My current theory on improving obstetrics

[hypatia]

I just had a thought about a way to improve obstetric care: What if surgeons, rather than obstetricians, performed C-sections? Obstetricians would continue to do the things they do now (primary gynecological care, prenatal care, labor care, vaginal births), but C-sections they would hand off to another doctor.

It seems to me that if C-section were being done by surgeons, instead of obsetricians, a lot of things would improve:

Obstetricians would no longer have an economic incentive to perform C-sections, and presumably would be less likely to schedule unnecessary C-sections. No more C-sections scheduled because the OB is going on vacation next week.

Obstetricians would be able to focus more on providing quality primary care and on vaginal births.

Obstetrics would attract fewer "surgery buffs," who go into obstetrics because they really wanted to be surgeons but couldn't. [Therefore, hopefully, more obstetricians would be more people-friendly and have a more holistic interest in women's health.]

Quality of C-sections would probably be better if performed by surgeons, not obstetricians.

[liseux]

But obstetricians are surgeons. I agree with all of your points, except I think OB`s are very well trained in surgery. I think it would be best if midwives took care of everyone who wants prenatal care and then moved into the OB dept only if they had a real need. So, no more early u/s, extreme pressure to do all the tests, etc. Just good care of healthy low risk pregnancies and if you develop a problem, you get sent on to OB. Much like the system in most of Western Europe right now.

What I really hate is that OB`s are the ones who do routine circumcision. Why do they have to help babies out and then hurt babies? Thats my personal pet peeve about Ob`s.

[sciencemama]

I always tell people to remember that OB's are trained as surgeons. You don't go into the field unless you want to perform surgery (C/S as well as gynecological surgeries).

I've worked closely with many surgeons and have a great deal of respect for what they do and for the type of skills, mentality and focus that they must develop. But I agree with the PP, most pregnant women need a different type of care. I've known a few OB's that combine the best of both worlds but i think they are few and far between.
Incidentally (not to start a debate) but the majority of OB residency programs also provide training in 1st and second trimester abortions, as well as infant circumcision. It must be more than a little disconcerting to be an OB student or resident... to deal with such a wide range of procedures over a short period of time.

[Undercover Hippie]

I agree with everyone else, an obstetrician is a surgeon. But I know what you are saying, most pregnant women do not need to see a surgeon during their pregnancy and the system really needs to be changed. I'm thinking that rather than changing what an OB does, we should just increase awareness so most people with normal pregnancy needs would see midwives or family practice doctors. (FPs are usually trained to do surgeries like c/s but do not use it as an option nearly as much, they are not as "surgical" in mindset I don't think).

[jessicaabruno]

I agree with everyone else, an obstetrician is a surgeon. But I know what you are saying, most pregnant women do not need to see a surgeon during their pregnancy and the system really needs to be changed. I'm thinking that rather than changing what an OB does, we should just increase awareness so most people with normal pregnancy needs would see midwives or family practice doctors. (FPs are usually trained to do surgeries like c/s but do not use it as an option nearly as much, they are not as "surgical" in mindset I don't think).

Tara,

Same here on this.

Thank you.

[CarrieMF]

What if surgeons, rather than obstetricians, performed C-sections? Obstetricians would continue to do the things they do now (primary gynecological care, prenatal care, labor care, vaginal births), but C-sections they would hand off to another doctor.

I think it would be worse rather than better. i think the c-section rate would be higher. Plus I wouldn't want to be handed off to a strange dr to do such a major surgery, I would want someone I knew.

Locally we have 3 dr's who do c-sections, 2 are obgyns and the 3rd is a family practitioner. The 2 ob's and 6 or 7 FP's are the ones who do deliveries.

[doctorjen]

I don't think having non-surgeons do the majority of prenatal care and births would increase the cesarean rate at all. If you have to consult for a cesarean, you tend to make sure one is really needed. In countries where OBs are only consultants, the cesarean rate tends to be much lower. As a family doc, sometimes my clients are concerned about the fact that I don't do c-sections, but I tell folks that they at least don't need to worry that they'll have a cesarean because I have dinner plans. I can't just call up my OB back-up and say "hey, you know I'm tired here" or "I have dinner plans" and get him to agree to operate for me. Also, I am always in the hospital with my clients during active labor while most OBs (and my OB back up) just swoop in to cut and catch, so I'm more likely to pick up quickly on a true need for surgical birth. I always go to the OR with my clients and scrub on their surgery, and having me there, who doesn't have to focus so hard on operating means I can help preserve a birthing atmosphere - talking to the parents, calling baby by name, getting the partner involved, helping to see that parents wishes are upheld - and I'm immediately available for the baby in the unfortunate event that baby needs resuscitation or urgent care.
OB is a surgical specialty, and surgeons think like surgeons. The saying goes "If the only tool you have is a hammer, everything looks like a nail." If surgery is your ace in the hole, you tend to use it

[orkid]

But obstetricians are surgeons. I agree with all of your points, except I think OB`s are very well trained in surgery. I think it would be best if midwives took care of everyone who wants prenatal care and then moved into the OB dept only if they had a real need. So, no more early u/s, extreme pressure to do all the tests, etc. Just good care of healthy low risk pregnancies and if you develop a problem, you get sent on to OB. Much like the system in most of Western Europe right now.

What I really hate is that OB`s are the ones who do routine circumcision. Why do they have to help babies out and then hurt babies? Thats my personal pet peeve about Ob`s.

:yeah: I couldn't agree more.

[applejuice]

But obstetricians are surgeons. I agree with all of your points, except I think OB`s are very well trained in surgery.

My feelings exactly.

I think all pregnant women should go to a midwife first, and only go to an ob/gyn on a referral because of a complication.

The Caesarean Section rate is as high in places as Canada (+/- a few % points) where the ob/gyns are paid the same per birth as they are for a normal birth because they think they are G-d and believe that what they do is good.

[applejuice]

All medical doctors are licensed to do some kind of surgery, AFAIK.

Medicine is an art, a practice, and as we all know, practice makes perfect.

Doctors like to do what they are trained to do, and that is surgery.

Surgery should be reserved for illness, not natural processes as birth.

Midwives are the world's oldest profession, next to motherhood and prostitution. Midwives should handle the 80% of births that do not require intervention, as they have for the last several millenia.

The problem is that there is a culture, a mindset, in our world today that tends to worship technology as gods and medical doctors as priests. We need to change that wrong thinking and go back to the basics.

[applejuice]

Another thought on the same subject, if you do not mind, is that there have always been obstetricians also throughout history. But obstetricians of yesterday handled the upper class women and catered to the members of the king's court and their families. These women did not get much in the way of healthy activity; they were a pampered bunch. I would not know what their diets consisted of, but I do know that processed foods were expensive and hard to come by, so I can only guess that they could have been well fed, but overfed on the wrong kind of food as processed grains, lots of spices and lots of sweets......I am not sure, as no one ever invited me to one of the banquets...:irked:

:lol

In the past people tended to follow what the aristocracy did the same way we like to follow what celebrities do. The problem is with the electronic media, we know everything instantly. Up to the middle of the nineteenth century, the mindset in Europe considered it necessary for women to suffer in childbirth because it was "Eve's Curse"; then in the middle of the nineteenth century, Queen Victoria, proud member of the Church of England, delivered her sixth child under the influence of anaesthesia, I am assuming it was "ether" or something inhaled.

Thereafter, women began to demand the "Queen's Anaesthesia" in childbirth; it was now proper and popular! Queen Victoria became a real trendsetter!

[saritabeth]

yeah to all the above...

We need more trained midwives. We need the medical community to recogonize the vital role midwifery plays in welcoming babies into the world.

Women need to be informed and encouraged....to believe in the process of birth and not to be afraid.

OB's will always be surgeons.

[cyjenkins]

Here's MY solution:

Let malpractice cost continue to rise and put OBs out of business, so that midwives HAVE to be allowed to practice in order to fill the maternity care gap!

Seriously, I live in a state which is not friendly towards midwives, especially direct entry. However, legislation was FINALLY passed that is a step in the right direction of allowing midwives to practice, in part because of the malpractice issue and lack of care in the rural areas of our state.

[jessicaabruno]

Here's MY solution:

Let malpractice cost continue to rise and put OBs out of business, so that midwives HAVE to be allowed to practice in order to fill the maternity care gap!

Seriously, I live in a state which is not friendly towards midwives, especially direct entry. However, legislation was FINALLY passed that is a step in the right direction of allowing midwives to practice, in part because of the malpractice issue and lack of care in the rural areas of our state.

cyjenkins,

Same here.

Thank you.

[Artisan]

OB is a surgical specialty, and surgeons think like surgeons. The saying goes "If the only tool you have is a hammer, everything looks like a nail." If surgery is your ace in the hole, you tend to use it


Very well said!!!

[applejuice]

How many surgeons does it take to change a light bulb?

[AnditheBee]

I always tell people to remember that OB's are trained as surgeons. You don't go into the field unless you want to perform surgery.
Or perhaps it would be more accurate to say: You don't go into the field unless you are willing to perform surgeries. I think there are a reasonable number of OB/GYNs who go into the field primarily in order to help women and babies, though granted, they may not be the majority.

I find it interesting that there are two OB's here who appear to not enjoy performing c/s...one of them was in charge of my friend's breech delivery, and rather than automatically suggest a c/s, she did an EV and then induced (the baby was postdates and they didn't want him to flip again). Not a fabulous solution but at least better than surgery... And when I had my c/s, the OB who had spent so much of the afternoon with me while I pushed, actually did not perform the surgery--she assisted a non-obstetric surgeon (and in my case, he did a great job). I never found out why she wasn't the one who cut--she did deliver my daughter and suture me, and she's been an OB long enough to have performed many c/secs--but it did break the "tradition," for whatever reason.

So I don't think surgery is always the primary motivation or focus for OBs, although I'm sure it is for some (perhaps most).

[cyjenkins]

I agree, I think there are some WONDERFUL OBs out there, I just have not been lucky enough to know them! But I've heard many positive stories from online friends whose OBs really went to bat for them.

On the flip side, there are midwives out there who are VERY medical, or even worse, very RECKLESS. But OBs are trained to think of everything as an emergency, and just that perspective makes them less trusting of the birth process and our bodies' ability to give birth. Which is why I don't trust an OB for prenatal or birth care unless I AM in an emergency.

[demetria]

The issue with OBS is that they are NOT trained to handle NORMAL birth. Thyue are trained to work with women who are high risk, or riskier clients. Family practice and CNM (in hospital) traditionally handled all birth unless their was an issue. The OB handled riskier birth issues. At some point women thought they could get "better" care from seeing an OB and the OB then started to handle normal pregnancies and we know what happened after that:) No pregnancy is now safe or normal... (being snarky).

OB are not trained to assist in delivering normal healthy babies. I have been a doula now to two OBs and I provided them BOTH with childbirth education, positioning and birthing techniques because they didn't know what a normal birth was.

"On the flip side, there are midwives out there who are VERY medical, or even worse, very RECKLESS. ."

I just wanted to quickly respond to this quote--
Very FEW midwives practice recklessly and have bad outcomes. I would bet that less than one a year looses her liscense. I know for a fact that MANY complaints are lodged against OBs, the difference is that the media does not get involved in an OB case. To say their are very RECKLESSS midiwives seems unsupported and I would love clarification on what you mean. Most Dr. attend 12 births a year to keep being able to attend births, CNMs attend 32 to get their credential and CPMs have to


I. As an active participant, you must attend a minimum of 20 births.

II. Functioning in the role of primary midwife* under supervision, you must attend a minimum of an additional 20 births:

A. A minimum of 10 of the 20 births attended as primary under supervision must be in homes or other out-of-hospital settings; and

B. A minimum of 3 of the 20 births attended as primary under supervision must be with women for whom you have provided primary care during at least 4 prenatal visits, birth, newborn exam and 1 postpartum exam.

C. At least 10 of the 20 primary births must have occurred within three years of application submission.

III. Functioning in the role of primary midwife* under supervision, you must document:

A. 75 prenatal exams, including 20 initial exams;

B. 20 newborn exams; and

C. 40 postpartum exams.

*The primary midwife has full responsibility for provision of all aspects of midwifery care (prenatal, intrapartal and postpartal) without the need for supervisory personnel.

I guess I take case with reckless. Very few midiwives have been proven of being truly reckless, and it seems to easy to say that.
Demetria

[tinyshoes]

ITA that pg women should receive care from a midwife...not an OB.

If you're feeling depressed or stressed, to get professional help, you see a psychologist or other type of therapist...even a psychiatrist!....... but you don't go to a brain surgeon. That would be stupid. (Maybe just as stupid as being pregnant and seeking normal care from an OB?)

I'll go to the brain surgeon when it's determined that there's really something wrong with me--not just because I'm feeling down or anxious (and I'll go to the OB when there's something truly wrong with me--not just 'cause I'm pregnant.)

Surgeons cut.

[KittyKat]

Very FEW midwives practice recklessly and have bad outcomes. I would bet that less than one a year looses her liscense. I know for a fact that MANY complaints are lodged against OBs, the difference is that the media does not get involved in an OB case. To say their are very RECKLESSS midiwives seems unsupported and I would love clarification on what you mean.

I agree, there are probably very FEW reckless midwives, there are plenty of MED-wives out there who got CNM slapped at the end of their name after a few years as L&D nurses, and deciding they wanted to get more involved...

But saying the reckless midwives are rare or whatever is ZERO comfort when it's your baby under the ground. There are good and bad caregivers out there of every label. Just because someone has "midwife" somewhere in there doesn't guarantee ANYTHING, and neither does someone having "MD" after their name.

Kathryn