mortality rate for cesarean section is 4 times higher than for vaginal birth and is still twice as high when it is a routine repeat cesarean section without any emergency.
While many of the complications listed above are rare, the chance of a cesarean birth is not. Please do not interpret my strong stance against cesareans to mean that they should never be done, or that you will have problems should you need one. The cesarean is a valuable intervention when used appropriately. However, much research supports that our misuse of this surgical procedure leads to complications and, in some rare cases, maternal death.
If you are interested in learning more this subject, there is a very intriguing, detailed 20 minute video called Birth by the Numbers. Eugene R. Declercq, PhD, Professor of Maternal and Child Health, Boston University School of Public Health, presents the sobering statistics of birth in the United States today. Click here for a direct link.
***Please note, that this blog entry is not meant to scare pregnant moms. I am just shedding some light on a growing problem in our society when it comes to wellness of moms and babies.
