Art Class or Martial Art Class, a primer on choices
Recently there have been a series of original research papers and some review articles favorable to what I have been advocating for several years. Articles supportive of the safety of home birthing have come out recently. Possibly in response to the flawed Wax paper. The catalyst for these papers could be a return to sanity and evidence based writing or it could be because more investigations are occuring due to rising consumer demand for an alternative to the hospital model. Whatever the reasoning it is good to see well done studies that concur with common sense.
In a recent study of more than 11,000 VBACs looking at outcomes and timing of intervention to prevent fetal injury it was found that the rupture rate was 0.3%, that of those only about 17% suffered serious injury and the success rate for VBAC in this study was 84%!!
Glezerman, et al had a well written paper in Medscape that reviewed the history of breech delivery and clearly defined the damage done by the poorly conducted Term Breech Trial in 2000 by Hannah. “This single piece of research profoundly and ubiquitously changed medical practice and effectively removed planned VBD from delivery wards in the western world.” And, “The TBT was a blatant example of how an inadequate randomized controlled trial can change medical practice.” In the year that followed release of this study the breech c/section rate in the Netherlands went from 57% to 83%.
The subsequent Premoda study from 2006 included 8000 (4 x TBT #s) women with singleton breech. This study found no difference in perinatal morbidity or mortality in breech babies delivered by c/s versus vaginal delivery. Yet nothing has changed as far as hospital policies toward breech nor has residency training in this skill returned.
Similar papers have come out in the last decade about the safety of term vaginal twin delivery. Surprisingly, and little known, was a paper published in 2000 in the Green Journal by Blickstein, et al which concluded, "There was no evidence that vaginal birth is unsafe, in terms of depressed Apgar scores and neonatal mortality, for breech first twins that weighed at least 1500 g.” So there is even evidence in ACOG's own journal about the safety of first twin breeches and yet more than 80% of all twins and nearly 100% of breech first twins are delivered by c/section in the United States. Even more surprising was this conclusion: “We did not see any intrapartum fetal entanglement, one of the most frequently cited specific complications of vaginal birth of breech first twins despite its overall rarity.”“ Our series that combined the experience of 13 centers and was five to eight times larger than previous reports, cast doubts on the relevance of the locked twins as a contraindication to vaginal birth.” Yet for as long as I can recall until present day, midwives and physicians are taught to fear the dreaded interlocking head scenario of Breech/vertex twins. While there are anecdotal cases, usually in premies, there is no hard data to support this ubiquitous premise.
Some who advocate for hospital birthing and condemn any and all who participate in home birthing are quick to point to the "safety" argument. The "what if something goes wrong" crowd will always use fear and blame to make their point. This blog is not to discuss the open argument about the safety of home vs. hospital birthing. I have done that before and will again. My point today is to reiterate the AMA code of ethics that supports respect for patient autonomy and decision making. “Conflicts of interest should be resolved in accordance with the best interest of the patient, respecting a woman’s autonomy to make health care decisions.”
What are the risks of the choice? What are the benefits of the choice? Whose choice is it? What is the role of the practitioner to give true informed consent based on evidenced based science? What is the role of the practioner when the patients choice differs from the practitioner's bias? These are very important questions and should always be analyzed with respect to a code of ethics. If I cannot support what a patient desires I am free to refer her elsewhere but I should not deny her information or skew my counseling to funnel her down a path of my choosing.
How we interpret risk vs benefit may be quite different from family to family. Differing life experiences and levels of education make blanket policies inadequate and dishonest. Something that carries a risk of 0.3% (or 1/333) also means that there is a 99.7% chance it will not happen. To have policies or adminstrators or insurers or writers condemn a woman for choosing a path based on her own risk assessment is totalitarian and not ethical. Banning VBAC, outlawing midwifery, skewing counseling on breech or twin deliveries for reasons (true or false) of safety is disingenuous at best. Is it not safer to put your child in art class than martial arts? Tennis is safer than football. Watching National Geographic Channel carries less risk that SCUBA diving or rock climbing. Should some higher authority decide which activites are allowed under the canard of safety? Would we allow or lives to be restricted in this way? I wouldn't want that sort of restraint on my liberty.
When it comes to choices such as home birthing, VBAC, breech and twins we must continue to respect the individuality of the decision. Same goes for choice of caregiver. Patients have the right to be educated. Educated people cannot be expected to always come to the same conclusions. Ethics dictates allowing for personal choice and responsibility. Decisions concerning one of life's most memorable events are personal and big government, big business and busy body know-it-alls (yes, you Dr. Amy) should just shut up and respect our differences.
Warmly, Dr. F
In a recent study of more than 11,000 VBACs looking at outcomes and timing of intervention to prevent fetal injury it was found that the rupture rate was 0.3%, that of those only about 17% suffered serious injury and the success rate for VBAC in this study was 84%!!
Glezerman, et al had a well written paper in Medscape that reviewed the history of breech delivery and clearly defined the damage done by the poorly conducted Term Breech Trial in 2000 by Hannah. “This single piece of research profoundly and ubiquitously changed medical practice and effectively removed planned VBD from delivery wards in the western world.” And, “The TBT was a blatant example of how an inadequate randomized controlled trial can change medical practice.” In the year that followed release of this study the breech c/section rate in the Netherlands went from 57% to 83%.
The subsequent Premoda study from 2006 included 8000 (4 x TBT #s) women with singleton breech. This study found no difference in perinatal morbidity or mortality in breech babies delivered by c/s versus vaginal delivery. Yet nothing has changed as far as hospital policies toward breech nor has residency training in this skill returned.
Similar papers have come out in the last decade about the safety of term vaginal twin delivery. Surprisingly, and little known, was a paper published in 2000 in the Green Journal by Blickstein, et al which concluded, "There was no evidence that vaginal birth is unsafe, in terms of depressed Apgar scores and neonatal mortality, for breech first twins that weighed at least 1500 g.” So there is even evidence in ACOG's own journal about the safety of first twin breeches and yet more than 80% of all twins and nearly 100% of breech first twins are delivered by c/section in the United States. Even more surprising was this conclusion: “We did not see any intrapartum fetal entanglement, one of the most frequently cited specific complications of vaginal birth of breech first twins despite its overall rarity.”“ Our series that combined the experience of 13 centers and was five to eight times larger than previous reports, cast doubts on the relevance of the locked twins as a contraindication to vaginal birth.” Yet for as long as I can recall until present day, midwives and physicians are taught to fear the dreaded interlocking head scenario of Breech/vertex twins. While there are anecdotal cases, usually in premies, there is no hard data to support this ubiquitous premise.
Some who advocate for hospital birthing and condemn any and all who participate in home birthing are quick to point to the "safety" argument. The "what if something goes wrong" crowd will always use fear and blame to make their point. This blog is not to discuss the open argument about the safety of home vs. hospital birthing. I have done that before and will again. My point today is to reiterate the AMA code of ethics that supports respect for patient autonomy and decision making. “Conflicts of interest should be resolved in accordance with the best interest of the patient, respecting a woman’s autonomy to make health care decisions.”
What are the risks of the choice? What are the benefits of the choice? Whose choice is it? What is the role of the practitioner to give true informed consent based on evidenced based science? What is the role of the practioner when the patients choice differs from the practitioner's bias? These are very important questions and should always be analyzed with respect to a code of ethics. If I cannot support what a patient desires I am free to refer her elsewhere but I should not deny her information or skew my counseling to funnel her down a path of my choosing.
How we interpret risk vs benefit may be quite different from family to family. Differing life experiences and levels of education make blanket policies inadequate and dishonest. Something that carries a risk of 0.3% (or 1/333) also means that there is a 99.7% chance it will not happen. To have policies or adminstrators or insurers or writers condemn a woman for choosing a path based on her own risk assessment is totalitarian and not ethical. Banning VBAC, outlawing midwifery, skewing counseling on breech or twin deliveries for reasons (true or false) of safety is disingenuous at best. Is it not safer to put your child in art class than martial arts? Tennis is safer than football. Watching National Geographic Channel carries less risk that SCUBA diving or rock climbing. Should some higher authority decide which activites are allowed under the canard of safety? Would we allow or lives to be restricted in this way? I wouldn't want that sort of restraint on my liberty.
When it comes to choices such as home birthing, VBAC, breech and twins we must continue to respect the individuality of the decision. Same goes for choice of caregiver. Patients have the right to be educated. Educated people cannot be expected to always come to the same conclusions. Ethics dictates allowing for personal choice and responsibility. Decisions concerning one of life's most memorable events are personal and big government, big business and busy body know-it-alls (yes, you Dr. Amy) should just shut up and respect our differences.
Warmly, Dr. F