Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 10.6 Natural Birth Claims
Dr. Howard Harrell explores common questions about birth alternatives posed by Anna, a mom-to-be with questions, examining scientific evidence behind claims often found online that challenge evidence-based obstetric practices. The discussion separates facts from philosophy by analyzing actual research data on interventions like epidurals, oxytocin, and birthing positions.
• Maternal mortality has decreased 173-fold since 1850, coinciding with the rise of modern obstetrics
• The "cascade of interventions" theory isn't supported by scientific evidence
• Studies show epidurals don't increase cesarean delivery rates, contrary to popular belief
• Oxytocin augmentation, when properly used, can decrease cesarean rates rather than increase them
• Upright birthing positions don't show improved outcomes compared to lying on back
• Hospital/provider cesarean rates matter more than specific interventions in predicting your risk
• For low-risk pregnancies, intermittent rather than continuous fetal monitoring may reduce unnecessary interventions
• Best approach combines respecting physiologic birth while using appropriate medical tools when needed
Visit thinkingaboutobgyn.com for more information and follow us on Instagram. We'll be back in two weeks.
00:00:02 Introduction to Natural Birth Questions
00:02:09 Historical Maternal Mortality Statistics
00:05:54 Nutrition Myths and Modern Food Safety
00:11:34 Debunking the Cascade of Interventions Theory
00:21:32 Epidurals: Facts vs. Misconceptions
00:35:59 Birth Positions and Perineum Protection
00:44:20 Avoiding Unnecessary Cesareans
00:48:56 Continuous vs. Intermittent Fetal Monitoring
00:56:24 Artificial Rupture of Membranes Discussion
Follow us on Instagram @thinkingaboutobgyn.
Welcome to Thinking About OBGYN. Today's episode features Howard Harrell discussing common natural birth questions.
Speaker 2:Dr Harrell.
Speaker 3:Ana.
Speaker 2:What are we thinking about on today's episode?
Speaker 3:We're going to answer some common questions about birth alternatives that patients will ask. Common questions about birth alternatives that patients will ask. Ana is going to ask these questions on behalf of all the moms out there who come to our offices with information that they've often found on the internet that challenges much of what we would call evidence-based obstetrics. Now, Ana is not a real person.
Speaker 2:I'm not a real person. I feel like I'm a real person. I have a pulse.
Speaker 3:But isn't that what a fake person would say?
Speaker 2:Okay, I'm a real person. My name just isn't Anna.
Speaker 3:All right, then. Anna is a real person with an identity crisis.
Speaker 2:My real name is not Anna, but I'm going to represent all the women out there who view birth as a normal physiologic process that a woman's body is inherently designed to accomplish. We recognize the innate wisdom of the body and the importance of allowing labor to unfold with minimal interference. So I've got a few questions for you.
Speaker 3:Okay, this should be fun and just for clarity, I agree with the statement that you just made. A lot of the debate centers around the philosophy of childbirth and upon this idea of whether or not birth is a natural process or a medical event, and maybe we can talk about that a little bit as well. But it clearly is a natural process and clearly women's bodies are designed to give birth, but we've also used science to make that process safer than it normally would be.
Speaker 2:People on my side of this argument believe that birth is a healthy and empowering life event, not an illness, and the focus on birth attendance should be supporting the laboring woman's natural rhythms and her natural abilities. We believe that unnecessary interventions can disrupt the delicate hormonal cocktail that drives labor and bonding, and we suffer from a lot of birth trauma due to adverse birth experiences that affect both us and our children from the rest of our lives. Our ancestors never had to deal with some of the problems that we now have to deal with due to the disruptive forces of medical intervention and natural birth process.
Speaker 3:I think we should try to answer very specific questions that can be held to some scientific scrutiny. So statements like the one you just made are really philosophical and not necessarily informed by data. But I would like to counter one idea which I hear a lot, and it's that birth was either not dangerous or maybe even safer in old times, like before modern obstetrics. It was better. I think the idea is that obstetrics is a tool of the patriarchy, if you will, that controls women's bodies, and that the interventions that we use today just lead to worse outcomes and that our interference is for naught.
Speaker 2:I see that sentiment too and I think that that's an overstatement. But there are definitely those who argue that. But it is true that there was a time when birth became more dangerous in the 19th century, when it moved into the hospital setting and women died of infections that they didn't die from at home, and I think that's where a lot of the sentiment comes from. But I think I would focus on what's lost when we over-medicalize the birth process more than trying to argue that birth used to be safer. But still you have to admit that one in three women receiving cesareans is not good for anyone's health.
Speaker 3:Perhaps. So let me answer the first question. In 1850, the rate of maternal mortality in the United States was 1,250 per 100,000 births, which is 1.25%. By 1986, the rate of maternal mortality had dropped to just 7.2 deaths per 100,000 women, compared to 1,250. That's the best argument I can make for obstetrics. That is, a 173-fold decline in maternal mortality in a time period when childbirth has moved largely into the hospital and under the control of what you might call the obstetrics profession or the obstetric model.
Speaker 3:Even that number doesn't tell the whole story, though, because we use different definitions and different criteria for defining maternal mortality today than we did then. When we try to match our modern definition of maternal mortality to the one used in 1850, there's almost a 250-fold decrease in the risk of death with childbirth. Now, that was the risk of death with each birth, but women had an average of about nine pregnancies in 1850, which means that a woman had a 7.3% chance of dying in childbirth in her lifetime. And because the birth rate is lower today than it was then, due to birth control and other interventions like sterilization that we have today, by the way, these things have dramatically improved the role of women in society.
Speaker 3:Not just maternal mortality. But today the average woman in America has only about a 0.01% chance of death in her lifetime due to childbirth and that is a 700-fold reduction in her risk of death. And I don't think any woman alive today would accept a 1 in 13 chance of dying in childbirth. But that's what women dealt with in this country before obstetrics. And coupled with this decline in maternal mortality has been a decline in child and infant mortality. 40% of children in the United States died before the age of 5 in 1850, and that compares to 0.8% today. Infant mortality has declined from 25% that's death to one year of life in 1850, to just under six per 1,000 today.
Speaker 2:Okay, but those numbers don't mean that we have to accept the modern birth system as it is. Aren't most of those improvements in child and maternal mortality due to things like improved nutrition and hygiene? Isn't it unfair to claim that obstetrics and pediatrics is the reason why women and children don't die at least as commonly as they might have?
Speaker 3:once died. The largest single factors that have led to a decrease in maternal mortality have likely been the discovery of medicines to treat hemorrhage, postpartum hemorrhage and the ability to transfuse blood when women do bleed, along with our ability to detect preeclampsia, hypertensive disorders of pregnancy, and deliver those patients before they get too sick and die, using medicines like oxytocin or prostaglandins for induction of labor. And then combine those things with, certainly, antibiotics for the treatment of infections and blood thinners for the treatment of blood clots and other things that have made the cesarean delivery and surgery in general safer. Then throw in the flu shot and the COVID vaccine, and then you have a nice short list of the things that have most dramatically impacted maternal mortality since that time. You can see this clearly if you look at the rates of maternal mortality before and after each of these interventions came into practice and see the decline associated with them. And that's one of the reasons why birth started to move into the hospital setting was because that's where those interventions were immediately available, along with the provider's skill to know how to use them in those patients.
Speaker 3:Now, yes, hygiene and nutrition have helped mothers for sure. They've likely helped children in the child mortality rate even more than the maternal mortality rate. But even there I have to push back a little bit. We think that roughly 4% of children in 1850 didn't survive the actual birth process, either because they died just before birth, during birth or shortly after birth. That's an absolutely unconscionable number to modern sentiments and it has nothing to do with hygiene or nutrition. Babies die then due to a lack of cesarean delivery for difficult births, or they die due to things like hydrops fatalis, which we've entirely prevented with the RhoGAM shot, almost entirely, or infections from diseases like rubella, which we've basically eliminated due to vaccination, and just things like prematurity, which was almost universally fatal, really until the last 50 years at least, before, say, 34 weeks. You can't avoid congenital rubella infections with vitamins or supplements or better nutrition.
Speaker 2:We know so much more about nutrition now than women did in the 1850s. What's wrong with the idea that, through improved nutrition, empowered women to have healthy pregnancies and support them with physiologic birth? That avoids many of the complications that women might have had in the past.
Speaker 3:We definitely have improved the nutritional status of women and children, but let's be careful not to talk in circularities here. So let me ask you a question Would your ideal nutritional environment include avoiding GMOs, eating organic food without chemical pesticides or fertilizers, eating meats that haven't been pumped full of hormones and antibiotics, avoiding processed foods, instead eating whole natural foods, unprocessed foods, avoiding high fructose, corn syrup and other additives and preservatives and food dyes and chemicals that we find in our modern processed food stocks, and maybe even avoiding things like milk pasteurization and fluoridation of water?
Speaker 2:Yes, that sounds wonderful and that's exactly, in essence, what we try to do in my family. The modern food industry strips out the vital nutrients that you just can't replace, and so we have to focus on eating whole, natural foods grown in a sustainable manner that preserve all of the nutrients and nutrition that's meant to be there.
Speaker 3:Okay, I thought you would say that because it sounds good. It sounds like an Instagram post actually.
Speaker 2:It is.
Speaker 3:In fact, I just described the diets, though, of every woman and child living in 1850. A lot of what's advertised as nutrition today is really some misguided yearning for the things of the past, but we largely solve the issue of nutritional deficiencies by fortifying foods with vitamins, and a lot of what's commonly attacked by the alt-health movements are the things that make us healthy, like pasteurization, food preservatives, water processing plants, fortification of foods with vitamins, minerals and things like that, and what many people call stripping foods of their nutrients, is actually the end to diseases like scurvy and rickets and pellagra and other vitamin and mineral deficiencies that we've all but conquered in the last 100 plus years. In the simple or more wholesome, natural, organic world of 1850, free of pesticides and vaccinations and pasteurization and processed foods and chemicals and preservatives and food dyes, the average life expectancy was just under 40 years old and nearly half of children died before the age of five.
Speaker 2:Okay, you clearly sound like a person who's bought and paid for by the chemical industries.
Speaker 3:You clearly sound like a person who's bought and paid for by the chemical industries. I do have a degree in biochemistry, if that's what you mean, but we should talk about terminology for a second, and then let's try to answer some specific questions about birth. So words like natural or organic or chemical or artificial or synthetic they don't have any actual meaning. These are terms that are used to vilify or praise certain interventions or products that people sell, and they're emotionally laden and they carry no definable meaning. We can't know whether or not something is good for you or bad for you by putting one of these labels on it. Instead, we need studies that show the safety or dangers, the risk-benefit profile of a particular item, whether it's a food or a medical intervention or a supplement or anything else. So let's try to focus on specific questions that have a testable hypothesis so we can provide an evidence-based answer.
Speaker 2:But don't you think that if nature organically created something for us, if it's made in plants, that we can just assume that it's compatible with our physiology and is there for our benefit? I think all we're saying is that we should assume that the big chemical and pharmaceutical companies who are creating unnatural, never-before-seen compounds are the ones that are endangering our health.
Speaker 3:I think that the scientific approach to medicine doesn't pick any favorites like that. I think we have to have equal distrust for big pharmaceutical companies as much as we do big supplement companies and everybody else in between. We should hold all compounds, regardless of their origin or what industry they came from, to scrutiny. But just to give a few examples of things that are labeled natural that need to be held to more scrutiny Ephedra is a natural supplement, again. Whatever natural means that's been used for weight loss, but it causes heart disease, insomnia, anxiety, seizures, psychosis, death. Sounds like a pharmaceutical commercial.
Speaker 3:Kava is popular for supposedly helping with relaxation and reducing anxiety, but it can lead to hepatitis, cirrhosis, liver failure and death. St John's wort is a popular treatment for depression that even has a few trials that show that it does have some efficacy. But due to the way this drug is processed by the body, it can have dangerous interactions with other drugs. And yes, I deliberately referred to that as a drug, because it's just a trick when people call it something other than a drug. It's a drug no different than Prozac or anything else, and we have to hold it to the similar safety and efficacy studies.
Speaker 3:Pennyroyal was a natural remedy for menstrual issues, but it's associated with liver and kidney failure and seizures and death. Yohembe is sold to treat erectile dysfunction, but it can cause high blood pressure, heart attacks and death, along with a bunch of psychiatric problems, and we could go on for three hours just on this list. So even very popular supplements like turmeric, which is all over the place for everything, are known to cause iron deficiency, anemia and kidney stones and liver injury, and it's even led to death when it's been used at the doses recommended by influencers online. So a person who would avoid a medication that's been through numerous safety and efficacy studies and scientific scrutiny but instead take a supplement with no data showing efficacy or safety, marketed by a company that is completely unregulated and unaccountable, is honestly just denying reality.
Speaker 2:First you called me not real. Now you're saying I deny reality. Come on.
Speaker 3:For our listeners. Ana is not real and that's the third offense.
Speaker 2:Okay, I'm going to ask you some specific questions. We can both agree that the rate of cesarean delivery is too high, right?
Speaker 3:Sure, I'll agree with that, and listeners to this podcast know that we discuss ways of reducing the rate of cesarean very frequently, but the appropriate rate of cesarean delivery is not zero either.
Speaker 2:Okay, people in my community are trying to advocate for themselves and not be a victim of an unnecessary cesarean.
Speaker 3:You can call it an unnecessary if you want flows better.
Speaker 2:I think I would like to Fine breaking or pitocin, leads to more pain, and then more pain leads to more pain. Medication or epidurals, and then epidurals lead to cesarean by interfering with the body's natural labor process. That's what our community sees happen to us all of the time. So are you saying that this idea is wrong?
Speaker 3:Let's work our way backwards for a minute and we can break this down into a series of questions. But I first would say that the natural birth community if that's the term we're going to use does largely miss on this theory. It's the most prevalent and sort of overarching theory about this cascade of interventions. But what I would say is that's actually not why there are excess cesarean deliveries. It's just the thing that is easy to peg it to, because it's the thing that people can look at and see in the story of their delivery. And by focusing on these issues patients may actually be missing an opportunity to actually reduce the rate of overarching. Theory is in how widely and vastly different the rates of cesarean delivery are among different hospitals and among different obstetricians in the United States.
Speaker 3:I personally have a very low rate of cesarean delivery, but I use all of the things that many natural birth advocates blame for the high rate of cesarean delivery oxytocin, epidurals if the patient wants breaking people's water, prostaglandins, inductions, all those things. So we have to be careful not to demonize things unfairly. Oxytocin is neither good nor bad. It's a tool that can be used appropriately or it can be misused. Cesarean delivery is neither good nor bad. It's a tool, a life-saving tool, that can be used appropriately, and it can be misused, and so on and so forth.
Speaker 3:So the first question I think, then, is do epidurals increase a woman's risk of cesarean delivery? Because that's the idea, is that the cascade leads eventually to epidurals and it disrupts the natural labor process and the body fails. And the answer, though, is no. So all of these things, and this in particular, these are difficult things to study, because we don't randomize women blindly to epidural versus no epidural and then see how the outcomes differ. But we do have a large body of scientific evidence, and I'll put a link to a Cochrane review which shows that epidurals have no impact on the rate of cesarean delivery. They have no association with things like long-term backache, and they don't have an impact on neonatal status or even risk of admission to the NICU, things like that, and, at least among the studies done in the last 20 years or so, there's also no increased associated risk of operative vaginal delivery, which is one of the things you hear a lot. So the premise that avoiding epidurals will help you avoid any of those things is misguided to begin with. It's just not scientific, and this is why we have to avoid anecdotal stories.
Speaker 3:A lot of the anecdotal evidence in the natural birth community is based upon women comparing their story to someone else's or comparing their first birth which was always going to be in a hospital in a disaster of some sort, to their second birth, and second births are just easier than first births. Try saying that three times fast. It's not uncommon at all for a woman to maybe push for three hours in her first birth and then by the time she has a second baby she pushes for five or 10 minutes in the second birth. But you see these stories on social media and groups and things like that of some patient who pushed for three hours.
Speaker 3:She ended up with an epidural at some point and then she ended up with an instrumental delivery or even a cesarean delivery, and then in the next birth she did a home birth or she went natural in the hospital or something. And in the next birth she did a home birth or she went natural in the hospital or something, and in the second birth she only pushed for 10 minutes, and this is held up as proof that epidurals are the problem. But we don't make such mistakes in scientifically collected data. I've delivered almost 5,000 babies and I know personally of stories like that all the time both push three hours with no epidural in the first birth, then in the second got an epidural and push for five minutes, or vice versa, or no epidural in both or epidural in both all sorts of varieties of it. The simple fact is that the scientific analysis of this supports the safety of epidurals for women who want them, and they're not associated with an increased risk of cesarean delivery or worsening neonatal outcomes.
Speaker 2:I think you're going to have a pretty difficult time convincing many of my friends of that.
Speaker 3:I agree, but when influencers make statements that say otherwise, women should advocate for themselves and demand scientific references for those claims. I've spent a lot of time in the last few months looking at social media influencers who dominate the natural birth movement, that space on social media, and the story is always the same they make big claims and provide no data to support them, and anyone can say anything on TikTok or Instagram and it just becomes this narrative and it's a mantra that people live by. But women need to demand better from that, both from their doctors and from social media random social media influencers. People need to support their claims with scientific evidence. Now, the other idea that you had in there was that somehow oxytocin increases the rate of cesarean delivery. Maybe it does this directly I think this is most people's conception of it that by increasing pain and then increasing the need for epidural and then, when you want to see the epidural, that leads to cesarean. But we've just shown that that idea is not backed up by science. So maybe it does it indirectly, by increasing the risk of fetal distress or other reasons for cesarean delivery in a situation like that, or it creates some dysfunctional labor pattern. But this is another one of those areas where it's just really difficult to study because we don't generally randomize women to oxytocin versus nothing. But there are some data that can help us answer this question. There are randomized trials that give women us answer this question. There are randomized trials that give women a higher versus a lower dose of oxytocin and in general those trials either find improved outcomes with lower rates of cesarean delivery with a higher dose of oxytocin, or no difference in the rate of cesarean delivery with a high versus a low rate of oxytocin. What they never show no study shown is more cesareans with higher oxytocin. So there's at least no dose-dependent effect on oxytocin in the risk of cesarean delivery specifically.
Speaker 3:But perhaps our best information about the effects of oxytocin on labor progress comes from trials done in Europe and in South Africa on something called active management of labor. We've never really done active management of labor here in the United States, at least broadly, but in Europe there have been many trials with what we might call more aggressive oxytocin augmentation strategies versus less aggressive or things like this. So women will present in labor and they're just started on oxytocin, regardless of the progress of their labor or different definitions of how slow their labor might be. One example is a trial published in the British Journal of Obstetrics and Gynecology from South Africa and they randomized women to either a very aggressive oxytocin protocol or an expected management protocol like using it more, like we would in the United States. The difference was really how much oxytocin women received and when it was started and for what reasons. What they found was that the expectantly managed women had a 23.4% rate of cesarean delivery, which is very similar to the noliparous singleton term vertex cesarean rates that we see in the United States now, which, yes, are too high. But the more aggressively managed patients, the one who got more oxytocin, more often and earlier, only had a 16% rate of cesarean delivery. Many trials of this sort have been done where you might have either early versus delayed oxytocin augmentation for women with slow labors, and the findings are consistent that more oxytocin leads to fewer cesareans and fewer operative deliveries and that earlier intervention is better than late intervention. Now the effects of this will vary by unit and I think that the culture of the labor and delivery unit might be the most important thing here.
Speaker 3:On the last episode, we talked about some literature recently that shows how widely variant cesarean rates are in different parts of the country or even in the same communities, in different hospitals in the same city. The Lying Inn Hospital in Dublin, ireland, has one of the lowest rates of cesarean delivery in the developed world and they spearheaded this idea of active management, this aggressive, lots of oxytocin management of labor 50 plus years ago, lots of oxytocin management of labor 50 plus years ago. Their protocol was implemented in other groups by other studies and one group did a trial in which they did the more aggressive oxytocin augmentation compared to usual care and they found in that study they didn't find a difference in the rate of cesarean delivery. But the place that did it already had a very low rate of cesarean delivery and this was published in the New England Journal of Medicine in 1995. But they still found, even though they already had a low rate and they didn't make their rate any lower by doing this, like the Irish did, they still found shorter labors and overall better maternal and neonatal outcomes without an increased risk of cesarean. And the point being that if the premise is true that giving oxytocin somehow increased the risk of cesarean, then that study and many of the other studies should have shown an increased risk and in this particular group they had a low baseline. So a group had a low baseline risk would be very sensitive to an increased risk associated with oxytocin and they didn't find more cesareans.
Speaker 3:This idea of active management of labor was pioneered in the 60s in Dublin by Kieran O'Driscoll and colleagues and you see a lot of their literature out there referenced, and I'll put a link to one of their articles from 1973, where they describe their original process. So basically, if a woman was admitted in labor and she wasn't changing by at least a centimeter every hour, then they started this active management protocol which included fairly aggressive oxytocin administration and they ended up with only a 5.2% rate of cesarean delivery, with a 19.5% rate of forceps delivery and that seems high today but both of those were low numbers for the time. This group and others who followed their protocol showed over many decades that oxytocin is really a critical component to lowering the rate of cesarean delivery.
Speaker 2:Okay, but what about pain? That pitocin hurts, and many of the women in my community are trying to avoid epidurals, so won't it lead to more epidurals?
Speaker 3:So the question is does oxytocin cause more need for epidurals? I guess due to the pain, and this too is very difficult to answer because the patient who needs oxytocin often has a prolonged and difficult labor and may become exhausted and tired. And when she finally receives oxytocin after a slow and arrested labor and she gets into real active labor for the first time, she may find that this is significantly more painful than what she was doing before she got that epidural. The important part there is to note that for that individual patient she's comparing her experience when she wasn't really in active labor. It was less painful, but instead she was in some slow, arrested or prodromal phase, and now she's comparing that experience to when she's in active labor. So again, we can't use anecdotal experiences to understand the answer to this question.
Speaker 3:In the 1973 paper Odris Gall and colleagues had epidurals available, but they were very rare then and only 13 out of 1,000 women received one. Roughly half the women in that group did deliver completely natural and about half received some IV narcotic, did deliver completely natural and about half received some IV narcotic. So again, today epidural rates are around 90%, so a lot different. It is true that women who are induced are more likely to receive epidurals and they're more likely to get oxytocin at the same time. But this isn't just a straightforward relationship. This is a complex relationship. Women, hopefully, are being induced for a good reason, and we shouldn't be unnecessarily augmenting women with oxytocin in the United States or inducing them without a good reason. So don't get oxytocin if you don't need it, but if you do need to be induced or augmented, then it'll decrease your risk of needing a cesarean.
Speaker 2:But there's a difference between natural oxytocin and IV pitocin, right.
Speaker 3:One's a brand name and one's the chemical name. They are the exact same chemical in the body, but obviously they're administered in different ways. When you receive it in an IV, as a continuous infusion, it's not the same as your brain releasing it, but in both cases it essentially needs to reach some steady state, some equilibrium, in the blood and then have its effect on the oxytocin receptors in your uterus.
Speaker 2:Right. But when it's produced naturally, it leads to calming and pain-relieving effects because it crosses the blood-brain barrier and IV oxytocin doesn't. So you just get thrust into this abrupt and intense painful labor with strong and frequent contractions and no pauses, and that's not what happens with natural labor.
Speaker 3:Some IV oxytocin does cross the blood-brain barrier. Most of it remains in the maternal blood, where it needs to be to affect the uterus. I think this is one of those quasi-facts that's repeated on the internet a lot to create a narrative fallacy and maybe a fact that just doesn't mean much in reality. But it's an explanation about why IV oxytocin in the blood is different than the oxytocin released from your brain. They're chemically identical, but the way they're released in this blood brain barrier thing is something that you see a lot. I'll put a link to an article from Nature in 2020 that explains the mechanism of action by which oxytocin from the IV does go into the brain. Interestingly, it binds to a protein called RAGE that facilitates this transport.
Speaker 3:But the second part of what you said is that when the oxytocin is made in the hypothalamus, that somehow it leads to calming and has pain-relieving effects, and that's just part of a narrative fallacy that doesn't have scientific evidence.
Speaker 3:These are dose-dependent effects and the natural birth community focuses so much on oxytocin as the love and bonding hormone, or perhaps even the hormone associated with orgasm and therefore pleasure, that the distinction is not made between the doses of oxytocin and everything else going on in your body at that time. These are two different events and two different scenarios. We prefer spontaneous labor to induced labor? We do. When we measure the strength of contractions of women in spontaneous labor they're typically much stronger and much more consistent compared to those from induced labor, and since they're stronger, you would expect maybe that they would hurt worse. But there likely is a difference, as you said, in the abruptness, how quickly the pain comes on. This is sort of the boiling frog hypothesis, where if you put the frog in a pot of water and turn the heat on slowly he'll boil to death, but if you throw him in he senses the heat and jumps back out, and so, certainly with IV oxytocin, it's getting you more abruptly.
Speaker 2:I heard that was a myth.
Speaker 3:The frog thing is a total myth, but the analogy is still helpful to understand that there probably is something different about having a slow prodromal phase, a slow onset of labor over many hours that eventually leads to strong rhythmic contractions, versus just skipping all that early part and getting there in the space of a couple, three hours with induced labor. Now still the question is are women who receive oxytocin more likely to require an epidural or pain relief than women who do not? But we have to be very careful about the question we're answering here. Another question might be are women who are induced more likely to receive epidurals than women who go into spontaneous labor? The answer again is yes. The studies clearly show that. But this is more related to the length of the induction or the labor than anything else. A woman who shows up to the hospital and is already six or seven centimeters in spontaneous labor is far less likely to receive an epidural than a woman who's admitted with a closed or one centimeter cervix for an induction of labor that may last 24 hours. And of course, the woman who's going to receive that induction is going to have oxytocin. That's the correlation, whereas the woman with a natural labor is almost certainly not going to receive oxytocin or need it. So the focus should not be on oxytocin with this question but on induction of labor. And even that effect is likely limited to women with unfavorable cervixes or women who are first-time mothers. Inducing a woman who's had three children before and is three or four centimeters dilated at the beginning of her induction is not likely to increase her need of an epidural, but conversely it might increase her opportunity to get one.
Speaker 3:So many of the women who are being induced in that situation are being induced specifically so they have time to get an epidural because they really want one. And I think that the natural birth community kind of ignores that fact. There's some self-selection going on here. So this is also a failure of cross-sectional analyses. The women many times who are choosing inductive elective inductions are not the same as the women who are declining induction and the epidural rates are necessarily different in those two populations. I think a lot of women in the national birth community don't realize that the vast majority of women want pain relief during childbirth and they often choose inductions specifically to make sure that they have time to receive their epidural before they deliver. So if you just take a snapshot of women who've been induced and compare them to women who've not been induced, you're not controlling for the most important factor, which is their desire for an epidural. I'll ask you a question what are the negatives of an epidural?
Speaker 2:Finally, what I read all the time is that they slow labor down and actually inhibit natural hormones, causing arrest of labor along with difficulty pushing and getting into positions that are more favorable for birth and operative vaginal delivery, and this is due to limited mobility.
Speaker 3:And then, on top of that, there's side effects like spinal headaches and low blood pressure and nausea, and that can cause difficulty breastfeeding or even fetal distress, okay, but I think what I'm trying to get at is that most of those things just simply aren't true or aren't super important, like low blood pressure and nausea, can be treated, and many patients are gladly accept those treatable side effects for relief of pain. It is true that pushing may take longer because some women are so numb that it takes them longer to learn how to push effectively, but for a particular woman, pushing might actually take less time because many women who are going completely natural, they'll avoid beginning to push for a long time and they're working to find some position that's more comfortable. They're just trying to endure for a while because the pain of fetal descent down into their pelvis is something. And I think another thing I heard is that mobility is important and that the position that you push in is something. And I think another thing I heard is that mobility is important and that the position that you push in is important. But this is another thing that's simply not supported by science, and I'm not going to argue that one position is necessarily better than another, but there's simply no evidence that pushing on in an upright position or something like that is better than pushing on the back. There's no data that indicate that one position is better in terms of eventual vaginal delivery or avoiding cesarean. And when women go natural, what they do is they seek various different positions to try to find the most comfortable one for the moment that they're in, and their mobility is very important to them so that they can find a position, rotate and flip and do things like that. That helps get through the next part of labor.
Speaker 3:Now, paradoxically, the most comfortable position the one she finds is often the one in which the fetal head is somewhat de-stationed, so, in other words, the head is descending into the pelvis and it's really uncomfortable. And so if you get on all fours and have your butt in the air, the baby falls forward a little bit and out of your pelvis and it's more comfortable. But it's actually anti-gravity. There's also no evidence that routine position change and movement during labor results in a lower rate of cesarean delivery. And the truth is, in radiologic studies, the anterior to posterior diameter of the pelvis is actually largest when the mother is on her back. So I'll explain what I mean by that.
Speaker 3:The pelvis is like a connected ring and the narrowest part is from the front to the back and the widest part is from hip to hip on the pelvic inlet. When you're squatting or you're in an upright position and you have the pressure of your legs on the lateral aspects of your pelvis, that ring gets wider laterally and that's what people talk about when they talk about opening the pelvis up. But unfortunately, because the ring is closed, the front to back diameter gets smaller and that front to back diameter is the one that's the limiting factor, so there's actually a smaller pelvis in the diameter that matters the anterior to posterior diameter. When a woman is squatting, now it doesn't matter for most patients and if they can deliver in that position and they want to, then we're all for it. But the idea that you see on social media that laying on your back is somehow the worst position and makes the pelvis narrower is just simply not true at all. The great irony is that the science supports the pelvis being in its most favorable position when the woman is pushing on her back, and that's just the exact opposite of what you see on social media.
Speaker 3:There's also all this talk about gravity and how gravity helps. But again, many of the positions, particularly the all fours position, destations the fetus out of the pelvis and, if anything. It's anti-gravity. The gravity is actually fighting against the birthing process in that position. But it does feel better if you're going natural to get the head out of your pelvis for a little bit and get that pressure relief from the pelvic floor. So mobility is helpful and necessary and great for women who are going natural because they seek different positions for their comfort. But those different positions they don't translate into fewer cesarean deliveries.
Speaker 2:But these other positions will lead to fewer tears.
Speaker 3:Okay, that's another claim and very popular repeated claim, but it's based upon comparing hospital data that's old, in a time where there were higher rates of episiotomies and things like that, to situations where episiotomies aren't cut, like birthing centers or things, natural home births, things like that. So, yes, if you're on your back in a hospital in 1980 and a doctor or midwife cuts an episiotomy, then yeah, obviously your risk of tearing is higher. But you can't compare a data set old data sets from hospital births where episiotomies were commonplace, to data sets where episiotomies aren't commonplace. The real data set here is do you cut episiotomies or don't you? And yes, the traditional birthing position on the back has been traditionally associated with hospitals where episiotomies are cut. But we haven't recommended from a science-based perspective that women have episiotomies since really the mid-1980s. And yes, they still happen and I would tell somebody that they shouldn't go to someone who routinely cuts episiotomies or even cuts episiotomies more than 1% of their deliveries. There are some rare emergency situations where cutting episiotomies is useful.
Speaker 3:The other thing that happened is we went through this generational change where we had doctors who cut episiotomies routinely in the 70s and 80s and then they were told not to. And when they were told not to. They didn't know anything really. They hadn't been taught about protecting the perineum. They didn't do anything to actively protect the perineum. Now, in modern training, we're starting to emphasize and research and look for ways to protect the perineum, and so, again, it's an unfair comparison when people claim that upright birthing positions or other alternative birthing positions are associated with fewer lacerations. There's a 2014 NICE review, which is the UK's National Institute for Health and Care Excellence where in Europe, by the way, they do favor birthing on the side traditionally, but anyway. This 2014 review found no difference in the rate of intact perineal bodies when you had a supine position compared to an upright position, and that's probably our best modern evidence, even though it's from 2014. And that's probably our best modern evidence, even though it's from 2014. We're learning as an obstetric profession more and more to emphasize perineal protection in ways that we didn't even then.
Speaker 3:Upright birthing positions are actually, in this literature, associated with more postpartum hemorrhage and an increased risk of second-degree tears. So intact perineums just means is there any tear at all? But that would include first and second degree, for example, but actually more second degree tears with the upright position, because there's really not an opportunity, particularly with modern delivery methods that protect the perineum. There's not a good opportunity of protecting the perineum when the woman delivers in an upright position, so you're not getting that potential benefit. The other thing is when you're comparing hospital births and perineal tears.
Speaker 3:This is another difficult comparison because if I'm worried, or a person's, having a hospital birth and you're worried about a big baby, you're worried about shoulder dystocia or the patient who needs to have an operative delivery for some reason fetal distress, things like that forceps or vacuums All of those women are going to be in the supine position when they deliver the shoulder dystocia so that you can do shoulder social management, things, operative deliveries.
Speaker 3:So when you just do a cross-sectional analysis, you're often seeing a group of healthy women who were allowed more liberties because they weren't worried about how big the baby was, the fetal tracings were good, they weren't anticipating a need for operative delivery, and you're comparing those to a group of women who may have larger babies, who may have gestational diabetes and your anxiety is higher and may have labor, slow labors or things like that, who are going to be in a supine position. So you can't just do a numbers comparison. You have to have the right controlled data and compare apples to apples and when you do, the claims that both the duration of the second stage of labor and the risk of perineal trauma are different or better or favorable with upright positions, go away and, if anything, you find more second degree tears and more postpartum hemorrhage in the patients who deliver upright.
Speaker 2:Sounds like you want all women to get epidurals and I've got to ask do you get a kickback?
Speaker 3:Evidence-based medicine doesn't have a preference for whether or not a patient gets an epidural or doesn't get an epidural. Our job is to support women in achieving the birth experience that they want. But our job isn't to lie or to coerce women into some predetermined outcome and, frankly, a lot of times the information in the natural birth community is really predisposed to make women afraid of epidurals and afraid of oxytocin, afraid of some of the options that they have, narrowing their options down to fewer choices, because they've determined already that one pathway is better than the other and we don't do that. I am perfectly happy if a patient gets an epidural. I'm perfectly happy if she doesn't.
Speaker 3:But a lot of the stuff that we've been discussing so far do seem to be predicated upon creating fear through misinformation or even lies. Women don't need to avoid getting an epidural if they want one because they've been coerced or misinformed into believing that somehow an epidural is dangerous for them or dangerous for their babies. Somehow an epidural is dangerous for them or dangerous for their babies. If people are telling you online that epidurals are unsafe for you or your baby because they cause your baby to have more complications or they cause you to have unnecessary surgery, cesarean things like that, then they're lying to you.
Speaker 2:If you answered my first question but not my second, do you get a kickback?
Speaker 3:I don't get a kickback.
Speaker 2:Okay, if any of this stuff you're telling me is true, then what can women do to avoid unnecessary interventions like cesarean deliveries, unnecessarians as I believe you put it earlier?
Speaker 3:The main key to avoiding cesarean deliveries really is just patience, and you have to pick a birth attendant that you can trust and that you have to ask them questions. You need to ask them about their rates of interventions. You need to avoid unnecessary and unindicated inductions, particularly if you're a first-time mother, and that definitely plays a part in all this. But I also want to reiterate that you can have a very low cesarean rate and frequently use oxytocin and frequently rupture membranes early and do some of these other things. There are many patients who've received cesareans because they didn't get rupture of membranes or they didn't get oxytocin augmentation and their labors became dysfunctional and they were slow and they arrested. So these things aren't good or bad. They're just tools. It's also not specific to the location of birth or the type of birth attendant. In other words, I'm a hospital-based obstetrician and I, as an individual, have a lower primary cesarean rate for my normal term singleton vertex patients than do most home birth midwives, and if that sounds weird, I'll explain it to you. It's important to compare the right populations to the right populations. One thing that online commentaries often do is they broadly compare things that happen in a hospital to things that happen in a birthing center or at home, but appreciate that we have two completely different populations of patients. Hospitals have the sickest patients. They have more obesity, they have more diabetes, they have more hypertension, they have more of all the things that potentially can cause complications in pregnancy. These patients, in a good midwife system, have been screened out for risk and are not present in a home birth population, and most women who choose a home birth with a midwife even before screening, are already among the healthiest and most nourished and most educated patients. But still, even at that, 15% of those patients who attempt a home birth are transferred to the hospital and unfortunately, the majority of those hospital transfers result in a cesarean delivery. And many of those could have been avoided had there been earlier or more appropriate intervention. Many of these labor arrests if they'd had their water broken earlier or if they'd had oxytocin earlier when their dysfunctional labor was recognized, they might have gone on to have a vaginal delivery. And some I mean I take care of these patients and some of them come and they get an operative delivery and that was a way of avoiding a cesarean, because we don't need zero rates of operative deliveries. We don't even need zero rates of cesarean.
Speaker 3:There are midwives, of course, who practice in hospitals. That's where most midwives practice and their rates of cesarean delivery in hospital-based midwifery is well above the national average, and so their rate of cesarean delivery, even though they don't technically perform the surgery, is well above the national average. So a lot of times this isn't about doctor or obstetrician versus midwife or even setting. It has to be individualized down In those cases a home birth midwife or a hospital based midwife.
Speaker 3:Again, they don't do the cesareans, but you have to look at it from an intent-to-treat perspective. The patients that they were taking care of is turned over to an obstetrician who then does the cesareans. So from an intent-to-treat perspective, they still get some credit for that cesarean delivery. So you've got to look at all of this from that intent-to-treat perspective and then control it for the complexity of the patient and adjust for the risk. It for the complexity of the patient and adjust for the risk.
Speaker 3:The number one thing that a patient can do to avoid an unnecessarian, from an intent-to-treat perspective, is to find a hospital and a birth attendant who both have low rates of cesarean delivery to begin with. And when you find those people, you're still going to find a person who likely frequently uses oxytocin, who frequently does rupture of membranes, and they'll have a mix of patients who go natural and a mix of patients who receive epidurals and a mix of patients who receive IV pain relief and a whole bunch of things in between, because those things aren't the issues, they aren't the deciding factors in whether or not someone receives an unnecessary Listen, I have a lot more questions.
Speaker 2:I want to hear your side regarding the vitamin K shot, antibiotics for group B, strep eye appointments for newborns. I have some really important questions about vaccines too, actually.
Speaker 3:I assumed you might have some questions about those things, but I think we'll have to have you back later on to get to more of those.
Speaker 2:Let me ask you one more question at least, then. What about continuous versus intermittent fetal monitoring? How does that affect all these interventions and the cesarean rate?
Speaker 3:Yeah, I think that's a really good question in a place where maybe there's an opportunity here to agree to some extent. I will say a lot of these things. People look at their own birth experiences and what happened to them and maybe they got a cesarean or their friend got one and they look at what must have gone wrong. And one thing is the assumption I think the preset assumption is that all cesareans are unnecessary and so if you got a cesarean, something went wrong amongst at least some of the people who comment on this. And so again, we have to agree that some cesareans are necessary and some cesareans make a difference, or else we wouldn't see this dramatic decline in infant and maternal mortality that we've seen. Cesareans are a part of that. But we can also agree we're doing too many and a lot of the responses are reactionary. My friend got a cesarean the other day, or I got a cesarean and it just seems like they induced her for no reason agreed avoid unnecessary inductions, or her labor was putzing along and she was okay, but then they broke her water and they gave her oxytocin and she got the epidural and she ended up with a C-section. Maybe her labor wasn't progressing right and she needed her water broken and they were trying to give oxytocin to make the labor progress and she just had arrested labor and, more to the point, they probably weren't patient. But it's a reactionary kind of response where it must be the things they did. It must be the IV, it must be the pain medicine, it must be the oxytocin, or it must be the things they did. It must be the IV, it must be the pain medicine, it must be the oxytocin, or it must be the fetal monitoring. In so many C-sections at least a part of the reason for the C-section the in many cases unnecessary C-section part of this conversation is we're worried about what we're seeing on the fetal monitor. It's nothing big, but maybe it's not tolerating it. I don't want to do this for X number, more hours, things like that, and some of that may be true and so and some of it may just be adding on like it's late, I'm not patient, your labor is slow progressing, the baby has these decs occasionally. Maybe I can put all this together into something that equals cesarean.
Speaker 3:So in studies, one option for low-risk pregnancies is to have intermittent monitoring rather than continuous fetal monitoring. So what is a low-risk pregnancy? We need to not have hypertension, we need to not have preeclampsia, we need to not have kidney disease or diabetes, like there are certain maternal things that would make you low risk, and for the baby, there needs to not be fetal growth restriction. We don't need to have significant vaginal bleeding, we don't need to be a previous cesarean attempting a VBAC to be a previous cesarean attempting a VBAC and we need to be a term pregnancy 37 to 42 weeks. We need to not have premature rupture of membranes and the labor needs to be spontaneous. So no oxytocin, spontaneous, not induced labor and no meconium.
Speaker 3:And some might say no epidural. I think most people say no epidural because it is true that an epidural could cause low blood pressure and the symptoms of that low blood pressure, which is correctable, could be on the fetal monitor in the form of late decelerations, but we can fix that. So if you're a low risk patient, if you're the kind of patient that you are or you're representing and you're in spontaneous labor, intermittent monitoring rather than continuous monitoring is great. Now, that's not compared to no monitoring and I think people make this mistake too. People are rightfully criticized where we've gotten with continuous monitoring and the impact that may have had on the cesarean delivery rate and on rates of interventions. But it's not monitoring compared to nothing. It's not that those patients need no monitoring. So it's compared to intermittent monitoring, which looks like listening to the heart rate every 15 minutes in the early part of labor and then every five minutes or so when you're pushing and maybe putting it on to continuous if something develops that we're worried about.
Speaker 3:Okay, what does that look like from an outcomes perspective? So for those low risk pregnancies, there is no significant difference or no benefit in continuous monitoring in improving things like perinatal death or cerebral palsy, so in other words, the fetal things that we would like monitoring to be more helpful in. But, to your point, continuous monitoring is associated with higher rates of cesarean sections and instrumental vaginal births, because this continuous monitoring provides some data that makes people anxious and we have a hard time sometimes in discriminating between what's really worrisome and what isn't. But there is a lot of data about this and it is a recommendation. This is something that obstetricians support. So no improvement in those major outcomes for low-risk pregnancies with continuous monitoring and you can have a lower cesarean rate and a lower instrumental delivery rate, vacuums or forceps with intermittent monitoring. Now there are some studies that have shown a slight reduction in neonatal seizures with continuous fetal monitoring, even in low-risk patients, but this isn't consistently reported throughout the studies and overall this is a relatively rare event, but it does happen, and so that would be the pushback against that. But we endorse ACOG.
Speaker 3:The American College of Obstetricians and Gynecologists endorses the idea that low-risk patients should have the option of doing the less intensive monitoring. I think most of the pushback comes from. In some ways, it's just easier to do continuous monitoring, and a lot of times hospitals now have adhesive monitoring that just stays on your belly and it's there all the time, and this is something that we think about from an evidence-based perspective, about how extra data gives us information that sometimes leads to interventions that we don't need. This also looks like things like monitoring the blood pressure during pregnancy too often and finding incidental false positive findings, because that's what we're really talking about is limiting how much intervention or how much monitoring we get to limit the false positives that then lead to intervention. But perfectly happy for you to have intermittent monitoring as long as you're low risk. I do want to make the point, though, that that doesn't mean throw away monitoring altogether and that doesn't mean ignoring risk factors for this potential benefit.
Speaker 3:OK, my last question, I guess, will be does artificial rupture of membranes increase the risk for an epidural the answer to this question is as complex as the answer is about oxytocin, and really the answers are the same. The trials that just look at a cross-section of people who've received artificial rupture of membranes and then relate that to epidural or IV narcotics or things like that, they definitely show an association. But it's the same issue of why were they getting amniotomy to begin with? So the controversies about amniotomy and this evidence has changed over time and the trials have changed over time have a lot to do with does it shorten labor? Does it affect the cesarean rate? We're pretty confident that doing amniotomy doesn't decrease the cesarean rate. It does shorten labor in newer trials but not necessarily in older trials. It might be associated with an increased rate of infection if it's done too early or too many hours remote from delivery, and so those are things to think about.
Speaker 3:And not every trial shows an increased risk of more analgesia, but some people have pulled this data together and seen potentially an increased risk of epidural or IV anesthesia related to it.
Speaker 3:On the other hand, for an individual patient who is eight or nine centimeters and is on the verge of, can I do this for another hour or two If amniotomy gets the head position correctly and she delivers the next 15 minutes, it might decrease it.
Speaker 3:So I would encourage people to be open-minded about this and understand still that the data is complex and you're comparing women who potentially need amniotomy or augmentation of labor compared to women who don't, and so you see longer labors, you see different patients, you see patients who are being induced or augmented because they're not in spontaneous labor. What we don't have are high quality trials of women who are in spontaneous labor, who the only difference in them is we broke water in one and didn't in the other, and then see that translate into more need for anesthesia. I often think that amniotomy may save the patient from needing oxytocin. So you can't be afraid of both and if you would, if you want to avoid oxytocin augmentation, amniotomy may be the way to do that. I think you're out of time. You'll have to save your other good questions for the next time you're back.
Speaker 2:I was curious if you'd hold me to that being my last question or not. And there's my answer.
Speaker 3:Make a list for next time you got it. We'll see everybody in a couple of weeks.
Speaker 1:Thanks for listening. Be sure to check out thinkingaboutobgyncom for more information and be sure to follow us on Instagram. We'll be back in two weeks.