Qs to see if you'll get evidence-based practice

[MegBoz]

I’ve thought for a while there are a handful of Qs you can ask a hospital-based HCP to determine if you’d get evidence-based care. Specific Qs I think are important & big RED FLAGS if you get certain anti-evidence answers.  Would love your opinions on this list.

1. What do you think of doulas?

   • Doulas are evidence-based. They’re proven to shorten labor, reduce CS rates, reduce requests for epidurals. & with ZERO “side-effects” – except women using them may be more likely to stand up for themselves & ask Qs.

2. Under what circumstances do you do episiotomy?

   • I'm pretty sure ANY answer other than, “baby in distress” is anti-evidence based. i.e. “First time Moms may need one, a cut is better than a tear, I cut to prevent upward tearing, etc.” I might also ask the HCP's epis rate – I believe evidence-based is near 5%, whereas the nationwide rate in the US is now about 25%.

3. Under what circumstances do you think labor needs to be induced?

   • There are lots of legit reasons to induce. But an HCP who thinks induction at 41 weeks is always necessary is a major red flag to me. ESPECIALLY considering first-time-Moms go to 41w1D on average! So that would mean literally the majority – over HALF of all FTMs would be induced with this policy!

4. How do you monitor heart tones in labor?

   • For low-risk births, EFM should be intermittent with occasional hand-held Doppler checks as an option too. Continuous EFM for low-risk birth is anti-evidence based.

5. Can I eat & drink in labor?

   • It seems even some decent hospitals have a policy ‘on the books’ that you can only drink clear-fluids & not eat --but the nurses & MWs don’t follow that. That was the case with the very good hospital-MWs I went to. But an HCP who states that “nothing by mouth” is the policy they personally believe & follow is a major red flag – totally anti-evidence based!

6. Can I labor in a tub or shower?

   • Again, I went to a good hospital & they didn’t allow you to give birth in the tub. While water birth is great, I wouldn't necessarily consider a hospital that doesn't allow it to be anti-evidence. But the hospital I went to had a big tub for labor & every room had a shower you could use too. Not allowing low-risk women hydrotherapy is another major red flag to me. Although I can understand higher risk births would require continuous EFM, in which case hydrotherapy might be incompatible- but the option should be there.

[msmiranda]

These are all good questions, but as someone who was recently strong-armed into an unnecessary induction by a doctor who probably would have answered all of these questions "correctly," I think it's impossible to come up with a definitive test for whether a provider will practice evidence-based medicine or not.  I found out the hard way that the bait and switch is real, even for providers who claim to favor natural childbirth.  In my case, the motivating factors were money and liability fears.  So I would add in questions about how the doctor is paid (e.g. are there financial incentives to rush/induce births?) and what their level of risk tolerance is re being sued -- if they seem mortally afraid of the idea of being sued, RUN.  I didn't and regret it. 

[womenswisdom]

While not exactly questions to determine whether the doc is practicing evidence based questions, I usually suggest clients ask:

Are there any procedures or policies that are non-negotiable? The answer should be "no" because YOU are the one making the decisions and should be able to decline things that you don't want. A provider who is willing to use bullying or scare techniques in this discussion is probably going to do the same at the end of pregnancy and during labor.

Also, I suggest going in and telling them you are considering declining something that you know they recommend. Is the discussion one between equals or is the provider trying to scare you into doing what s/he wants you to do. For example, you could say you are thinking about declining the saline lock (which just about every provider will tell you they recommend). Is the answer "Well, I recommend that for xyz reasons, but it's your decision." or is the answer "OMG, you can't do that, your baby could die." Big difference.

I've found these questions generally give an idea of what kind of care provider you're dealing with and how they might act during labor if you are outside of "average".

[MegBoz]

Quote:

Originally Posted by womenswisdom 

Are there any procedures or policies that are non-negotiable?

<snip>

Also, I suggest going in and telling them you are considering declining something that you know they recommend. 

This is a BRILLIANT idea! thanks!

[*MamaJen*]

I've always heard that the "what do you think of doulas" question can be a really great litmus test. But I do think that doulas are getting more and more common, so it might be a little less robust of a marker for a NCB-friendly OB. I do like the idea of asking about non-negotiable interventions.

Also, I don't think I'd ever birth with a doctor who ever cut an epesiotomy without one hell of a good reason.

[lamamaloca]

Routine induction at 41 weeks IS evidence based, though it shouldn't be required. It lowers mortality, morbidity and may even lower the risk of cesarean. http://childbirthconnection.org/article.asp?ck=10652

[jeminijad]

Before 'testing' a provider to see if their care is evidence based, be very certain that your understanding of the evidence is correct.

[mmaramba]

Originally Posted by lamamaloca 

Routine induction at 41 weeks IS evidence based, though it shouldn't be required. It lowers mortality, morbidity and may even lower the risk of cesarean. http://childbirthconnection.org/article.asp?ck=10652

I am totally open to this being true, but...  First of all, you referenced an article, not the study or studies themselves.  There were endnotes, but I'd like to get a direct link to which study/ies suggest this.

Second of all, this is what I saw in the article:

• Pregnancy lasting beyond 41 weeks: Various studies have compared induction of labor at or after 41 weeks with expectant management, which involved repeated tests of fetal well-being between 41 and 42 weeks. Taken together, the studies suggest that for every 369 women induced during the week between 41 and 42 weeks, one stillbirth or neonatal death may be prevented. The risk of meconium aspiration syndrome (a serious illness that causes respiratory distress) may also be reduced, although studies have come to different conclusions on this outcome. The risk of c-section does not seem to be increased with induction between 41 and 42 weeks, and some studies have shown a decrease.

Is this what you took to mean that routine induction at 41 weeks is evidence-based?  Or did you have other evidence?  Because what this says is that induction around this point (vs. expectant management) may prevent stillbirth/neonatal death without necessarily increasing the C/S rate.

1) "This point" is defined as "at or AFTER 41 weeks."  If routine induction does (relatively, in terms of acceptable risks) more good than harm at or after 41 weeks, when does the balance tip?  41w0d?  41w1d?  41w2d?  42w0d?  There's a pretty big difference when the best study we have says that (white) primips average 41w1d gestation.

2) Speaking of which... what's the difference between routinely inducing primips and multips at 41 weeks (or so)?

3) We don't know what repeated tests were done in the "expectant management" group, thus I'm not willing to say that any such studies compared routine induction with, say, NSTs (and nothing else) and not doing anything unless/until those look questionable.

4) If we are just looking at the above quoted section, we actually do not know if we're talking about routine inductions, per se.  There are lots of reasons women might be induced at or after 41 weeks which are not routine, and which would definitely be likely to have better results than expectant management.  What I mean is...  The quoted section is definitely not clear.  We could just be talking about a study which compared women who went 41+ weeks and were induced at some point vs. women who were never induced.  That's not at all the same as, say, women who were routinely (and with no medical indication) induced at 41 weeks vs. women who weren't, but also might have been induced later if NSTs didn't look good, etc., etc. 

Just to throw out extremes to make a point, theoretically, a really disproportionate number of the women who were induced could have been induced because they had major blood pressure spikes (we'd expect induction to be a better option in that case)-- confusing cause and effect, as you'd be heavily pressured or forced to induce in that case. OTOH, a disproportionate number of the women who were never induced could have been, for example, women attempting VBAC (smartly avoiding induction, but *possibly* slightly more likely to have an issue that ends up necessitating a RCS or causes a health issue, or to have HCPs that see her as a ticking time bomb in some respects, not "letting" her labor as long before giving her a C/S, which have higher mortality rates, etc., etc.)  You get my drift.

5) We don't know which methods of induction were used in these studies, in what proportion, nor if some are safer/more likely to have positive outcomes than others.

Etc., etc.

Like I said, I'm all for more evidence-based information!  But unless we have more to go on than the article you linked to (itself), I'm not seeing it (yet).

[MegBoz]

Originally Posted by mmaramba 

Second of all, this is what I saw in the article:

• Pregnancy lasting beyond 41 weeks: Various studies have compared induction of labor at or after 41 weeks with expectant management, which involved repeated tests of fetal well-being between 41 and 42 weeks. Taken together, the studies suggest that for every 369 women induced during the week between 41 and 42 weeks, one stillbirth or neonatal death may be prevented. The risk of meconium aspiration syndrome (a serious illness that causes respiratory distress) may also be reduced, although studies have come to different conclusions on this outcome. The risk of c-section does not seem to be increased with induction between 41 and 42 weeks, and some studies have shown a decrease.

This doesn't separate primiparas (First time moms) & multiparas (those who've had kids.)

However -

http://www.ncbi.nlm.nih.gov/pubmed/2342739

"The length of uncomplicated human gestation.

Mittendorf R, Williams MA, Berkey CS, Cotter PF.

Source

Abstract

By retrospective exclusion of gestations with known obstetric complications, maternal diseases, or unreliable menstrual histories, we found that uncomplicated, spontaneous-labor pregnancy in private-care white mothers is longer than Naegele's rule predicts."

--------------------------------------------------------------------------------------------------------------------------------------------------------------

That synopsis doesn't list how large the sample size was in the analysis - a data point that is very important. A little more Googling found this:

http://transitiontoparenthood.com/ttp/birthed/duedatespaper.htm

"n the 1980’s, Mittendorf noticed that birth dates for women in his practice, primarily second-generation Irish-Americans, averaged seven days past their “due dates”. He reviewed his records, then went on to review records of 17,000 births, and determined the average healthy, white, private-care, primiparous woman averaged 288 days from LMP to birth: 8 days longer than Naegele’s rule."

17K at least - that's quite substantial. To ROUTINELY induce even primiparas at 41W 0D is crazy. That means OVER HALF of all first-time Moms will be induced, and primiparas are more likely than mulitips to ahve induction fail (I've heard as high as 50% of induced primips will end in CS).

Common sense alone tells you that inducing over 50% of all primips with ZERO RISK FACTORS (aside from the "risk factor" of being 41W0D) isn't evidence-based practice. (Again, taking "known obstetric complications" out of the picture here - of course you induce for good reason.)

Originally Posted by jeminijad 

Before 'testing' a provider to see if their care is evidence based, be very certain that your understanding of the evidence is correct.

Well what would your understandings be? Routine induction at 41W is currently under debate. Do you take issue with any of the other points I listed in the original post?

[mambera]

It seems the available evidence does suggest that routine induction at 41 weeks and beyond lowers the risk of caesarean section.  In this sense, it is indeed evidence-based practice to recommend induction after 41 weeks.

 

Sometimes evidence-based practice and 'common sense' are opposed.  Research findings often don't give you the intuitive conclusion, or the one you were expecting.  What to do in cases like this is a matter of ongoing debate in all medical fields.  Larger studies would help.  But if you are strictly looking for an evidence-based practice criterion, then given our current state of knowledge, it seems that induction at 41 weeks - even for the otherwise low-risk patient - meets that standard.

 

 

http://www.ncbi.nlm.nih.gov/pubmed/12798542

Obstet Gynecol. 2003 Jun;101(6):1312-8.

Labor induction versus expectant management for postterm pregnancies: a systematic review with meta-analysis.

Sanchez-Ramos L, Olivier F, Delke I, Kaunitz AM.

Source

Department of Obstetrics and Gynecology, University of Florida, Jacksonville, Florida, USA. [e-mail]

Abstract

OBJECTIVE:

To compare routine labor induction with expectant management for patients who reach or exceed 41 weeks' gestation.

DATA SOURCES:

Computerized databases, references in published studies, and textbook chapters in all languages were used to identify randomized controlled trials (RCTs) evaluating induction and expectant management of labor for postterm pregnancies.

METHODS OF STUDY SELECTION:

We identified RCTs that compared induction and expectant management for uncomplicated, singleton, live pregnancies of at least 41 weeks' gestation and evaluated at least one of the following: perinatal mortality, mode of delivery, meconium-stained fluid, meconium aspiration syndrome, meconium below the cords, fetal heart rate (FHR) abnormalities during labor, cesarean deliveries for FHR abnormalities, abnormal Apgar scores, and neonatal intensive care unit (NICU) admissions. The primary outcomes assessed were cesarean delivery rate and perinatal mortality.

TABULATION, INTEGRATION, AND RESULTS:

Sixteen studies met inclusion criteria for this review. For each study with binary outcomes, an odds ratio (OR) with 95% confidence intervals (CIs) was calculated for selected outcomes. Estimates of ORs for dichotomous outcomes were calculated using fixed and random-effects models. Homogeneity was tested across the studies. Compared with women allocated to expectant management, those who underwent labor induction had lower cesarean delivery rates (20.1% versus 22.0%) (OR 0.88; 95% CI 0.78, 0.99). Although subjects whose labor was induced experienced a lower perinatal mortality rate (0.09% versus 0.33%) (OR 0.41; 95% CI 0.14, 1.18), this difference was not statistically significant. Similarly, no significant differences were noted for NICU admission rates, meconium aspiration, meconium below the cords, or abnormal Apgar scores.

CONCLUSION:

A policy of labor induction at 41 weeks' gestation for otherwise uncomplicated singleton pregnancies reduces cesarean delivery rates without compromising perinatal outcomes.

http://www.ncbi.nlm.nih.gov/pubmed/19687492

Ann Intern Med. 2009 Aug 18;151(4):252-63, W53-63.

Systematic review: elective induction of labor versus expectant management of pregnancy.

Caughey AB, Sundaram V, Kaimal AJ, Gienger A, Cheng YW, McDonald KM, Shaffer BL, Owens DK, Bravata DM.

Source

Stanford University, Stanford, CA 94305-6019, USA. [e-mail]

Abstract

BACKGROUND:

The rates of induction of labor and elective induction of labor are increasing. Whether elective induction of labor improves outcomes or simply leads to greater complications and health care costs is commonly debated in the literature.

PURPOSE:

To compare the benefits and harms of elective induction of labor and expectant management of pregnancy.

DATA SOURCES:

MEDLINE (through February 2009), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials (through March 2009), bibliographies of included studies, and previous systematic reviews.

STUDY SELECTION:

Experimental and observational studies of elective induction of labor reported in English.

DATA EXTRACTION:

Two authors abstracted study design; patient characteristics; quality criteria; and outcomes, including cesarean delivery and maternal and neonatal morbidity.

DATA SYNTHESIS:

Of 6117 potentially relevant articles, 36 met inclusion criteria: 11 randomized, controlled trials (RCTs) and 25 observational studies. Overall, expectant management of pregnancy was associated with a higher odds ratio (OR) of cesarean delivery than was elective induction of labor (OR, 1.22 [95% CI, 1.07 to 1.39]; absolute risk difference, 1.9 percentage points [CI, 0.2 to 3.7 percentage points]) in 9 RCTs. Women at or beyond 41 completed weeks of gestation who were managed expectantly had a higher risk for cesarean delivery (OR, 1.21 [CI, 1.01 to 1.46]), but this difference was not statistically significant in women at less than 41 completed weeks of gestation (OR, 1.73 [CI, 0.67 to 4.5]). Women who were expectantly managed were more likely to have meconium-stained amniotic fluid than those who were electively induced (OR, 2.04 [CI, 1.34 to 3.09]). Limitations: There were no recent RCTs of elective induction of labor at less than 41 weeks of gestation. The 2 studies conducted at less than 41 weeks of gestation were of poor quality and were not generalizable to current practice.

CONCLUSION:

RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid. There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided.

http://www.ncbi.nlm.nih.gov/pubmed/19140042

Acta Obstet Gynecol Scand. 2009;88(1):6-17.

Induction of labor versus expectant management for post-date pregnancy: is there sufficient evidence for a change in clinical practice?

Wennerholm UB, Hagberg H, Brorsson B, Bergh C.

Source

Department of Obstetrics and Gynecology, the Institute of Clinical Sciences, Sahlgrenska University Hospital, Goteborg, Sweden. [e-mail]

Abstract

OBJECTIVES:

To compare perinatal and maternal outcomes between elective induction of labor versus expectant management of pregnancies at 41 weeks and beyond.

DESIGN:

Systematic review and meta-analysis.

METHODS:

We searched PubMed, CINAHL, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE) and PsycINFO (1980 to November, 2007). Inclusion criteria were systematic reviews and randomized controlled trials comparing elective induction of labor versus expectant management of pregnancies at 41 weeks and beyond. Three or more reviewers independently read and evaluated all selected studies. Data were extracted and analyzed using Review Manager Software.

MAIN OUTCOME MEASURES:

Perinatal mortality.

RESULTS:

Thirteen trials fulfilled the inclusion criteria for the meta-analysis. Elective induction of labor was not associated with lower risk of perinatal mortality compared to expectant management (relative risks (RR): 0.33; 95% confidence intervals (CI): 0.10-1.09). Elective induction was associated with a significantly lower rate of meconium aspiration syndrome (RR: 0.43; 95% CI: 0.23-0.79). More women randomized to expectant management were delivered by cesarean section (RR: 0.87; 95% CI: 0.80-0.96).

CONCLUSIONS:

The meta-analysis illustrated a problem with rare outcomes such as perinatal mortality. No individual study with adequate sample size has been published, nor would a meta-analysis based on the current literature be sufficient. The optimal management of pregnancies at 41 weeks and beyond is thus unknown.

[lamamaloca]

I just linked to an article because it was by the Childbirth Connection -- generally a "crunchy" natural leaning source that I figured would be more respected on this board than some other sources. There is numerous available evidence on the benefits of routine induction at 41 weeks, I'll try to dig some links up for you. Most of the studies I found used regular BPPs or NSTs as the baseline for "expectant management." There have been many studies and there is good evidence supporting it as a routine policy that is likely to be beneficial and very unlikely to be harmful, although it isn't 100%, as in any area of medicine. The objections I've seen from the medical community are mostly not that it isn't beneficial, but that it is too expensive and would consume too many resources, given the lives saved, and that instead routine induction should wait until 42 weeks to conserve resources.

Early ultrasound dating has already been shown to result in far fewer "overdue" babies and unnecessary inductions. I don't think it is accurate to be quoting older data on the average length of pregnancy, from a time when relying solely on LMP was nearly universal. This data found that less than 20% of patients reached 41 weeks: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2603611/ In any case, arguing that 50% of patients shouldn't need an intervention is based on a philosophy that nature gets it right most of the time. The evidence suggests that this particular intervention is beneficial, on a population level. If one wants to find a care provider who shares the same philosophy, that is absolutely understandable, but be honest that this is what you're doing, not looking for someone who is "evidence based."

Here is the systematic review cited by Childbirth Connection: http://212.150.243.194/~karlosc/files/wordocs/induct%20of%20lab%20revieww%202009%20.pdf

And some other resources:

http://www2.cochrane.org/reviews/en/ab004945.html

http://www.ajog.org/article/S0002-9378(10)01001-X/abstract

http://www.ejog.org/article/S0301-2115(04)00486-5/abstract

http://www.biomedcentral.com/1471-2458/11/S3/S5/abstract

http://www.ncbi.nlm.nih.gov/books/NBK38683/

To be fair, there is also some evidence that elective induction of labor is associated with improved neonatal outcomes in general, and not just after 41 weeks, but that evidence isn't as strong: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888294/

Edited by lamamaloca - 7/7/11 at 4:54am

[lamamaloca]

Some of the studies do look specifically at nulliparous women. The link between induction and cesarean is actually more controversial than one might think, and again, there is a good amount of evidence showing no increased risk of c/s, or even a decreased risk of cesarean, with routine induction at 41 weeks.

Here's an interesting study: http://www.ajog.org/article/S0002-9378(08)01021-1/abstract

[lamamaloca]

In response to your other questions, most are good. With doulas, though, some care providers may have had poor experiences with the local doulas, who may have overstepped their roles as labor support. I would want to ask their reasons for their views on this one. On the EFM issue, the data is more mixed than is sometimes portrayed, so I'd want someone who takes the time to communicate the nuances of the literature, as is encouraged in the Cochrane review on the topic. On the eating during labor, NPO would be a red flag for me, but I'd want details if the provider says "clear fluids." With my second birth, the doctor agreed to clear fluids, but the nurse insisted that meant ice chips.  When I asked my current doctor this question, I wanted to know specifically what he considered OK during labor. He said clear fluids, and clarified -- broth, jello, popsicles, clear juices, gatorade, hard candy, etc. For me, that's fine. I tend to vomit my way through labor and don't want to eat anyway. If I want something else, I'll eat it with or without approval.

I also asked some general questions -- what is your philosophy of pregnancy and birth? And I'd encourage asking ALL questions in such a way that your own views aren't clear at first. You want to try to get the care provider to state what they really think, not what they think you want to hear. Of course, the fact that you're asking question may be a tip off that you're natural leaning. Keep in mind that what you want may be very different than what the majority of patients want. When I asked my doctor, "When would you want to induce labor?," his response was, "I'd prefer never to induce labor if it is not necessary. I will allow an elective induction only after 39 weeks, and only with a ripe cervix." (He did go on to talk a bit about medical indications) His usual experience is women asking for an induction, not wanting to avoid one. I asked if he encouraged natural birth, and again his response was that 95% of his patients expected him to make their births as pain free as possible. He then did explain that he was supportive of natural birth, and described some of the coping mechanisms he encouraged. Still, I know that I'm in the minority in my area (and in the US) in terms of my birth preferences.

[lamamaloca]

For a midwife, (I've had two OOH births, one with CNMs and one with a CPM) I'd want to ask such questions as

When do you recommend an ultrasound? Or -- What do you see as the pros and cons of ultrasound? (Personally, I think the evidence supports early ultrasound dating and I prefer an anatomy scan)

What blood tests do you do or recommend? Why? 

When do you transfer care to a doctor? Share care with a doctor?

What methods do you suggest to start labor or augment it in an OOH birth? (The CPM I used actually induces/augments with misoprostol, but I had NO idea until she wanted me to take it in labor to "get this over with." I'm not sure that she'd admit this in an interview, though, her own blogs states that she doesn't induce or augment outside the hospital but that's just not true.)

I'll have to think more about this. My own experience is that my CPM did NOT practice evidence based care at all, but I simply trusted her to do so because she was a midwife. I was wrong. So I think looking for an evidence based practitioner has to go both ways.

[MegBoz]

Originally Posted by lamamaloca 

My own experience is that my CPM did NOT practice evidence based care at all, but I simply trusted her to do so because she was a midwife. I was wrong. So I think looking for an evidence based practitioner has to go both ways.

Good point there. Personally, I have my doubts about a lot of herbal & homeopathic treatments being "evidence-based." I spoke with one woman (a doula, CBE & MW in training) & her response was, "Just because it's not in the New England Journal of Medicine doesn't mean it's not evidence-based." Um, yeah, actually, it sorta does - "evidence" refers to hard science. If these treatments have never been formally studied, or the studies haven't shown they are beneficial then they are NOT "evidence-based." Just because maybe studies have never been done, doesn't mean they're not effective, but a lack of evidence does mean they're not "evidence-based."

[lamamaloca]

I agree. I also am concerned about the assumption of safety with regards to herbal remedies. There is little information on safety or efficacy of many herbs, and sometimes there is some information that should lead to extreme caution, as in the case of blue cohosh. Not knowing the risks and benefits doesn't mean that there aren't any.

[Turquesa]

All of these are good.  I'm also wondering about a good way to word a question about transfer rates, how often and under what circumstances?

Originally Posted by lamamaloca 

For a midwife, (I've had two OOH births, one with CNMs and one with a CPM) I'd want to ask such questions as

[Turquesa]

Originally Posted by lamamaloca 
So I think looking for an evidence based practitioner has to go both ways.

Agreed.  I'm ardent about maternity care reform and birthing rights.  I also wonder why my activist peers complain about the lack of evidence-based care in hospitals all the while lotus birthing and swigging their placenta smoothies (I'm going to get jumped on for that one, aren't I?  )  Granted, unlike a lot of hospital-based interventions, neither of the latter have proven to be seriously harmful and I'm all for women having them as an option.  But they're not exactly Cochrane-reviewed, either.  Or am I wrong....? 

I also agree with MegBoz on "effective" v. "evidence-based" (or, I would add, "safe")  As one example, those terms get switcheroo'd a lot during the classic Cytotec-for-induction debate. 

[MegBoz]

Originally Posted by mambera 

It seems the available evidence does suggest that routine induction at 41 weeks and beyond lowers the risk of caesarean section.  In this sense, it is indeed evidence-based practice to recommend induction after 41 weeks.

OK, fair enough. My comments under Q # 3 needs to be modified.

HOWEVER - I think one thing that complicates the research here is that - this is [very likely] comparing medicalized birth to medicalized birth. I.e. Even the "expectant management" (NOT induced) group still had medicalized births. (& I say this simply because the vast majority of American births are medicalized.)

For me, induction is a step into the world of TOTAL medicalization of my birth.

First off - it requires cEFM, which in itself raises the risk of CS. (And without induction or other risks factors, I wouldn't - and didn't - have cEFM.)

Second, if induced, I figured I would have opted for the epidural. (Whereas otherwise, I'd hoped to avoid it - and did.) with extra painful, pitocin-induced ctrxs, plus cEFM prohibiting me from hydrotherapy (I don't think my hospital had water-proof EFM) AND spending ALL my labor in the hosptial (as opposed to my plans to do most laboring at home & go to the hospital later),

Again, some research shows epidurals increase the CS rate.

Of course, most births, even if NOT induced, have epidurals & cEFM anyway - but for me personally, given the drastic changes to my whole birth experience, it's hard to imagine induction NOT increasing my CS risk.

I've  heard that said about other issues, I think pelvic floor damage & post-partum hemorhage as examples - that instead of comparing medicalized births with XYZ intervention to medicalized births without XYZ, what we should do is compare physiological, evidence-based births with and without XYZ intervention.

Sure, a shot of pit reduces the risk of PPH, but the risk of PPH is lowered in the first place if births weren't augmented with pit, babies were kept with mama & BF immediately, cords weren't pulled, or placentas manually extracted. (all of which are still too common - although I don't know stats on the latter.)

Likewise there's no risk of perineal lacerations with a c-section, but perineal damage would be lessened with vaginal births if we had less episiotomy, purple pushing, lithotomy position, and "vagina wrenching" (aka "perineal 'massage'"). 

So - TO ME - the true comparison is to look at physiological, evidence-based practice and see what my risks are there for PPH and perineal damage, THEN decide if I want a prophalaytic shot of PPH (and on that point, I decided it was unnecessary for me personally.)

[MegBoz]

Quote:

Originally Posted by Turquesa 

Agreed.  I'm ardent about maternity care reform and birthing rights.  I also wonder why my activist peers complain about the lack of evidence-based care in hospitals all the while lotus birthing and swigging their placenta smoothies (I'm going to get jumped on for that one, aren't I?  )  Granted, unlike a lot of hospital-based interventions, neither of the latter have proven to be seriously harmful and I'm all for women having them as an option.  But they're not exactly Cochrane-reviewed, either.  Or am I wrong....? 

LOL, I'm totally with you on those 2 points. At least many lotus birthers have said it's a "spiritual" thing - and of course there is no such thing as applying "evidence" to anything 'spiritual.' Although I've read once or twice that Lotus birthers view it as "violent" to cut the cord. Um, it's dead tissue!! [once it stops pulsing.] Is it also "violent" to cut baby's nails & hair? No, on the contrary, it's vital because babies WILL scratch themselves if you don't file down the nails (or keep on mittens.)

I browsed the paucity of data on placenta-consumption & wasn't swayed in the least. So no, I think you are correct that placento-phagy (sp?) is not evidence-based.