Birth

My OB Said What? Commentary

The website "My OB Said What?" offers a very raw look at just how bad the birthing industry can get. The site is filled with appalling quotes that obstetricians, midwives, nurses and other medical staff have said to their patients (along with the occasional good quote). It is by no means a fair representation of all maternity professionals, more like a classic example of how a few bad apples can tarnish the reputation of their profession for others. Below is a collection of those quotes, along with the reasons why the comments are considered so bad, and what should have been said and done instead.

"If a baby hasn't engaged by 37 weeks, we need to do a cesarean section." – OB to mother.

What's wrong with this comment…

Firstly, 37 weeks is far too early to consider a cesarean. "Full term" is when a fetus reaches the approximate gestational age of 40 weeks. If the fetus and mother are doing well at 37 weeks, there is no reason to interfere and the pregnancy should be left to unfold at its own pace.

While many medical staff technically consider 'full term' to be between 37 – 42 weeks, current research shows this is a dangerous assumption – infants born between 36 – 38 weeks triple their risk of mortality compared to infants born at 39 – 42 weeks.27 Infants born before 36 weeks face even greater risks. These risks decrease with each additional week of pregnancy.1 Post term pregnancies (beyond 42 weeks) can also be left to unfold at their own pace provided there are no complications, and regular checks for complications are performed.2

Risks to late preterm infants (36-38 weeks) include 27...

3 fold increased risk infant mortality
4.6 fold increased risk neonatal mortality
28 fold increased risk admission to intensive care unit 
5.5 fold increased risk intravenous fluids
4 fold increased risk mechanical ventilation
7 fold increased risk respiratory distress
3 fold increased risk of infection
10 fold increased risk temperature instability
42% increased risk jaundice
60 fold increased risk apnea
4.5 fold increased risk difficulties with feeding
3 fold increased risk hypoglycemia
3 fold increased risk of hospital readmission 

As for the doctor wanting to do a cesarean…Cesareans carry substantial increased risks for both mother and baby, and should only ever be done when absolutely medically necessary.9 Because of the increased risks, some hospitals have banned elective cesareans.10 Cesarean risks include...

For the mother
5 fold increased risk cardiac arrest 28
4 fold increased risk maternal deep vein thrombosis 25
2 fold increased risk acute renal failure 28
2 fold increased risk anesthetic complications 28
2 fold increased risk hemorrhage requiring hysterectomy 28
3 fold increased risk hysterectomy 28
5 fold increased risk wound hematoma 28
2 fold increased risk in-hospital wound disruption 28
3 fold increased risk major puerperal infection 28
2 fold risk maternal rehospitalization for reasons such as uterine infection, gallbladder disease, surgical wound complications, cardiopulmonary conditions, thromboembolic conditions, and appendicitis 21
2 fold increased risk of failure to breastfeed 25
2 fold increased risk of major post partum pain 25
27 fold increased risk of uterine rupture in future cesarean 25
57 fold increased risk uterine rupture in future vaginal birth 25
4 fold increased risk placenta accrete in future pregnancy 25 (the placenta attaches itself too deeply into the wall of the uterus significantly, increasing risk of hemorrhage during its removal)
3 fold increased risk placenta previa in future pregnancy 25 (the placenta is attached to the uterine wall close to or covering the cervix, it is a leading cause of vaginal hemorrhage)

For the infant
2-3 fold increased risk neonatal death 24, 35
2 fold increased risk neonatal death in preterm infants 32-36 weeks 26
8 fold increased risk neonatal pneumothorax (collapsed lung) 19
3-7.4 fold increased risk neonatal persistent pulmonary hypertension (failure of blood to circulation through the lungs properly) 44, 45
2-5 fold increased risk of serious respiratory morbidity (the earlier gestation the higher the risk) 29
2 fold increased risk neonatal pulmonary disorders 23
87% increased risk neonatal transfer to neonatal intensive care unit 23
4.3 fold increased risk neonatal intracranial hemorrhage 23
30% increased risk later development of asthma 25

There are also many other risks, click here for more details.

If the doctor in question had indeed performed a cesarean on this mother at 37 weeks gestation, he/she would have been needlessly putting the mother and infant at significantly increased risks.

Regardless of the doctors intentions, every woman has the legal right to accept or refuse a cesarean, or any medical procedure, drug, treatment or test. And after a woman makes her decision, she has the right to change her mind.11

"I might have to cut you." – OB to a mother who had made it clear she preferred to tear, moments before making a second degree episiotomy.

What's wrong with this comment…

An episiotomy is a surgical cut in the perineum as the baby is born in order to increase the opening of the vagina. Routine episiotomy is proven to offer no benefit and is no longer advisable, it increases the need for stitching, causes pain, extended healing time, increased bowel incontinence, and increased pain during intercourse.3, 4, 36

Obviously the doctor in question was not aware of current research and recommendations to abandon the practice of episiotomies. Regardless, he/she should not have cut this mother, he should have honored her request to not be cut. Again, every woman has the legal right to refuse an episiotomy, or any procedure, drug, treatment or test.11

Steps the doctor could have taken to maintain the integrity of the mothers perineum include using a caster oil heat pack held on the perineum during pushing.14

"Let's break your water and get an IV going to speed things up." – OB to mother who had made great progress until asked to get out of the tub and flat on her back on the bed.

What's wrong with this comment…

Firstly, laboring in water can effectively reduce the need for obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery).8 Had this mother not been forced to leave the water, the need for obstetric intervention may have never been 'needed'.

Secondly, the 'supine' position (lying flat on back) is considered one of the most ineffective positions in which to give labor. When compared to an upright position, the supine position is associated with longer pushing time, more fetal distress, more pain, and more injury to the perineum (a 3 fold risk of perineal tears, and a 2 fold risk of severe tears).5, 6, 7

Every woman has the legal right to labor in any position she wishes. Every woman also has the legal right to freedom of movement during labor, unrestricted by wires, tubes or other apparatus. And again every woman has the legal right to refuse to get out the water, having her waters broken, having an IV, or any procedure, drug, treatment or test.11

"So what, do women who give birth naturally get a trophy or walk around with gold stars on their foreheads?" – L&D nurse to mother during transition.

What's wrong with this comment…

The cavalier and unsupportive attitude of the medical staff in question undermines the fact that epidurals carry a myriad of substantial risks to both mother and baby, these include...

For the mother
88% increased risk of being dissatisfied with birth 31
4 fold increased risk of malposition of baby 30, 41
5.6 fold increased risk of dystocia 38
3 fold increased risk of needing synthetic oxytocin 30 (see above for risks associated with induction)
2 fold increased risk of needing the maximal dose of synthetic oxytocin 40
31.6 fold increased risk of motor blockade 37
18 - 74 fold increased risk maternal hypotension 30, 37
5 fold increased risk of shivering 37
29 fold increase risk of itching 43
46% increased nausea 30
3.3 - 5.6 fold increased risk of maternal fever 30, 37  (see below for risks associated with maternal fever)
42% - 6 fold increased risk of needing a forceps / vacuum delivery  37, 39 (see below for risks associated with forceps / vacuum delivery)
2.4 - 3.7 fold increased risk of cesarean for failure to progress  30, 39 (see above for risks associated with cesarean delivery)
43% increased risk of ceasarean for fetal distress 37
2-5 fold increased risk of postpartum hemorrhage 30
3.2 fold increased risk of anal sphincter tear 42
85% increased risk of 3rd and 4th degree perineal lacerations 30
2 fold increased risk of not breastfeeding at 6 months postpartum 13

For the infant
3.3 fold increased risk of variable or late decelerations 30
80% increased risk of bradycardia 43
3.5 fold increased risk of neonatal infection 30
75% increased risk of jaundice 30
19% Increased risk of admission to NICU 37

Infants whose mothers had a fever while giving birth face increased risks, these include…
3 fold increased risk of having 1 minute Apgars scores less than 7 30
10 fold increased risk of being hypotonic after delivery 30
4 fold increased risk of requiring bag and mask resuscitation 30
6 fold increased risk of needing oxygen in nursery 30

When both forceps and vacuum are used the risks substantially increase, these include...
11 fold increased risk perineal tear 12
4 fold increased risk neonatal seizures 12
8 fold increased risk neonatal intercranial bleeding 12
13 fold increased risk neonatal facial nerve damage 12

Risks of induction include...
3 fold increased risk fetal asphyxia 46
2 fold increased risk of cesarean 32
2 fold increased risk of hemorrhage 33

The following adverse reactions have been reported in the mother:
Anaphylactic reaction Premature ventricular contractions, Postpartum hemorrhage Pelvic hematoma, Cardiac arrhythmia Subarachnoid hemorrhage, Fatal afibrinogenemia Hypertensive episodes, Nausea Rupture of the uterus, Vomiting, Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus. The possibility of increased blood loss and afibrinogenemia should be kept in mind when administering the drug. Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.34

The following adverse reactions have been reported in the fetus or neonate:
Bradycardia Low Apgar scores at five minutes, Premature ventricular contractions and other arrhythmias Neonatal jaundice, Permanent CNS or brain damage Neonatal retinal hemorrhage, Fetal death. Neonatal seizures have been reported with the use of Pitocin.34

Instead of patronizing these laboring mothers, medical staff should have taken every measure possible to facilitate natural birth and avoid an epidural. My guess is the medical staff simply weren't sufficiently trained to facilitate a natural birth, nor were they aware of the risks associated with an epidural and the interventions that often follow. Otherwise, the medical staff did know, but they simply didn't care.

One of the most effective methods of managing labor pain is to have a doula (professional birth supporter) in attendance at the birth, the effects include 15

50% reduction in the cesarean rate
25% shorter childbirth
60% reduction in epidural requests
40% reduction in oxytocin use
30% reduction in analgesia use
40% reduction in forceps delivery

Other techniques that help facilitate natural birth include having a safe, private room to birth, water birth, supportive companions, abdominal breathing, vocalization, visualization, affirmation, self-hypnosis, repetitive movement, standing up, experimenting with different positions, massage, perineal massage, acupressure and hot or cold packs.14 Click here for more details.

"If you hadn't declined vaginal exams we would have known the baby was breech." – OB to mother who had declined vaginal exams at her prenatal appointments.

What's wrong with this comment…

This doctor should have palpated (felt) the mothers abdomen at regular intervals throughout pregnancy to determine whether the baby was breech. This is the most common method of examination, and studies show that it is 70% effective. If there was any doubt of the baby's position, the doctor should have ordered an ultrasound. And this should have been done well before the onset of labor.16

Vaginal exams are not recommended to determine whether a baby is in the breech position, there is no need to perform a vaginal exam. I could find little evidence to show that a vaginal exam could possibly ever determine whether a baby was breech. All that can be felt by a vaginal exam is the condition of the cervix.17

Further, vaginal exams carry an increased risk of infection, a perfectly sterile vaginal exam is impossible – as soon as a sterile glove hits the air it's exposed to bacteria. Further, when a finger is inserted into the vagina, bacteria is pushed up towards the cervix, increasing the risk of infection. The more vaginal exams, the higher the risk of infection.18 Having a vaginal exam at the beginning of labor increases the risk of neonatal infection 2.5 fold. 17 Infants born with an infection face a 4 fold risk of mortality.

Other risks caused by vaginal exams include prematurely stimulating the cervix into labor, and premature rupture of membranes (PROM).17

The main reason maternity carers ask to perform a vaginal exam is to determine the condition of the cervix, for instance how many centimeters the cervix has dilated. However vaginal exams are not necessary, and it can be very discouraging for women in labor to hear a labor assistant announce 'you are not progressing fast enough'. Provided there are no complications, a labor should be left to unfold at its own pace.17

Again every woman has the legal right to refuse a vaginal exam, or any procedure, drug, treatment or test.11

These are just a couple of quotes from "My OB Said What", I'll be writing a commentary on more in the future.

Sources:

1. Study Gives New View of 'Full-Term' Pregnancy
http://www.webmd.com/baby/news/20110523/study-gives-new-view-of-full-term-pregnancy

2. Postterm with favorable cervix: is induction necessary?
http://www.sciencedirect.com/science/article/pii/S0301211502002439

3. Outcomes of Routine EpisiotomyA Systematic Review
Katherine Hartmann et al, 2005
http://jama.jamanetwork.com/article.aspx?articleid=200799

4.Episiotomy for vaginal birth (Review)
Carroli G, Belizan J
http://apps.who.int/rhl/reviews/CD000081.pdf

5. Randomised controlled trial on modified squatting position of delivery.
http://www.ncbi.nlm.nih.gov/pubmed/12319813

6. Postpartum Outcomes in Supine Delivery by Physicians vs Nonsupine Delivery by Midwives
http://www.jaoa.org/cgi/content/full/106/4/199

7. Supine position compared to other positions during the second stage of labor: a meta-analytic review.
http://www.ncbi.nlm.nih.gov/pubmed/15376403

8. Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour
http://www.bmj.com/content/328/7435/314.full

9. Elective cesarean sections are too risky, WHO study says
http://www.scientificamerican.com/blog/post.cfm?id=elective-cesarean-sections-are-too-2010-01-11

10. Banner Hospitals banning elective C-sections, induced labor for pregnant women
http://www.abc15.com/dpp/news/region_phoenix_metro/central_phoenix/banner-health-banning-elective-%22convenient%22-c-sections-and-induced-labor-for-pregnant-women

11. The rights of childbearing women
http://www.childbirthconnection.org/pdfs/rights_childbearing_women.pdf

12. Epidural Effects on Labor - Defined
http://naturalmamanz.blogspot.com/2011/05/epidural-effects-on-labor-defined.html

13. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study
Siranda Torvaldsen et al, 2006
http://www.internationalbreastfeedingjournal.com/content/1/1/24

14. Natural Pain Relief During Childbirth
http://naturalmamanz.blogspot.com/2011/02/natural-pain-relief-during-childbirth.html

15. Doula Studies
http://doulaadvantage.blogspot.co.nz/p/doula-studies.html

16. Exam can fail to detect breech birth
http://www.irishhealth.com/article.html?id=9995

17. The Dangers of Vaginal Exams
http://www.natural-pregnancy-mentor.com/vaginal-exams.html

18. Prevention of Perinatal Group B Streptococcal Disease: A Public Health Perspective
http://www.cdc.gov/mmwr/PDF/rr/rr4507.pdf

19. The Influence of Timing of Elective Cesarean Section on Risk of Neonatal Pneumothorax
http://www.sciencedirect.com/science/article/pii/S0022347606011851

20. Prevention of iatrogenic neonatal respiratory distress syndrome: elective repeat cesarean section and spontaneous labor.
http://www.ncbi.nlm.nih.gov/pubmed/7081331

21. Association between method of delivery and maternal rehospitalisation
Mona Lydon-Rochelle et al, 2000
http://jama.jamanetwork.com/article.aspx?articleid=192686
http://jama.jamanetwork.com/article.aspx?articleid=192686

23. Planned cesarean versus planned vaginal delivery at term: Comparison of newborn infant outcomes
http://www.daraluznetwork.com/documents/csectionrisks4newborns.pdf

24. Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with ''No Indicated Risk,'' United States, 1998–2001 Birth Cohorts
http://webcache.googleusercontent.com/search?q=cache:http://www.pbh.gov.br/smsa/bhpelopartonormal/estudos_cientificos/arquivos/cesariana_eletiva_x_parto_birth_2006.pdf

25. Risks Associated With Cesarean Delivery
http://www.medscape.org/viewarticle/512946_4

26. Impact of cesarean section on intermediate and late preterm births: United States, 2000-2003.
http://www.ncbi.nlm.nih.gov/pubmed/19278380

27. Late Preterm Infants, Early Term Infants, and Timing of Elective Deliveries
http://www2.cfpc.ca/local/user/files/%7BFC626F94-49DC-4B25-B586-7D3C87679DDB%7D/Late%20term.pdf

28. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term
http://www.cmaj.ca/content/176/4/455.full

29. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study
Anne Kirkeby Hansen et al, 2007
http://www.bmj.com/content/336/7635/85

30. Side Effects of Epidurals: Research Data
http://transitiontoparenthood.com/ttp/foreducators/ceinfo/Side%20Effects%202.htm

31. Maternal satisfaction and pain control in women electing natural childbirth
http://www.ncbi.nlm.nih.gov/pubmed/11561269

32. Elective induction of labor as a risk factor for cesarean delivery among low-risk women at term
http://www.ncbi.nlm.nih.gov/pubmed/10831992?dopt=Abstract

33. Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony
http://download.journals.elsevierhealth.com/pdfs/journals/0002-9378/PIIS0002937810010264.main-abr.pdf?jid=ymob

34. Pitocin Side Effects
http://www.drugs.com/sfx/pitocin-side-effects.html

35. Incidence of Early Neonatal Mortality and Morbidity After Late-Preterm and Term Cesarean Delivery
http://pediatrics.aappublications.org/content/123/6/e1064.abstract

36. ACOG Recommends Restricted Use of Episiotomies
March 31, 2006
link

37. Pain management for women in labour: an overview of systematic reviews
Leanne Jones et al, 2012
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009234.pub2/tables#CD009234-tbl-0028

38. Obstetric risk indicators for labour dystocia in nulliparous women: A multi-centre cohort study
Hanne Kjærgaard et al, 2008
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569907/

39. Epidural analgesia and risks of cesarean and operative vaginal deliveries in nulliparous and multiparous women.
Nguyen US et al. 2010
http://www.ncbi.nlm.nih.gov/pubmed/19760498

40. Epidural analgesia during labor vs no analgesia: A comparative study
Wesam Farid Mousa et al, 2012
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299112/

41. Changes in fetal position during labor and their association with epidural analgesia.
Lieberman E et al, 2005
http://www.ncbi.nlm.nih.gov/pubmed/15863533

42. Risk Factors for Anal Sphincter Tear During Vaginal Delivery
Mary P. FitzGerald et al
https://www.pfdnetwork.org/Portals/0/PFDN/Papers/P13_2A09.pdf

43. Fetal bradycardia due to intrathecal opioids for labour analgesia: a systematic review
Chahe´ Mardirosoff et al, 2002
http://ape.med.miami.edu/Doc/Resident%20Web%20Site%20Articles/Complications%20of%20regional%20anesthesia/Fetal%20bradycardia%20due%20to%20intrathecal%20opioids-BJOG%202002%20Vol%201.pdf

44. Persistent pulmonary hypertension of the newborn following elective cesarean delivery at term
Kim C. Winovitch et al, November 2011
http://informahealthcare.com/doi/abs/10.3109/14767058.2010.551681

45. Risk Factors for Persistent Pulmonary Hypertension of the Newborn
Sonia Hernández-Díaz et al, 2007
http://pediatrics.aappublications.org/content/120/2/e272.full

46. Influence of maternal, obstetric and fetal risk factors on the prevalence of birth asphyxia at term in a Swedish urban population.
Milsom I et al, 2002
http://www.ncbi.nlm.nih.gov/pubmed/12366480



You Might Also Like

4 comments

  1. So disturbing! Thanks so much for putting up all these well-researched posts. Much appreciated.

    ReplyDelete
  2. You really dug in there, NMNZ!!!

    Now, imagine how exhaustive it would be if we did that at every... single... one.

    Love to hate the things on myobsaidwhat. :)

    Peace, and good work,
    E

    ReplyDelete
  3. There are literally thousands of quotes on My OB Said What! Reading them made me so glad I had a great midwife who never behaved like any of the birth carers quoted. But unless you've actually researched a little about birth, some people reading the quotes wouldn't realise what's so bad about them. I've tried to hand pick the quotes that were very common. There were A LOT of quotes from medical staff making fun of women for wanting a natural birth. Sad indeed.

    ReplyDelete