Wednesday, October 20, 2010

Where's the Evidence-Based Medicine?

Birth Advocates are always saying that obstetricians shouldn't be doing such-and-such routine procedure anymore, because it is not the best for mother and baby. Doulas always talk with their clients (and anyone who will listen) about how unnecessary and unhelpful episiotomies, continuous electronic fetal monitoring and pushing on your back, just to name a few examples. But we are frustrated time and again by obstetricians (and sometimes midwives) who do them anyway! And we ask, "Why don''t they follow evidence-based medicine?!"

So have you ever wondered what exactly IS the evidence?Well, thanks to the Midwife Next Door, I didn't have to go find all the studies myself!

Complete with references, here are 10 Common Obstetric Procedures Not Supported By Science  (Please note:  many of these procedures are beneficial in specific situations.  It is their routine use without medical indication that is being addressed here) 

1.  Inductions/elective c-sections for suspected macrosomia (big baby): The Cochrane Database reports “no evidence of improved outcomes following induction of labour for non-diabetic women who are thought to be carrying large babies. Babies who are very large (macrosomic – over 4500 g) can sometimes have difficult and, occasionally, traumatic births. One suggestion to try to reduce this trauma and to reduce operative births has been to induce labour before the baby grows too big. However, the estimation of the baby’s weight in utero is difficult and not very accurate. Clinical estimations are based on feeling the uterus and measuring the height of the fundus of the uterus, and both are subject to considerable variation. Ultrasound scanning is also not accurate.”

2.  Pitocin to speed labor: I am referring here to the routine use of pitocin to speed up a normal labor.  Unfortunately, this happens more frequently than one might think.  Doctors and midwives have lives outside the hospital, and the temptation to speed labor in order to get home sooner is difficult to resist when you’re tired and anxious to get home.  Evidence shows:  “Early amniotomy and high doses of oxytocin may both increase the risk of fetal heart rate anomalies, but are both useful for avoiding prolonged labour.” 
  • Verspyck E, Sentilhes L.  Abnormal fetal heart rate patterns associated with different labour managements and intrauterine resuscitation techniques.  J Gynecol Obstet Biol Reprod (Paris).2008 Feb;37 Suppl 1:S56-64. Epub 2008 Jan 9.
  • Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E. A guide to effective care in pregnancy and childbirth. 2000et al. New York: Oxford University Press.
  • Fraser W, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour. The Cochrane Database of Systematic Reviews. 1999;4:CD000015.F.
  • Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol. 2009; 200(1):35.e1–6.
3.  Amniotomy to speed labor: The Cochrane Library reports:  “Evidence does not support the routine breaking the waters for women in spontaneous labour.  The aim of breaking the waters (also known as artificial rupture of the membranes, ARM, or amniotomy), is to speed up and strengthen contractions, and thus shorten the length of labour. The membranes are punctured with a crochet-like long-handled hook during a vaginal examination, and the amniotic fluid floods out. Rupturing the membranes is thought to release chemicals and hormones that stimulate contractions. Amniotomy has been standard practice in recent years in many countries around the world. In some centres it is advocated and performed routinely in all women, and in many centres it is used for women whose labours have become prolonged. However, there is little evidence that a shorter labour has benefits for the mother or the baby. There are a number of potential important but rare risks associated with amniotomy, including problems with the umbilical cord or the baby’s heart rate.  The review of studies assessed the use of amniotomy routinely in all labours that started spontaneously. It also assessed the use of amniotomy in labours that started spontaneously but had become prolonged. There were 14 studies identified, involving 4893 women, none of which assessed whether amniotomy increased women’s pain in labour. The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”

4.  Continuous electronic fetal monitoring:  The American Congress of Obstetricians and Gynecologists (2005) recommends that healthy women with no complications may be monitored with intermittent auscultation or with EFM. Intermittent auscultation instead of EFM may safely reduce the cesarean rate.
  • American College of Obstetricians and Gynecologists [ACOG]. (2005). ACOG practice bulletin #70: Intrapartum fetal heart rate monitoring. Obstetrics and Gynecology, 106(6), 1453–1460.
  • Gourounti, K., & Sandall, J. (2007). Admission cardiotocographyversus intermittent auscultation of  fetal heart rate: Effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumentaldelivery—A systematic review. InternationalJournal of Nursing Studies, 44(6), 1029–1035.
5.  Requirement of “immediate” emergency services for women attempting a VBAC.  The recent NICHD consensus statement speaks:  “Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.”
6.  Routine Episiotomy:  None of the following studies found a benefit to routine episiotomy.  Current recommendations are to use episiotomy when there are  indications of fetal distress and birth does not appear to be imminent.
  •  Dannecker, C., Hillemanns, P., Strauss, A., Hasbargen, U., Hepp, H., & Anthuber, C. (2004). Episiotomy and perineal tears presumed to be imminent: Randomized controlled trial.Acta Obstetricia et Gynecologica Scandinavica, 83(4), 364–368.
  • Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., & Lohr, K. N. (2005). Outcomes of routine episiotomy: A systematic review. Journal of the American Medical Association, 293(17), 2141–2148.
  • Klein, M., Gauthier, R., Robbins, J., Kaczorowski, J., Jorgensen, S., Franco, E., et al. (1994). Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American Journal of Obstetrics and Gynecology, 171(3), 591–598.
7.  Routine ultrasound to estimate fetal size:“Fetal weight estimation is inaccurate, with poor sensitivity for prediction of fetal compromise.”  (Dudley 2005).  “Prediction of fetal macrosomia remains an inaccurate task even with modern ultrasound equipment” (Henrickson2oo8). ”Considerable error in fetal weight estimations. . .may limit the accuracy and clinical utility of these measurements” (Landon 2000).
  • Dudley NJ.  A systematic review of the ultrasound estimation of fetal weight.  Ultrasound Obstet Gynecol. 2005 Jan;25(1):80-9.
  • Henrickson T.  The macrosomic fetus: a challenge in current obstetrics.  Acta Obstet Gynecol Scand. 2008;87(2):134-45.
  • Landon MB.  Prenatal diagnosis of macrosomia in pregnancy complicated by diabetes mellitus.  J Matern Fetal Med. 2000 Jan-Feb;9(1):52-4.
8.  Immediate cord clamping:  “Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy” (Hutton & Hassan 2007).
  • Hutton, E. K., & Hassan, E. S. (2007). Late vs early clamping of the umbilical cord in full-term neonates: Systematic review and meta-analysis of controlled trials. JAMA, 297(11), 1241-1252.

9. Directed (purple) pushing:  The following studies concluded that allowing the mother to push spontaneously (when, how long, and how hard to push are left up to the mother rather than directing her how to push), is superior to directed pushing.  Directed pushing is not recommended as there is greater risk of perineal trauma, fetal distress, and it does not significantly shorten the pushing phase of labor.
  • A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194(1), 10–13
  • Mayberry, L. J., Wood, S. H., Strange, L. B., Lee, L., Heisler, D. R., & Nielsen-Smith, K. (2000). Second-stage management: Promotion of evidence-based practice and a collaborative approach to patient care. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).
  • Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.
  • Schaffer, J., Bloom, S., Casey, B., McIntire, D., Nihira, M., & Leveno, K. (2006). A randomized trial of the effects of coached vs. uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. American Journal of Obstetrics and Gynecology, 192(5), 1692–1696.
10. Supine Pushing:  This, along with routine amniotomy and continuous fetal monitoring, is used in the vast majority of hospital births.  The following studies concluded that supine pushing is not beneficial and can even be harmful to the mother, by working against gravity, decreasing blood pressure which can lead to fetal intolerance of labor, increased episiotomy, increased use of vacuum/forceps, and increased pain for the mother.
  • Gupta, J. K., Hofmeyr, G. J., & Smyth, R. (2004). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD002006.
  • Johnson, N., Johnson, V., & Gupta, J. (1991). Maternal positions during labor. Obstetrical and Gynecological Survey, 46(7), 428–434.
  • Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.


  1. Brilliant post!

    I have a midwife and am planning a homebirth in May. However, for insurance reasons, I have to see a doctor in our HMO system at least once, prenatally, in order for them to cover any costs in the event of an emergency transfer.

    This doctor spent an hour trying to get me to consent to an ultrasound I didn't want. She insisted she couldn't know the baby was okay, or how far along I was without one.

    I wouldn't agree to one, and after reading your note here on #7 I'm glad I didn't!

    Keep up the great blogging work!

  2. Love the blog! I know this is an old post, but in hopes that you might still be reading... Concerning #5...

    Got the bill for my vaginal delivery in September. The total came to $16,442 for the vaginal delivery and 2-day hospital stay, with another $1,438 for some tests that were run the day before, trying to decide whether or not to induce. By far the largest charge on there was a whopping $4,492 for "operating room services - general classification."

    Does this mean they had a c-section team standing by or something? Is it normal to be charged for operating room services when having a vaginal delivery without pain meds? I had some risk due to edging pre-eclampsia, but didn't think I was all that high risk.

  3. @Proserpina,

    I'm not sure! that would be a great question to ask your insurance and the hospital.

  4. Hi AnthroDoula - I asked my doctor about it at an appointment yesterday. He said that, when I got to the pushing phase, my son was having decels and did not seem to be coming out, and there was a pop-off on the vacuum, so they had told the c-section team to get ready just in case. Amazing that it's a $5000 charge on the bill for maybe 5-10 minutes of c-section prep that was ultimately not needed. Guess that's how hospitals make their money!

    Thanks for considering my question, take care!

  5. If a doctor suggests these things, maybe you ought to ask them why, instead of assuming it's for no reason. Or find a new doctor, because you clearly don't have a good relationship with them.

    Do you really think it takes 5-10 minutes to prep an OR? To completely sterilize the room, gather the surgeon (who may need to drive from home to the hospital), the circulating nurse, the assist, possible a second assist, the pediatrician (who also might be on call) who is in the OR, the baby's nurse, the anesthesiologist (who also might be on call), the lab to have the right blood in case you need it, the pharmacy to deliver all of the medications (meds for anesthesia, resuscitation, possibly antibiotics, blood, blood products), to gather the supplies to do this surgery (not every surgery uses the same tools). The reason mother and infant morbidity and mortality is so low in this country is because of the useless doctors and nurses that help bring your babies into the world and care for them when they are ill ... or when people irresponsibly take their babies lives into their own hands.


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