by Birth Sense on Sunday, October 17, 2010 at 5:00pm
I was recently both amused and not surprised to read a comment written by a physician who was disparaging midwives for their lack of scientific research and evidence-based practice. The physician wrote:
“Modern obstetrics, in contrast, has always been, and continues to be based on scientific research.”
I will be one of the first to admit that midwives have been guilty of poor interpretation of statistics, embracing various clinical practices and promoting them as if they were evidence based when in reality they are not, and recommending things to their clients for which they have no evidence of benefit. A clear example of this is the many midwives who still recommend evening primrose oil (EPO) to their clients in order to “ripen” the cervix, even though study after study has cast doubt upon EPO’s efficacy.
But what about the physician’s comment that modern obstetrics is based on science? Could this be a case of the Emporer that has no clothes? Modern obstetrics is riddled with accepted procedures that demonstrate how wide the gap is between practice and evidence.
- Inductions/elective c-sections for suspected macrosomia (big baby): I can’t count the times that I have had a patient put on my schedule for induction or elective c-section because the OB thinks her baby is getting big. The best evidence shows that early induction or elective c-section have not improved outcomes for these babies, and may carry greater risk of complications. Evidence, please?
- Pitocin to speed labor: Although evidence shows that pitocin given without indication of medical need is not beneficial and may increase fetal distress and/or risk of c-section, it continues to be widely used for any (or no) reason. What science supports this practice?
- Amniotomy to speed labor: In my practice, I am almost always called by the nurse at some point early in the woman’s labor to “come and pop her bag and get this baby out”. Despite the clear evidence that amniotomy does not significantly speed labor, and carries with it a risk of infection and increased fetal intolerance of labor, this practice is nearly universally performed on laboring women. How is this based on science?
- Continuous electronic fetal monitoring. Another “sacred cow” of obstetrics that is not evidence based. For low and moderate risk labors, intermittent monitoring has been shown to have outcomes as good as with continuous monitoring, without the increased rate of c-section associated with continuous monitoring. Where’s the evidence?
- Requirement of “immediate” emergency services for women attempting a VBAC. Although the NIH states there is little evidence to support this recommendation, it continues to be the standard practice. The effect of this policy is to create barriers to VBAC availability for many women. Every OB I talk to about this problem admits there is not adequate evidence for this requirement, but seems at a loss (or doesn’t care) what to do about it. What science is this continued practice based upon?
- Episiotomy: Still practiced by physicians in as many as 20% of births. This procedure was taught for years as an essential to reducing pelvic floor problems in women later in life. Only in the last few years has science supported what midwives have always practiced–avoiding episiotomy unless it is necessary to get the baby out quickly. If modern obstetrics is always based on science and evidence, why do we get these polar opposite policies?
- Routine ultrasound to estimate fetal size: Although we know late term ultrasounds are very inaccurate in estimation of fetal weight, obstetricians continue to order them. Where is the evidence for this practice?
- Immediate cord clamping: Most physicians I discuss this with will agree the evidence shows benefit of avoiding immediate cord clamping, but it is a hassle and takes a few minutes more. They largely feel that it just doesn’t matter that much. What science are they basing this opinon on?
- Spontaneous pushing: In spite of clear evidence of benefit of spontaneous pushing, most doctors and nurses are still using the old “hold your breath and count to ten” method of pushing. Most are aware of the evidence, but state they “feel” like more progress is being made when the mother is pushing long and hard. Is modern obstetrics based on fact or feelings?
- Supine Pushing: Perhaps one of the best-documented practices in modern obstetrics is supine pushing. This is a practice which has absolutely no evidence of benefit and plenty evidence of potential harm. Yet almost every OB I know routinely delivers his/her patients in the supine position. Why?
An organization which flip-flops as drastically as the American Congress of Obstetricians and Gynecologists (ACOG) did this year, in its dramatic loosening of VBAC guidelines, is hard pressed to defend the statement that their practices are evidence-based. Did we suddenly discover new science that told us the woman who was refused a VBAC early in 2010 on the grounds that she was risking death to her baby and herself, is now out of danger and can safely attempt a VBAC? Where is this amazing new information that ACOG discovered?
In my next post, I will be discussing the problem of evidence and how the average woman can decipher the myriad of conflicting information.