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A Normal Pregnancy Is a Retrospective Diagnosis

The names in this article have been changed to protect the privacy of all individuals involved.

If every medical specialty has its homily for indoctrinating new members, “a normal pregnancy is a retrospective diagnosis” is the cynical soundbite for obstetrics. It is a patronizing and alarmist statement, meant to distance weary practitioners, terrify patients, silence objections from families, and establish the first defensive perimeter in the legal fortress that defines obstetrical practice in the US.

It is also the perfect, if inadvertent expression of how little obstetricians really know – and how limited the specialty is in its ability to test and expand that knowledge – thanks in part to the visceral fear inspired in patients by statements like “a normal pregnancy is a retrospective diagnosis.”

This homily serves as the opening taunt to one of the more quietly rebellious obstetrician/gynecologists (OB/GYNs) in my new book, Catching Babies. For reasons I’ll explain momentarily, the book began as an expose of the practice of high-risk obstetrics, but it quickly morphed into a novel, an ensemble drama about the brutalization of OB/GYNs during their residency training.

But tonight, none of that matters. Tonight, life is imitating art; nothing from my years of research on the subject is comforting or even interesting; and I want to cringe every time one of the Kaiser people asks this nervous, expectant uncle if he is “the one who wrote the book about us.”

As I hole up on the labor “deck” with worried expectant parents and juggle emails and callbacks from OB/GYN and certified nurse-midwife (CNM) friends around the country, the horrible truism about the medical mysteries that can hijack a “normal pregnancy” – often with devastating capriciousness and cruelty – loses the last of its intellectual and literary charm. This is not a cool case in my new book; this is my family.

Hannah’s growth has stalled in the final month of her pregnancy, and she has actually lost a small amount of weight. And even though ultrasound and all available tests indicate no other problems with what, at 39 weeks, is no longer a fetus but a baby boy with an emotionally charged family name, the protocols at Kaiser call for immediate admission and an induction of labor. There could be a problem with the placenta or umbilical cord, and “Baby Sam” – as we started calling him months ago – might be slowly starving. Or he might just be small. As the homily from internal medicine would have it, Baby Sam has a classic case of “GOK,” or “God Only Knows.”

Which is why I am frantically calling around the country for help, before Hannah gives the final go-ahead for the induction. “GOK” rankles and infuriates me, even if it is honest, even if it is not gussied up for our side of the medical curtain like “idiopathic” – a term meant to sound clinically authoritative by physicians who would rather not admit in plain English that they are clueless about what is happening with a patient, i.e., that they have been reduced by the case, literally, to idiots. But not knowing anything about Baby Sam’s status – other than he sits at the 7th percentile for fetal weight, he is still active, and his heart rate is normal – is especially frustrating, given the freefall Hannah is about to take into the world of cascade birth interventions and potential complications.

My first callback is from Meg, a CNM with 30 years’ experience delivering babies and training other midwives.  “She is right on the edge,” Meg says. “She really could go either way. I would not induce her. I’d have her stop all activity, monitor her closely, and let her deliver naturally.”

A few minutes after we hang up, I get a callback from Tom, Meg’s colleague, also a friend, and a professor of high-risk obstetrics at one of the most celebrated academic medical centers in the country.

“She is right on the edge,” Tom agrees.  “At 39 weeks and 7th percentile, she could go either way. Could be serious IUGR [intrauterine growth restriction] or nothing. And the risks of waiting, though they’re extremely remote, are developmental delay and retardation. I’d go ahead and induce and deliver her.”

Wonderful. IUGR. Developmental delay and retardation. Not an option. I already know what Hannah and her husband are going to do; extremely remote is not remote enough.

An induction, on the other hand, does not guarantee a good outcome either – and it is fraught with the potential for bad outcomes that are not all that remote. An induction, or the forcing of labor with drugs and procedures, often triggers downstream interventions, most notably emergency c-sections, which are already done with hair-trigger frequency throughout the US obstetrical care system; these in turn lead to numerous other complications, including the need for more interventions and c-sections in subsequent pregnancies. The blessing and the curse of modern medicine, from the NICU to the oncology unit, is its ability to stimulate its own demand, and obstetrical practice is the quintessence of this cost-curve-sustaining paradox.

The specter of these interventions – inflated by expectant families’ primordial fear of arbitrary physical harm to their babies and providers’ primordial fear of arbitrary legal harm to their careers – has instituted a permanent game of chicken between pregnant women and the medical establishment. In obstetrics, “defensive medicine” is not just assumed, but actively evoked as part of a normative explanation for medical decisions. I have heard the phrase “we have to do this to cover ourselves legally” uttered to patients with such frequency, it has gone from appallingly crass, to admirably candid, to nearly superfluous.

Whether or not this does explain every dysfunction in obstetrical care, as many would have us believe, medicine does not get any more defensive that this: the inexorable increase in birth interventions has driven a growing number of women away from the medical establishment, off the grid, to home births attended by “lay” or unlicensed midwives. It has spawned a cottage industry of “alternative birthing” activists. And it has inspired language no less ugly than terms like “birth rape” (seriously – Google it) to describe what many view as a mangling of womens’ bodies against their will by OB/GYNs held hostage by lawyers who do not ambulance-chase malpractice so much as hearse-chase mal-outcomes – many of which are the fault not of any doctor, but of nature, God, or bad luck, depending on your beliefs.

Not that a purely defensive induction of Hannah’s pregnancy would protect anyone at Kaiser from a lawsuit. Tom tells me that as an expert witness he has seen perfect replications of her case present twice and go perfectly wrong in both directions: one patient chose to wait, the baby was disabled, and the family sued and won; the other patient chose to induce, ran the gauntlet of severe birth-related complications, and the family sued – and also won. As anyone who has ever had the pleasure of litigation will tell you, its outcomes have more to do with a gothic mix of technical arcana and emotion than anything resembling fairness or truth.  And that is before parading dead or disabled children and devastated families in front of juries without medical training.

The Womb is Not a Study Site

During the long night before Hannah’s actual induction begins, I talk with two more friends, a teaching OB/GYN in Denver and a lay-midwife in rural Oregon. Guess how they vote? The OB/GYN agrees with Tom and recommends, reluctantly, that Hannah go ahead with the induction; the midwife of course recommends getting her and Baby Sam the hell out of the hospital.

“IUGR, placental disorder, developmental delay and retardation,” I remind the midwife. “This is not a family of gamblers.” Like a growing number of women, Hannah has been wanting as natural a childbirth as possible, inside the traditional birthing system. But “7th percentile” sounds tiny, puny, scary; maybe not for weight distribution among a sample packed as tightly as near-term babies, and definitely not to somebody who understands biostatistics and just wrote a book on this very subject; but it sounds terrifyingly small and vulnerable to people who want and expect a healthy baby.

More pacing on the labor deck. What to do, who knows? Perfectly consistent with the absence of definitive data and driven, like patients, by their own temperaments, values and biases, my OB friends say intervene and my midwife friends say do not intervene. So is this a normal pregnancy? Or a family heartbreak in slow motion?? Can’t we have our retrospective diagnosis now???

The smart-ass answer to this entire problem – the one I might give on a panel at a health care conference – is that we need to study the problem. We could settle this matter within months with a clinical trial: randomly assign 500 women who present with late-term stalled fetal growth to induction versus no induction, stratify by number of weeks of pregnancy and fetal weight, and see what happens.

What would happen, of course, is nothing. No expectant mothers would sign up for the trial, for fear of relinquishing control to randomness; and an absence of subjects would not matter because no hospital’s Institutional Review Board (IRB) would sign up to host the research. I imagine the only folks really interested in seeing anyone undertake such a study would be the plaintiff’s bar, who would line up and count off by ones-and-twos to represent the “victims” on either side of it. But even if, through the twin miracles of fundamental malpractice reform (meaning profound process reform, not just economic futzing) and an emboldened medical research bureaucracy, the study were initiated, it would quickly be terminated for ethical reasons. Many expectant mothers would suffer mildly or moderately bad outcomes, and a small number of babies would suffer catastrophic outcomes – something society could no more countenance than my family could for Baby Sam.

Which makes Hannah’s situation not only vexing, but a post-modern American medical classic: what is best for Hannah and Baby Sam, absent the retrospective diagnosis we desperately wish we had, is not what would be best for the overall population. The situation is even more complex when you factor in potential divergences between the needs of an expectant mother and her near-term baby – where the mostly male politicians start showing up with their mouths open – but we have enough to worry about tonight. For us, right now, Baby Sam comes first; he is Hannah’s baby, not everybody else’s data point. The nominal risks associated with an induction are minuscule compared with the remote but catastrophic risks associated with fetal distress, developmental delay, or the word Tom spared me on the phone but we both know is relevant to IUGR, the one word I dare not utter in Hannah’s labor and delivery room: “stillbirth.”

The induction process begins in the morning.  The Kaiser care team gives Hannah the drug CYTOTEC (misoprostol) – the drug used in conjunction with the politically incendiary medication, RU-486, or “abortion pill” – hoping this will ripen her cervix and stimulate labor.

Several hours of waiting, worrying, praying, and staring at the fetal heart rate and uterine pressure monitors, and nothing. Hannah’s care team escalates to intravenous injections of PITOCIN (oxytocin).  In clinical shorthand, they are “pitting” her – a weirdly apt way to describe throwing one’s body somewhere it does not want to go on its own.

The day wears on, turns into evening, then another day. Hannah’s labor does not progress. She is starting to weary of the process, and she’s hungry; they have put her on a restrictive diet, of course, assuming she will soon go into labor and deliver. When her blood sugar starts dropping, they let her go back on solid food.  Her energy picks up, enough to start arguing that maybe she should just go home and wait.  “Maybe this is a sign that Sam is fine,” she says, “and
he just doesn’t want to be born yet.”

The Kaiser people get wind of our conversation when they walk in to check her IV, and send in the CNM who has just begun her shift.

She runs through the same argument that had brought Hannah in two days earlier.

This time, Hannah argues back.

“Do you know what could happen, if you wait?” the CNM finally says with an impatient sigh. “Your baby – he could be – stillborn.”

The ugly stench of the word fills the chlorine air of the delivery room, where it hovers, like a dead infant in a shroud, for all of us to behold.

“It’s actually time,” the CNM adds, “to move things along and break your water.”

There is no argument from Hannah or anyone else.

The next stop on the standard tour of birth interventions is the rupturing of Hannah’s membranes, or the amniotic sac that holds and protects Baby Sam. This would be the point of no return, an irreversible procedure that could well result in a massive infection if it did not work in short order, thus guaranteeing the necessity of a c-section.

Why did all of this suddenly feel like a runaway train? It would be causally accurate and certainly easy to blame the American legal system for the collision in our nation’s delivery rooms between what patients want and what protocols demand. But our tort system, with its stupefying processes and swarm of venomous creatures, is not the root cause of the problem.  Rather, it is a symptom of our own denial, of Americans’ entrenched cultural inability – shared by this author – to accept life on its own occasionally heart-shattering terms. Our medical malpractice system, like much of the post-modern American health care system itself, is a house of broken mirrors for our own worst neuroses as a society; and a big part of these neuroses includes our pathologizing of childbirth, along with our pathologizing of shyness, baldness, the normal effects of aging, dry eyes, twitchy legs, and whatever other little misery we can figure out how to medicate next.

As Americans, we seem hellbent on controlling the uncontrollable; this is why we create so many breathtaking medical technologies and give the world almost all of its breakthroughs in the treatment of cancer, heart disease and other real diseases.  But it is also why we grind up tens of billions of health care dollars every year overtesting, overreacting, and overtreating; why we look for someone with deep pockets to blame when things go wrong anyway; and why we demand and expect to get retribution when nature wants – to add insult to our injury – simply to take its own difficult course.

Every Baby Tells a Story

In the hours I have to sit around the labor deck thinking back on every detail of Hannah’s pregnancy, I realize that perhaps none of this would have happened if she had not been overtested and overtreated in the first place. When her blood sugars started coming back just on the high side – based on a crude test known to generate suspicious results – her care team put her on a highly restrictive diet to prevent gestational diabetes. Gestational diabetes, after all, would result in too large a fetus. That intervention certainly worked.

What else would anyone do for their own baby? For every argument for and against Hannah’s dietary reaction, once again the fear of a remote catastrophic outcome outweighed the more likely mildly bad outcomes. These choices are not really rational or irrational, so much as they are differently rational; they are the human calculus of fear and dread winning out over skepticism. From the oversized pre-natal ultrasound clinic at one end of the hospital to the oversized ICU at the other end, patients and their families are driven not by reason, but by faith, fear, guilt, anger, entitlement, and nothing less than what they perceive as the rockbottom meaning of life. And God help anyone who tries to stand in their way, as the hysteria about “death panels” during the health reform debate made garishly clear. With childbirth, all of these forces go into overdrive.

Hannah’s husband and I pace the labor deck.  He reminds me that she is carrying the hopes of an entire family. Baby Sam will be the first child in a new generation, and because of that, he has been tagged by name with nothing less than the legacy of a recently deceased uncle who survived the concentration camps and walked from Poland to Israel. Against a landscape of hope that dramatic – and for every family, the landscape is that dramatic – it is difficult if not impossible for anyone to think clearly about imperfectly informed medical choices: not the mother, nor the family, nor anyone on a jury.

This is why Catching Babies morphed, almost against my own will, into a novel. In my earlier work about the economic and political conflicts that define the delivery of health care in the US, I kept noticing that the greatest variations in care – and deepest cultural angst and antagonisms – seemed always to be associated with women’s health: our grossly disproportionate misdiagnosis and undertreatment of heart disease in women; our obsession with breast cancer when lung cancer is far deadlier and far more preventable; the almost criminal variations in hysterectomy rates around the country; the uninformed, blanket imposition of one group’s religious values on all women’s reproductive decisions. What started out as an analysis of the health policy problems unique to obstetric medicine quickly escalated into outright drama, if only because nowhere else in our health care system have I found the needs and obsessions of individual providers on such a direct collision course with the needs and obsessions of patients.

Like Hannah, we all dream of perfect pregnancies and perfect babies, as if they were natural rights. This happy baby dream can be punctured, often in a few messy, terrifying moments, by the harsh and merciless realities of the working OB/GYN’s world – a world shaped by an OB/GYN resident’s disproportionate exposure not to happy baby dreams, but to disaster pregnancies among the poorest, unhealthiest, least insured, most vulnerable women in society. The specialty has learned to cope, barely, by muttering homilies about retrospective diagnoses; by learning to hate lawyers like they learn to hate cancer; and by hoping for the best (maybe) but always assuming the worst – and treating accordingly. Without sleep, without data, one patient at a time. Who would not find great drama in a medical culture so doomed and dysfunctional, and so utterly driven by the conflict between patient preference and provider prejudice.

But tonight, as I go back to pacing the labor deck alone, none of that matters. And then, a terrible thought: is this somehow my fault?  I’ve spent the past two days in Hannah’s room and the waiting room, exchanging emails about publishing details for Catching Babies. The idea of some perversely cosmic connection sounds totally absurd of course, more than a bit self-aggrandizing, maybe even paranoid. But it is perfectly consistent with the belief, held only half-jokingly by many otherwise perfectly rational OB/GYNs I know, in the existence of  “Call-Gods” – mischievous personal deities who preside over pregnancies on nights when they are on call at home or in the hospital, starving for sleep. But this teleology would not sound all that absurd to a billion or so Hindus, many of whom are just as rational and science-minded as a physician awakened to another precipitous delivery at 3 AM, ten minutes after finally falling asleep.

Breaking Hannah’s water finally works. The artificially induced contractions are severe, throwing her from the bed. The pain is too intense, and Hannah finally relents and agrees to an epidural, which will numb her from the midsection down and cut her off from the core sensations of the birthing process. It is the next car on the runaway train of interventions, and she did not want this one either, but the pain from the induced contractions are overwhelming.

Three hours of pushing later, and Baby Sam is born. He is perfect and pink and healthy.

It had been a normal pregnancy.

J.D. Kleinke is a medical economist, author, and health information industry pioneer.  He has helped create four health care information organizations; served on several public and privately-held health care information company boards; and written about health care business and policy for The Wall Street Journal. The names in this article have been changed to protect the privacy of all individuals involved.

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63 replies »

  1. Wonderful article,

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  2. Excellent blog, loved it!! The main thing that caught my eye is “Three hours of pushing later, and Baby Sam is born.” THREE HOURS!! I mean i’m really happy that baby sam was born healthy n adorable… but THREE HRS of pushing!! Hannah! u poor thing!!

  3. I have not read your books yet but I am truly looking forward to doing just that. I have to tell you that I have seen some truly gut-wrenching disasters created by hospital staff. Not all happened in July either.

    My experience is limited to 280 births as a doula, all but 4 of those births hospital planned births. I have never seen a problem that did not raise its ugly head long before strong measures had to be taken. Midwives in my area do not hesitate to transport in those cases.

    Is there anything you can do to help make the evidence-based skin to skin experience happen in hospitals? I see a lot of talk and promotion but not nearly enough carry through in the birth room.

  4. Doulas in my area are specifically trained to not contaminate anyone’s epidural sets or any other sterile set up! We DO NOT want our clients injured. Is that a surprise to you? Sometimes, because I stay for an entire labor, I am the only person in the room who knows what all happened during the course of that labor. I also usually know what issues the mother has, medical and otherwise.

    Oh, and it would be nice if the hospital actually had a history from her doctor when a woman is admitted in labor. I am tired of having my poor laboring clients asked ridiculous questions (that could certainly have been answered long ago) as they struggle to stay in their own head while they birth.

    As a doula, it is not my job to argue with or question doctors or nurses. I make no medical decisions. All that is the job and right of the parents. In a family centered facility, they are the leaders in the birth room.

  5. 1) There is always a range of error in US measurements. If you are told 7% you need to know the plus/minus. More importantly, what is the size compared with past US measurements, if you know. You note that the baby had lost some weight. How much?

    2) Just so you know, we do get women rushed in when things have not gone well at a birthing center. It is a bit challenging to receive a patient who you know nothing about, she and/or her baby is dying, and you get to resuscitate them while the baby is delivered. It would help if doulas and midwives had a history preprinted that they could send with the patient, a medical history not an OB one.

    3) In the hospital, doulas are mostly useless IMHO. Maybe they do something useful at outpatient deliveries. They are good at getting in the way and contaminating my epidural sets.

    4) Medicine can be thought of as needing to apply large scale statistics to individuals. That means uncertainty. In any particular case, it is difficult to draw bright lines much of the time.

    5) In general, we over treat and test.

    Steve

  6. Interesting post for those not involved in OB care. As a veteran of thousands of deliveries, this seems routine. I would agree with the first poster that if you substitute grandpa for baby, it is just as dramatic. Medical decisions are complicated and challenging. Doctors are asked by patients to make decisions where the “right” answer is lacking. This is why medical dramas still sell in Hollywood and you will no doubt sell many copies of your book. I have had parents make the other “non-intervention” choice as well – not pitocin, no c-section, and they have a permanently damaged baby. There are no guarantees in life. I base my practice on an open relationship with my patients and count on their participation with an open mind.

    My other point is that nested in the original post and responses is the belief that everyone knows best. Everyone who posts (myself included) has one or more past experiences that made the original post of interest. We read it, and are biases are now reaffirmed (doctors love c/s, patients have unrealistic expectations, hospitals are dangerous).

    The rub here is the patients that ignore probability. An example would be the 41 year old first time mom who is 50 lbs over weight before pregnancy. She lives in a country with a 30% c-s rate. And she never though that she might need a c-section.

    I want to open a medical practice that accepts all patients with an open mind (and provides a discount if you swear off magical thinking) regardless of their ability to pay.

  7. I use to work with physicians in the medical field. I know about the intense pressure on OB/GYN’s. I have known many people who did not choose that specialty because of high cost of med. malpractice and everything you have said.

    Re. too many C-sections performed my own experience with my first child was that I was two weeks overdue. I was induced and in labor for 15 hours before I heard the radiologist and the obstetrician arguing. The radiologist told the OB guy that there was no way my baby was going to fit through my pelvis. OB disagreed, said something about too many c-sections. He let me stay in labor for 3 more hours. She went into distress and they did an emergency C-section. The doctor then told me I would have to have C-sections in the future because the bottom part of my pelvis is too small. My daughter at delivery appeared to be fine, healthy, etc. but after she started going to daycare, then school I discovered that she has a learning disability that has made her life very difficult.

    My 2nd pregnancy was very complicated. But the complications were with me and not the baby. I had so many, I had many trips to the ER, many stays in the hospital. I had a planned c-section and my son was fine. Unfortunately for me during the C-section, a doctor sliced some nerves and I ended up with CRPS and I became disabled.

    It took several years for my CRPS to be diagnosed so even if I had tried to sue I couldn’t. My father is a lawyer and I know that many women with complications with their child or themselves choose not to sue or are able to find a lawyer who will take their case despite those advertisements on television.

    I have reviewed medical records from HMO’s for quality of care issues. I know that the administration is primarily interested in preventing liability an making money, not quality of care. I think there are far too many constraints on doctors that force them to practice defensive medicine. Health care reform should have a primary consideration of letting doctors take care of their patients without interference.

  8. Excellent post! My second child, a daughter, was born at home 17 years ago. I was a CPM in the midwestern state and stopped practicing when legislation clearly brought midwifery under advanced practice nursing. Interestingly, my CPM colleague and I were “clinically integrated” with a large hospital that accepted our intrapartum transfers of care into their system. The health system wanted to begin to reach out to the Amish community with their CNMs, and the arrangement was negotiated with the medical director for OB and worked well for all parties. I now work in healthcare IT and have worked in telehealth in the recent past, and I find the idea of remote connectivity intriguing. One of the challenges is that many home birth participants live in rural areas of the state without highspeed broadband. (In the case of Amish families, no electricity either.)
    Just downloaded Catching Babies on my iPad. Can’t wait to read it!

  9. Utterly enthralling, powerfully poignant and a logophiles delight.
    Welcome to the world Baby Sam!

  10. I loved this blog post. I currently have a 1 year old daughter who I gave birth to at a birth center. The experience was great and I enjoyed the whole process despite having no medications for pain. As a current nurse I was drawn to the CNM because of my experiences with them as my teachers in nursing school. Now as a new mother I can say that I made the right choice for me. What I found most interesting about the post was the recognition that over testing does not begin with your arrival at the hospital to deliver, but much earlier on. Of course there is a legitimate reason for most tests but the results must be taken in context and your next decision must keep in mind what you have already done. I think in this case, I would have been in agreement with the nurse midwives consulted and would have watched and waited expectantly. But, I can also see how once you are presented with so many possible paths and outcomes, it may seem best to act. This example clearly showed how the two models of care look at a case with different lenses and why it is so important for families to have a choice of providers and the ability to be involved in their own care.

  11. “Baby Sam comes first; he is Hannah’s baby, not everybody else’s data point.”
    A classic quotable line.
    One can substitute other terms such as:
    “Mr. Jones comes first; he is Mrs. Jones’ husband, not everybody else’s data point.”
    And so forth.

  12. This is one of the best, most moving posts I’ve read in a long time! As a woman who had 2 medicalized births and then became a certified doula & birth advocate, I recognize the life-saving place that interventions have; but I also know that many of these interventions have become common-place protocol and many hospitals pressure doctors to practice defensive medicine in an attempt to avoid litigation. Some have gone so far as to prohibit the families from capturing & documenting the momentous occasion by video or photography. We are a “fear-based” society & nowhere is this more evident than in the world of obstetrics.
    This has been a refreshing & candid look at the struggle that faces women, their families & the professionals who care for them.
    Congratulations to Hannah & all of you! I am very happy that she & Sam are well.

  13. I was not talking to another woman. I was talking to a man who described labor as “core sensations”. I don’t know any woman who would use the word “sensation” in this context.
    And as I started out with,”But that’s just me, and folks should have a right to make their own decisions of course”.
    Considering the onslaught of “natural opinions” here, it seems that I was wrong.

  14. J.D.
    An outstanding post. I have linked to it HealthBeat (www.healthbeatblog.org) and I look forward to the book.
    Jodi– I have to agree. When a woman “smiles condescendingly” when talking to another woman about giving birth, I am surprised and very disappointed.
    Blossomd– Thank you for your comments. I believe that doulas and nurse-midwives have a great deal to add to child-birth in the U.S. This is not a knock on OB/GYN’s–I liked the doctors who delivered my two babies.

  15. Reading an advance copy of “Catching Babies,” I have to say this story rings true for so many woman in America. J.D.’s blog and his book dives into the drama of giving birth, the emotional realm, the spiritual realm, the clinical realm, and they ways in which our healthcare delivery system is strained. His book also charts the ways that medical residents get trained in this system and how they deal with larger healthcare policy issues. It was a truly an inspiring read and I hope more blogs about women’s health get written.

  16. “I have to smile condescendingly. Having been there three times, I can tell you that you are more than welcome to those “core sensations”, because my definition of them would be more along the lines of “excruciating, [expletive of your choice goes here], pure hellish torture”.”
    I have to disagree. I have been there twice, and do not condescend to tell you that, while painful, natural birth is not akin to giving up modern conveniences for no reason. I would agree that a woman, unprepared for labor without an epidural, would probably be severely traumatized by such a thing. Properly prepared, however, I have done it and seen many women do it. It was not to win a medal, it was not simply to sweat up our brows, and as someone who could barley handle our central heating going out for less than 24 hours is is not simply an homage to getting back to nature. The reason I had natural births was to reduce my chances of complications to myself and my babies. I did not want them to get narcotics during labor, I did not want them to endure the unnaturally harsh contractions that induction brings, and I did not want major abdominal surgery. By opting out of an epidural I reduced my risk and my babies’ risk in all of those areas.
    So, you may smile condescendingly all you want, but considering that many women choose another path than you did, it may be worth considering that looking down your nose at us and implying that we are all Luddites is not the right response.

  17. Thank you to Dr. Kleinke for a well written and thoughtful article. I have been reading with fascination.
    As a Certified Child Birth Educator for 15+ years, I was delighted to see Dr. Kleinke realize that the Gestational Diabetes diagnosis was the beginning. Having spent 5 years studying with Dr. Tom Brewer, I know that we need to take a step back and focus on educating women about healthy diets before and during pregnancy. I have seen proper counseling prevent a diagnosis of gestational diabetes many times. It seems to have become the newest excuse for intervening.
    Dr. Kleinke, I am sorry you had to deal with Amy Tuteur. Welcome to spin doctor land! Do not blame yourself for your natural reactions — this is what happens any time she enters a conversation. She takes “devils Advocate” well beyond the limit.
    Ellen, Eloquently put!
    I would also recommend that you all look into the research for yourselves. There is plenty of good research out there on induction of labor. Just be careful to truly analyze biases, controls, & methods.

  18. Dr. Kleinke, Thank you for your last post. Everything you stated is what I was thinking was going on and points to a decent solution in the meantime. Good communication is the best way to avoid misunderstandings, anger, pain, and litigation.
    I am encouraged that some doctors are taking steps in the direction of evidence based medicine, better communication with mothers, and are becoming aware of their own fears as an interference in treatment.
    Thank you for your thoughtful exploration of the pitfalls in obstetrics. Congratulations on becoming an uncle and I hope your nephew’s mother has a smooth recovery from his birth, and that she can have a beautiful experience next time around (if that happens). ( hire a doula for her).

  19. @ Craig and others who have wondered how and why this post devolved into a shouting match vectoring so far off my original point:
    I apologize for allowing myself to be drawn into a angels-on-the-head-of-a-pin discussion about women’s medical fears. All of those scenarios are devastating and incomparable, one to the other, and to almost anything else we confront on life’s highways.
    The original points of this highly personal post: (1) we are flying blind in much of our obstetrical decision-making; (2) we too often overreact to that blindness out of raw animal fear; and (3) this syndrome exacerbates both of these problems, generates still more fear and mistrust, turns the heat up under the med-mal pot even higher, and drives women off the grid to potentially dangerous care settings that we might be best to consider integrating onto the grid.
    My solutions: (1) OBs and CNMs need to communicate risk IN CONTEXT, and more clearly with patients and families, rather than communicate more raw animal fear; and (2) we need to study, as absurdly obvious as that sounds, things like early induction at a highly granular level. And while I document my reasons for why a randomized prospective trial of early induction is unlikely (as is the case for most research of obstetric care), I echo everything Amy Romano says with regard to better collection and analysis of childbirth data.
    While no Pollyanna about EMRs and HIEs, I am emboldened by inspiring success stories of just such research (beyond obstetrics) at sprawling but highly wired places like the VHA, Kaiser and Intermountain; they all prove that with the emergence of good clinical IT, we will eventually get access to better data – no, not perfect, but better data – to power retrospective analysis of when we should and should not induce for suspected growth problems with a pre-term pregnancy.
    In the meanwhile, I’m sorry that I was emotionally worked up enough about the story to participate in a debate that quickly devolved into polemics and personal attacks…

  20. See, i counsel clients on life altering decisions as a lawyer, and one difference I see in my work is that if a client does want to “put it all on me” to make decisions I refuse to do so. It’s not my decision and I’m not the one who will spend the next 6 months or 5 years or whatever living with the consequences of that decision. I am always telling clients there is no “right” decision, and what’s the right decision for person A might not be the right decision for person B. I cannot make that decision for you, even if you’d like me too. Of course, there are situations in which I think a particular option is clearly better, and I will say so. But there are so many times when it’s impossible to know ahead of time which is better, and the client has to make the decision he or she can live with. I see these OB close calls the same way. I don’t see why any doctor would want to let the patient push those decisions off onto him or her.

  21. @Blossmd – Stellar post! This is why Doulas (in my opinion) are so important as family’s advocates in the birthing process whether women birth their babies at home or in the hospital!
    And at John…Glad you could work sex into the conversation, because after all, isn’t that usually (but not always) where it all starts?

  22. Wow! Quite a discussion here. I did enjoy this article and I could see the conflict that was in the mind of Dr. Kleinke. Which is why medicine is an art.
    I am a doula. It is not my job to make decisions for moms. But it is my job to help moms and dads get all the information they need to make wise decisions as parents. It is also my job to look out for the family’s emotional experience, help educate them about normal birth, and provide comfort, pain relief, and non-medical suggestions for labor progress.
    The mother’s entire life is going to be more profoundly effected by this experience than any one else. Therefore her thoughts and feelings and plans for birth should be of consideration.
    A baby’s death is a tragedy, it effects everyone involved. This child is not replaceable. Naturally, we would ALL like to avoid this loss.
    I have personally witnessed, more than once, the effects of a long induction process for a baby thought to be “too small”. It’s not a lot of fun for the family spending 3 days in the hospital for a birth they wanted to unfold as a natural process that turns into an overly medicalized event. It can be devastating, even if the baby is healthy.
    We have 2 camps here… the midwifery model of care and the medical model of care. These two camps are bound to conflict, yes? Yet, both camps agree… Hannah and baby Sam are on the edge. Neither camp thinks there is immediate danger, right? Potential worry, but not immediate danger.
    The midwives say wait and let birth unfold. The OB’s say with more or less intensity induce. I would venture to say Dr. Kleinke, having just written a book, already knew they would disagree when he made all those calls. But here’s the twist…
    We have Hannah… a lovely woman who is loved by many. And Sam, a longed for baby who’s life will enhance all who know him. These are people, not patients, statistics, numbers, ideas, ideals, or philosophies. What to do? what to do?
    I would say the doctor should THINK! Think, think it through. Set your worries aside for a few hours and think….
    Hannah is 39 weeks… sometimes moms do lose a little weight those last couple weeks. Baby Sam has a good heart beat and is moving around well. (yay!) Hannah has been on a very careful diet to prevent Gest. diabetes. This is known to grow smaller babies. Sam is small… no surprise there. Hannah wants a natural birth and has been healthy the whole pregnancy.
    What can be done to soothe the doctor’s concerns? Ultrasound… confirms that the baby is small, okay… now what? Biophysical profile? not done. Non-stress test? not done. Kick count? not done. Are there any other signs of distress for baby Sam or Hannah? they aren’t mentioned so I assume the answer is no. What other signs will a mother show of placental failure? What about baby? What is Hannah’s cervix like? Likely to respond it induction?
    Does Hannah want the induction? no… is she approached as a partner in her own care? As an adult capable of making decisions for herself and her baby without using scare tactics? I don’t think so.
    Couldn’t this situation have been handled with deep thought and logical consideration? Couldn’t the expensive, potentially traumatic result of induction been avoided, and scaring the mother and dad, and forcing a birth on a healthy baby been avoided by WATCHING? Even if Hannah is seen every day or 2? Wait to see if Sam is holding his own? Do some other assessments to determine the probability of stability? After all, Sam should be small based on his mom’s diet. Being small is not a problem necessarily.
    So, what would have happened if these steps were taken? Would it be bad if Hannah’s dr said, “well the baby seems small, but you have been on a careful diet, we wanted him small and he is. But let’s do some tests to make sure he’s doing okay. …. sometimes smallness in babies and weight loss in mom indicate trouble for baby but your tests are normal. There are some risks/benefits in waiting, there are some risks/benefits in inducing, (discuss them), what do you think? Here is my recommendation but you have a choice. I think it would be best to monitor you and Sam carefully, if you notice any changes let me know right away.”
    This would include mom’s thoughts feelings and desires, involve her in her baby’s care, educate her, avoid not-necessarily necessary medical procedure, respect her and solicit her cooperation if things take a turn, yet be very mindful about the health of the baby and be prepared to act if needed but not before.
    If you don’t know for sure there is trouble, and you take action that isn’t needed, aren’t you doing harm? THINK, think it through on a case by case basis. Not just for your sister-in-law. or the girl down the block. But for all women, regardless of diversity. Virtually all moms want what’s best for their babies, sometimes even beyond their own health. This means they will all (barring actual poor intelligence or mental illness, or maybe being 12 or 13) care about, be capable of, and invested in understanding what’s happening with baby and their own health. If you take the time to explain, without an agenda, you can trust them to assist in their own care decisions. If they indicate that they want to put it all on you, then by all means, make the safest recommendation.
    Blossomd Certified Doula
    Posted by: Blossomd |

  23. WOW! Hmmmm. We’re talking child birth here folks. The most common successful result of sexual intercourse. (Sure, IVF works too.) There, I got sex into the diatribe of a health policy debate.
    I think the author was successful through his/her example in challenging what can be an emotionally charged, but very frequent and common “procedure”. If there is not enough science for this group to agree on the most common “treatment” for creation events, then God help us all when the going gets tough in the areas where science innovates, solves and overcomes ignorance.
    I might suggest that there are continents where no certification is required to deliver a child and newborn mortality rates are vastly better than we experience. Perhaps that is something we might contemplate as we seek answers to the provocation…and maybe the answers are better explained in the book!
    J.D. Kleinke, thanks for the inspiration, and I look forward to reading the book.

  24. Ms. Tuteur,
    The EU requirements say nothing of a university degree, only that the midwife demonstrate in-depth knowledge of those things midwife related (i.e. anatomy, physiology, and embryology) as it is clearly outlined starting on page 8 (annex V.5: 5.5.1.). Canadian midwives are not ‘granfathered’ in, they are expected to pass a series of exams that test their knowledge of the same things (i.e. anatomy…) in all provinces except Nova Scotia, where they must have a degree.
    Now, I apologize to the other posters and the original author for allowing this rant to take such a detour. If we could please stop with the diversion and return to the original conversation on the board. If I recall, it was about the importance of both truly informed consent (something that mothers and families are rarely provided) and the problems with modern obstetrics care that there is a dearth of evidence (or poor evidence) supporting many of today’s ‘standards of care’.

  25. Ms. Lamb,
    Those links do not confirm your claim. The EU requirements include a university degree and the Canadian requirements appear to include options for grandfathering in midwives that were trained before the current requirement for a university degree. Moreover, American homebirth midwives (CPMs) do not meet either the EU or the Canadian requirements.

  26. And for the EU
    http://www.euro.who.int/__data/assets/pdf_file/0005/102200/E92852.pdf
    Pages 6 and 7 (Articles 40 through 42) in particular refer to the multiple routes by which one becomes a midwife with privileges in all EU member countries.
    Now that I have satisfied your concerns regarding my “glaring factual errors” can we return to the issue at had, which is the ambiguity of obstetrical screening techniques and the anxiety that they produce in families?

  27. “If you would like I would be happy to refer you to many references that might be of interest to you”
    Sure, can you show me reference that confirm your claim that EU, Canadian and Australian midwives are not required to have a university degree? To my knowledge, the only other country that had a non-degree option for midwifery was Canada and they abolished it years ago.

  28. Actually, Dr. Tuteur, you are wrong.
    A DEM means many things in many different countries. A university degree is only one of the many ways by which women (or men) can become practitioners. In Canada, where I am from, there are many pathways to becoming a DEM, only one of which is via a university degree. Although post highschool training would be admirable, I’m sure, many countries offer pathways to licensure that include tests, practicums (both in and out of the clinical setting), and as you so condescendingly noted ‘portfolios’.
    But alas, I have digressed and fallen for the diversion tactics that you so often use in posts that confront your beliefs. Such diversions help you to evoke emotion in readers and allow you to skirt the bigger issues in my post and the posts of others on this blog. That medical screening, in reality, is much more ambiguous than it is often presented to parents. Such screenings are presented as foolproof, infallible science. As are the procedures that inevitably follow. They are anxiety producing, and more often than not, the outcomes for mother and infant are no better than without the screenings and interventions. I suggest you read Rayna Rapp’s Book “Testing Women, Testing the Fetus” for a little bit of insight into the social context of prenatal testing.
    Don’t get me wrong, I would agree that modern medicine and obstetric practices have saved countless lives, but they have also altered countless lives for the worse. I only ask that those in obstetrics take the time to familiarize themselves with the most recent literature, and not only those articles that support their own positions. Many procedures used today are outdated and based on research that has since been refuted, again I bring in the example of the relatively standard NPO in labor and delivery wards, which we now know is detrimental to the process of labor and the health of mother and infant. This is the nature of scientific inquiry, research is replicated, support or falsified, and developed upon.
    If you would like I would be happy to refer you to many references that might be of interest to you.

  29. “You are referring to Certified Nurse Midwives (CNMs) and Direct Entry Midwives (DEMs) … Many countries, including Canada, the Netherlands, and Germany to name a few license direct entry midwives.”
    You appear to be unaware that “direct entry midwife” means something different in the US than it does in other countries. In Canada, the Netherlands and elsewhere, a direct entry midwife has a university degree, in hospital training, but not a nursing degree. In the US, a direct entry midwife is someone with a post high school certificate and no hospital training. Indeed, the certification for a direct entry midwife (certified professional midwife or CPM) is so lax that they don’t always need the post high school certificate; a “portfolio” can be enough.
    There is NO other country that allows midwives to practice without a university degree. American direct entry midwives are ineligible for licensing in ANY other first world country.
    This is only one of the glaring factual errors in your comment, a rather basic one and very easy for anyone to check.

  30. And one more additional thing:
    Dr. Tuteur, nice to see you have joined the discussion with your inadequate analogies and poorly researched ‘facts’. You are an ideologue. I have followed many of your various posts for a couple of years now, and no matter how tempted, I have never added my two cents. However, this time, I think that you have gone too far. An Ivy league education says nothing about one’s ability to contribute to the intellectual discourse in a meaningful way. In July of ’07 you stated that “The United States is the only first-world country that has two different kind of midwives.”. You are referring to Certified Nurse Midwives (CNMs) and Direct Entry Midwives (DEMs) and you proceed to denigrate midwives that work outside of the biomedical establishment as well as homebirth practitioners and advocates. Your initial statment is wrong. Many countries, including Canada, the Netherlands, and Germany to name a few license direct entry midwives. On this same vein, you claim that homebirth and anti-intervention advocates deliberately misrepresent data on the safety of natural/home birth and that such critiques are misguided. You consistently tell your readers that OBs are only looking out for the best interests of women and their babies, and that there are no ulterior motives. The goal is a healthy baby. I beg to disagree.
    Medicine (and science), like anything else, is a culture and physicians are socialized into the status of “doctor”. Doctors, as individuals, are enculturated into a society and they only know what they are taught.If they are taught that all women need an episiotomy to facilitate birth, then so be it. If they are taught that a ‘normal’ labor is no more than 12 hours (24 at the extreme) with at least 1 cm dilation ‘progress’ per hour, that that is obviously the truth. I am not arguing that you are deliberately spreading misinformation with the intent to do harm. I am only arguing that you, like all of us in our respective countries, cultures, subcultures, and professions have been socialized into your beliefs.
    Science is not infallible, only 30-40 years ago physicians were recommending particular brands of cigarettes as the doctor’s choice. Not much longer before that they were treating ailments with lead, mercury, and phlebotomy. At the time, medical professionals were just as adamant about the validity of their standards as they are today. Why would today’s doctors be any different.

  31. Where to start? First, J.D., thanks for a brilliant post that speaks to many of the very complex, emotionally charged issues in obstetrical care today. I have your book on order, and I look forward to reading it.
    As a medical anthropologist focusing on reproductive health, your writing resonates with me. As a woman who has given birth to two daughters under vastly different circumstances, in two separate countries, your work also strikes a chord. I think that you are bang on regarding the relative dearth of RELIABLE data on the standards that are used for the biomedical management of pregnancy and childbirth.
    Your comments are particularly important when you note that the interventions truly began when Hannah’s “blood sugars started coming back just on the high side – based on a crude test known to generate suspicious results” and her providers placed her on a restrictive diet. You hit the nail on the head here. Perhaps it was the modification of her diet, and restrictions on sugars and fats that may have led to a slightly smaller than ‘normal’ baby.
    I am not arguing that IUGR does not exist, it does, and thankfully we have the technology to catch such complications and minimize health impacts on mother and child. Rather, what I am arguing is that the standards upon which screening and interventions are based are flawed. As you mention, they are based on artificially produced baselines (like glucose tests on which the standards are drawn from a sample of men)or a cost benefit analysis of balancing risks. Neither of which are even near optimal at recognizing the lived experiences of pregnant women and their families.
    Governments, public health boards, social scientists, and professional medical organizations have long known that modern maternity care in the Western world (and most particularly in the United States) is far from evidence based. There are decades of publications contradicting modern clinical practices, that are often ignored (please feel free to contact me for a list of these, I would be more than happy to oblige)from NPO orders to ‘post-dates’ induction at 40+3 weeks gestation. Worse than these standards contradicting research evidence, they are often damaging and frequently lead to iatrogenic complications for mothers and infants.
    But alas, I could go on, but I won’t. I appreciate your post and I think that you very neatly draw attention to the tension between the intellectual ambiguity of obstetric standards and the emotional aspect of the women (and families) who experience them.

  32. Did we all read the same article? I took out of this the author came to the realization that all the testing we do may cause more harm than it does good. I thought he understood that we need to live our lives in a more stoic fashion, and take what nature gives us (or not). I took from him that all our diagnostics and therapeutics are best saved for clear cut cases. We have gone from one extreme of resigned stoicism to another extreme of (attempted) control. Neither of these is healthy. Did I misread?

  33. J.D. as I am reading these back and forth comments, I had to go back and read the original post, since I wasn’t sure anymore what the main idea was. I thought it was just a beautiful story about uncertainty and life’s strange ways.
    Now I think that perhaps you wanted to make another point to say that mom in the story was subject to over-testing, thus over-treatment and then over-aggressive intervention in what should be a natural process, thus robbing mom of some elevating spiritual experience as old as life itself.
    When you describe an epidural as something which “will numb her from the midsection down and cut her off from the core sensations of the birthing process”, I have to smile condescendingly. Having been there three times, I can tell you that you are more than welcome to those “core sensations”, because my definition of them would be more along the lines of “excruciating, [expletive of your choice goes here], pure hellish torture”.
    Thanks, but no thanks. Whatever the “data” ends up saying, I’ll take central air, running water, Internet and anesthesia over any ideological Monday morning quarterbacking, even it costs society more money. Maybe you can recoup that expenditure by returning to the equally spiritually elevating natural way of eating your food “by the sweat of your brow”.

  34. “You equate a stillbirth with the death of one of your current children? That is bizarre, and I am done trying to have a reasonable discussion with you.”
    I actually enjoyed the article. Good writing.
    But this quote is what strikes me as bizarre: I’m not a woman, but I’ve known some, including my wife and my mother, neither of whom would draw this distinction. Either death would devastate them. Are there really measurable degrees of devastation?
    The article seems to lament the lack of objective data surrounding childbirth. (I think.) Then, a discussion follows, in which two highly educated people, including the author, end up arguing…the relative badness of cancer versus stillbirth.
    It is no wonder medicine lacks data. Even the best and brightest in the field seem unable to define the problems.

  35. “You equate a stillbirth with the death of one of your current children?”
    It is just this attitude that makes things so difficult for women who have lost children to stillbirth. In the minds of many, apparently including you, babies who die before birth aren’t “real” children. But it’s not up to you to decide what women should believe about stillbirth or what women do believe about accepting risk to themselves to avoid risk to their babies; it’s up to women.
    I’ve cared for thousands of women and I’ve met pregnant women with cancer who have refused termination and life saving chemotherapy. I’ve also met women with serious medical problems who risked their own health and possibly life to continue a pregnancy. Obviously, they did not consider their own deaths (even from cancer) their worst nightmare.
    But we’ve drifted very far from my original point, that your portrayal of the risks and benefits of induction was scientifically incomplete and inaccurate and therefore, your speculation about how obstetricians view risk, interventions and defensive medicine is inaccurate.
    I’m struck by the fact that you began writing a non-fiction “expose” about high risk obstetrics and ended up writing a fictional account. I wonder if what you found in real life did not comport with what you believed you would “expose” about obstetricians, interventions and defensive medicine, so you created fictional situations to support those beliefs rather than change the beliefs.

  36. @Amy – so would most mothers make that choice. You asked specifically about stillbirths, not about the deaths of babies who have survived the childbirth process and grown into a mother’s “children.” You equate a stillbirth with the death of one of your current children? That is bizarre, and I am done trying to have a reasonable discussion with you.

  37. Wow! “Uncle” J.D., thanks for taking us on your personal journey, challenging our faith (blind as it may be) in the precision versus art of medicine, and treating us to a happy ending. Let’s be honest, how different is Sam,the future-12yr-old and baseball prodigy, who asks his dad if he can throw curve balls, from Sam, the back-to-future-39week-old amniotic aqua-boy, who depends on his mom to decide on when he should come out? Does father or mother really know best? Maybe, retrospectively. Is blaming adverse events on those from whom we seek guidance not responsibility-shifting equal to the less obvious “patient choice” advocates. Informed consumers make better decisions, so let’s empower patients with data they can use, like provider report cards. Yes, doctors need more studies and research, but at least they are trained to “read” and “think” about clinical detail, outcomes, and statistical significance. If in the absence of data, we are left with anecdotes of providers’ phenomenologic experiences, then let’s compare and choose our providers with at least the same confidence level that I will choose Ben Roethlisberger and the Steelers this weekend.

  38. “@ Amy – Stillbirths are travesties but women recover from them. I believe a woman’s worst nightmare is piecemeal disfigurement by scalpel, poison and radiation that still leads inexorably to a slow ugly death from breast cancer at an early age.”
    Don’t you think that’s a bit presumptuous? Telling a woman and a mother, what women consider their worst nightmare?
    I would die a thousand deaths of whatever kind to save the life of any one of my four children.
    I’m sure I’m not alone. For many mothers, their worst nightmare is the death of a child. Cancer pales in comparison.

  39. Wow, a lot of emotion here. Maybe that’s the object lesson.
    As someone in a similar situation as I was trying to deliver my (only) child after 10 years of infertility, I can attest it is difficult to make rational decisions in real time and, of course, the physicians and midwives are biased in their own ways also.

  40. I am glad she and the baby are healthy. But, this could have all been avoided. First babies are usually smaller than successive babies. On top of that she was on a ‘special diet’ known to cause babies to be a lower birth weight. If it were me, I would have gone home and thrown that diet away and ate well so the baby could actually grow and gain weight before he was ready to be born. Of course, I probably would have researched for myself about the special diet and gestational diabetes and probably opted to not partake, or at least not be so restrictive with the food I ate. That’s just me though. I don’t have my babies in a hospital anymore. I trust God, my baby and my body to know what to do. I have had 4 of my 7 babies at home. I absolutely love it and now I am planning my 8th baby’s home birth.

  41. @ Amy – Stillbirths are travesties but women recover from them. I believe a woman’s worst nightmare is piecemeal disfigurement by scalpel, poison and radiation that still leads inexorably to a slow ugly death from breast cancer at an early age.

  42. The post illustrate the position of the women to have such in a difficult position when she faces the Retrospective pregnancy,but the doctors don’t have any sympathy with them.

  43. Read my lips, Amy…correlation is NOT causation. Furthermore, to address your analogy – routine mammography is now being associated with increased rates of Breast cancer, especially in under 50s. In any case, breast cancer is a disease, pregnancy is not. The biggest reason STILL for perinatal mortality is prematurity related to IVF. The other casues like Pre-eclampsia and blood incompatibility (Rh Neg groups) have been reduced substantially over the decades. However, you will find that at in least half of stillbirths the cause is UNKNOWN. Lastly, ultrasound, as you rightly point out, is a screening tool. But we should not be initiating potentially harmful interventions based on that alone. “Wait and See” is still a very good option for pregnancy and birth. It is well known that induced labour, leading to epidural because of increased rate of pain, is tougher on both mother and baby. Natural labour tends to start more gently and baby does better. When we rupture membranes and hurry things along many babies cannot handle the stress and so to C/S.

  44. Excellent essay.
    Dr. Amy Tuteur is not a practicing doctor, to the commenter who made that understandable error.
    A cardiology fellow’s wife was in a similar situation at my training hospital, and I told him that third trimester ultrasounds are notoriously inaccurate. There are much more accurate ways to determine the health of the fetus – a non-stress test, a biophysical, even a kick count. Here is one good recent article on the topic of third trimester ultrasound being more likely to increase cesarean section than predict growth restriction.
    Dr. Tuteur has a bad habit of making faulty comparisons. The mammogram (or breast ultrasound, for that matter) may be similar to the fetal ultrasound as an imaging tool, but no physician would go straight to mastectomy without compelling indications. A good physician knows the limits of their imaging and uses them to make decisions in the best interest of the patient(s).

  45. ” An ultrasound that shows a 39 week fetus at 7th percentile for weight shows nothing. An abnormal mammogram shows what could be the start of a woman’s worst medical nightmare.”
    You don’t think a stillbirth is a woman’s worst nightmare?

  46. That’s a false comparison. An ultrasound that shows a 39 week fetus at 7th percentile for weight shows nothing. An abnormal mammogram shows what could be the start of a woman’s worst medical nightmare. The furor over last year’s shift in mammogram guidelines – echoed by many physicians decision to ignore them – bear this out. See a related post on here for how I think they are wildly different problems for patients, and how I believe typical women will react to this other imperfect screening technology. https://thehealthcareblog.com/the_health_care_blog/2009/12/your-money-or-your-wife.html#more

  47. “the baby did not have IUGR”
    And most women who have mammograms don’t have breast cancer. That doesn’t mean that mammograms are an overuse of technology.
    Fetal ultrasound, like mammography, is a screening test. By it’s very nature it cannot make the diagnosis, is not 100% accurate, and leads to many women having surgical biopsies that turn out not to be cancer.
    Given that a large proportion of women who have abnormalities on a mammogram subsequently have biopsy that shows no cancer, would you suggest that a woman ignore an abnormal mammogram? I suspect that you wouldn’t. How is that different from this case where the screening test showed an abnormality?
    What you have described here is not an overuse of technology, but the limitations of a screening test in predicted outcomes in individual cases. As with mammograms, those limitations do not mean that the screening test is useless or overused or that the angst generated by abnormal results of screening tests is greater than the benefits provided by the test.

  48. not to pick on Dr. Tuteur, but it makes me queasy that a practicing physician with an evidently superb command of English would so spectacularly miss the point of JD’s riveting post.

  49. There is only one fact in this case that matters: the baby did not have IUGR; he was small. The point of the entire article is the angst inspired by the fact that this could not be confirmed in utero.

  50. I find it startling that a piece that purports to be about whether IUGR babies should be induced contains no scientific evidence.
    Here’s some:
    According to Fetal and Perinatal Mortality, United States, 2005, produced by the CDC, the rate of stillbirth has fallen by 29% since 1990, and the primary cause for this improvement is the increased induction rate.
    Intrauterine growth restriction increases the risk of stillbirth by a factor of 3 or more and it is estimated that more than 1/3 of unexplained stillbirths are caused by IUGR.
    Do those statistics mean that every IUGR baby will be stillborn? Certainly not. It merely means that the risk is dramatically increased and that many babies who would be stillborn can be saved by induction.
    The author makes a monumental mistake in his conclusion. The fact that the baby was born alive does NOT mean that the pregnancy was normal. First of all, this patient was treated, so it is possible that if induction had not been undertaken, the baby may have been stillborn.
    Second, and this is a concept that lay people and apparently health economists have trouble with, the fact that the baby lived does NOT mean that the pregnancy was normal, in retrospect or otherwise. It means that the baby lived despite an increased risk of death posed by an abnormal pregnancy.
    The overuse of technology in obstetrics has many examples. This is NOT one of them.

  51. The author certainly knows, but also knows how the typical nervous patient reacts: “‘7th percentile’ sounds tiny, puny, scary; maybe not for weight distribution among a sample packed as tightly as near-term babies, and definitely not to somebody who understands biostatistics and just wrote a book on this very subject; but it sounds terrifyingly small and vulnerable to people who want and expect a healthy baby.” Half-communication with patients – the facts without context for example – is often worse than no communication at all…

  52. Does nobody get that 7th percentile is still normal (though on the small side)? The gold standard for a healthy baby is that it is still active within the uterus. If the placenta is failing, the baby goes quiet. Ultrasound is notoriously inaccurate for sizing in late pregnancy and many is the baby I’ve seen induced and then C-sectioned for IUGR which turned out to be average size. And why do people think they can totally avoid a death or morbidity by over-servicing. Even in hospital with all the intervention in use, babies still die – it is not a perfect world and there are no guarantees. It is not enough to apply “just-in-case” tactics when the results of those can be traumatic if not damaging. Stop the interference!!!!!!

  53. Beautiful piece indeed! Can’t wait to read the book… When is the “due date”?
    However, I suspect that just like a normal pregnancy, these thoughts are retrospective. And, Craig, “uncontrollable” is also a retrospective evaluation.
    Having been lucky enough to be on the receiving end of this retrospective diagnosis several times, with never any reason to contemplate a different retrospect, I have to confess that I have no understanding of advocacy or preference for the “natural” way here. I presume that “natural” by definition includes the natural deaths of both mom and baby as in days gone by, and I also presume that natural uniformly accepts the biblical curse of having to suffer much pain in the process of child bearing.
    So in an attempt to prospectively minimize the “uncontrolability” inherent in any biological process, I chose the best, biggest and most comprehensive academic medical center I could find, the most experienced and highly educated OB I could locate and every darn advantage science and technology had to offer.
    Expensive? You bet. Statistically redundant? Perhaps, but the only relevant sample I considered was that One baby in that one moment in time. In J.D.’s story, I would have opted for a C-section, right then and there, immediately, no waiting, no tinkering. But that’s just me, and folks should have a right to make their own decisions of course.

  54. great post, very eloquent! One thing you left out is our health care system or non system. one reason to sue besides our inability to accept that occasionally a tragedy occurs and a baby is born that suffered birth complications or there is a stillbirth, is to get money for the care of a baby that might need life long care.

  55. @ Kim – you are exactly correct and I started to go into the distinctions but this article was already too long! There are three home birthing models emerging and growing in popularity: “rogue” home births attended by unlicensed midwives, doulas and/or family members; CPM-attended home births (by licensed midwives, allowed in some states); and CNM-attended home births in a partially overlapping number of states. Their combined number still represents a tiny fraction of total live births in the U.S., and the traditional hospital-based system frowns on all three models – and not just for the obvious loss of “market share” but because those hospitals’ ERs often have to deal with the occasional but heart-wrenching ambulance-borne disaster that can occur in the home-birth setting.
    One of the things that would lessen the horrifying outcomes associated with the “legit” home-based disasters would be a hospital’s acknowledgment of, and clinical integration with (via CPM and CNM pre-communication and remote IT connectivity) those home-births. This is a common sense, if radical, idea I explore in Catching Babies, as one of the more progressive OB/GYNs in the book is chastised professionally for daring to suggest such an integration…

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