I spent Monday afternoon watching debates/talks from the ACOG (American Congress of Obstetricians and Gynecologists) 2016 annual meeting. And I am sharing some highlights of those talks as well as my own commentary with you all.
 
The first debate was titled “Is There a Place for Outpatient Pre-Induction Cervical Ripening at Term?’ and there are just a couple things with this debate I want to highlight. Dr. Anthony Sciscione argued the pro side of this and one thing he said as he was introducing himself sent off alarms in my head. “We do about 7,000 deliveries a year. We are about the 15th busiest DELIVERY SERVICE in the country.” These two sentences give so much insight to the opinions and beliefs of the people at ACOG, the people setting the guidelines and making statements as to what the standards of OB practice should be. They do not see women birthing babies; families growing. They do not see the sacred event of a new life entering the world. These two sentences are undeniable proof that to so many, the practice of obstetrics is not about the woman, the baby, or the family, but is about the OB. And at the core of the practice of obstetrics is the belief that the OB is the knight in shining armor saving (delivering) the family’s tiniest member from the toxic mother’s womb and the dangers of birth. At the core of the practice of obstetrics is the belief that OBs act as fairy godmothers, magically retrieving and presenting the family with their new baby. Obstetrics is a delivery service. And ACOG is a place in which the OBs gather to stroke each other’s egos and brainstorm ways in which to make their jobs easier, not discuss what is needed by and best for the mothers and babies of America.
 
This debate was about whether or not women should be “allowed” cervical ripening medications and procedures to be administered and performed in her OB’s office and then sent home the day before her induction date or if it’s best for these things to be done in the hospital. Both Dr. Sciscione (who I quoted above and was debating the pro side) and Dr. William Rayburn, who debated the con side said repeatedly that it was important that outpatient cervical ripening only be done patients that have been “cherry-picked” with pregnancies that are low risk and at term. My question is, why are women with low risk pregnancies being induced?
 
A few minutes later in Dr. Sciscione’s argument for outpatient cervical ripening, he stated when this is done the day before an induction is scheduled, that “93% of people deliver before midnight which is very attractive to our folks.”  Because what’s most important here is that the OB is able to “deliver” the baby to its family with enough time leftover to get a few hours of sleep before the next day begins.

My last highlight about this debate comes from Dr. Rayburn. During his argument of the con side of this topic, he discussed the cost of outpatient cervical ripening vs. cervical ripening being done under hospital admittance. He was encouraging OBs to consider the cost to the patient when deciding how they will practice when he said, “Have you looked at patients’ hospital bills and tried to make any sense out of it? I really find it to be difficult.” If a highly educated obstetric physician is unable to make any sense of the hospital bills of his own patients, there is a big problem with our maternity care system.
 
Let’s move on to the other debate that took place at the 2016 ACOG annual meeting Monday, “If No Elective Inductions Before 39 Weeks, Why Not Induce Everyone at 39 Weeks?” Frist of all, this was not a debate. This was two OBs convincing the other OBs in the audience that all women should be induced at 39 weeks. There was nobody debating the con of this ridiculous and dangerous idea. Both Dr. Errol Norwitz and Charles Lockwood were both “debating” for it to become standard practice.
 
Dr. Norwitz opened by explaining that their talk would not be a debate with one arguing the pro side and one arguing the con side. He said that “We [OBs] al read the same literature but we often come away with very different takes” so they decided to instead explain their individual reasons for both being pro mandatory induction at 39 weeks for very pregnant woman. The absurdity of this all still makes me want to vomit. As he was introducing himself, Dr. Norwitz announced with smirk that he himself was born at 39 weeks. He explained that he primarily works with high-risk pregnancies and boasted that “By the time my patients get to 39 weeks, the baby has been delivered, been circumcised, and is on its way to college.” The arrogance was palpable. (And let’s just overlook the fact that circumcision is no longer recommended by many health organizations).
 
He went on to quote a professor he had once had, Sir Alec Turnbull as saying “Nothing good happens after 39 weeks.” *sigh* I didn’t have the time to research any studies that may be out there on this. But, I very strongly feel that if that were true, God would have designed pregnancy to last 39 weeks. He’s not a careless creator, a sloppy artist, a mad scientist. I also know that it is a common belief in the birth world that labor is triggered by hormones that he baby’s lungs produce when s/he is ready for life in the outside world.
 
Dr. Norwitz justified his strong belief that all pregnant women should have their labor artificially induced at 39 weeks by saying “If a baby is born at 39 weeks, it is not at risk of still birth at 40 weeks.” This statement is so loaded, I’m not even sure I can appropriately convey all of my thoughts. And I have to be honest here and say that I would like him to say that to my dear, sweet friend who recently lost her baby at 39 weeks. (There is much more colorful language than that running through my mind, but I’m a lady and will leave it in my mind.) First of all, here is a glimmer of some good intentions with all of this madness. He wants to save babies. OR. Is he playing on other people’s fear with that statement? Does he say things like that to his patients to coerce them into interventions that they don’t’ want? That’s a common manipulation technique used in this profession. And lastly, once we start inducing everyone at 39 weeks and don’t see a big dent in our rates of stillbirth but see our cesarean section rates rise even further (and the rates of serious complications associated with cesareans like accreta become out of control), will there be debates about inducing everyone at 38 weeks? 37 weeks? He went on to say that although it is believed that elective labor induction is believed to increase risk of cesarean, he doesn’t think that is true. And he believes this because he looked at cesarean rates of women induced at 41 weeks. I’m not a doctor, or a scientist, or a mathematician. But, I’m not so sure that’s good science. A woman at 39 weeks of pregnancy is very very different than woman at 41 weeks. And a baby (not a fetus, but I digress) at 39 weeks gestation is very very different than a baby at 41 weeks.
 
To close, Dr. Norwitz told the audience to “Think like a fetus!” He said that if “you” (meaning the OBs in the audience, I presume) are a fetus just swimming around in the amniotic fluid with nothing to do but play with the cord and “you’ve read the literature” (But it’s a fetus! Obviously, not a baby, so how in the world can it read?!? *eyeroll*) and you are not smart enough to induce labor at 39 weeks, the OB care provider needs to step in. Wow. Just wow. Could this man be any more arrogant, insulting, and absurd? He then stated that he thinks the question posed at the beginning of the debate (If no elective inductions before 39 weeks, why not induce everyone at 39 weeks?) is a “No Brainer” and he doesn’t even know why it’s a debate at all.
 
To drive home his point, he cued up a slide with a photo of two newborns and the words “39 weeks and out!” along the top and, “…rescued by birth” under the photo. What exactly are you rescuing these babies from, Dr. Norwitz? I’m trying to give him the benefit of the doubt and remember that he mostly works with women who have high-risk pregnancies during which it DOES become safer for the babies to be out than in sometimes. But, this statement drives home my point that the OB believes s/he is a knight in shining armor, whisking the baby from imminent danger in its mother’s womb and “delivering” it into its mother’s arms.
 
Dr. Norwitz was followed by Dr. Lockwood who explained his reasoning for thinking mandatory standard inductions at 39 weeks are a good idea. In his “debate,” he stated that “Elective Induction of labor at 39 weeks is ALWAYS a better strategy,” using phrases such as “exposed in utero.” It absolutely blows my mind that these doctors sincerely think a mother’s womb is so dangerous compared to the outside world. Dr. Lockwood also explains that with his research, he has determined that the “optimal maternal age for delivery is about 29-30 years.” After instate mandatory “elective” inductions at 39 weeks for everyone, maybe they can further better our lives by only allowing women to birth babies around the “optimal maternal age” that they have determined for us.
 
During the rebuttal time, Dr. Norwitz said “I happen to think nature is a lousy obstetrician.” And then explained how midwives think it’s best to sit back and watch and let nature takes its course but he very much disagrees. Dr. Norwitz, you are a disgrace.
 
Before and after the debates, they polled the audience about their opinions on the topic being discussed. When asked the question, “Do you agree that it would be best to deliver most al women at 39 weeks gestation?” 63% of the audience answered “no” or “strongly no.” After this “debate” the audience was asked again and this time, only 9% answered “no” or “strongly no” while 70% answered “yes” and “strongly yes.” 81% of the audience answered “yes” to the question “Did the debate cause you to change or reconsider the view you had prior to the debate?” And the facilitator of this discussion responded to this with “Excellent. People are reconsidering their practice. Very good. We absolutely changed a lot of minds.” Disgusting.
 
The conclusion I have come to after spending two hours of my time watching these debates is that the mothers and babies of America are in a heap of trouble. We need to take back birth, mamas.
 
ACOG, the possessive, authoritative, demeaning, and insulting way in which you speak about women and babies is disgusting. Your failure to recognize the sacredness of the event of birth and that mothers are deserving of respect and bodily autonomy is alarming. Your dismissal of the centuries-old wisdom of midwives who are exceptionally skilled and trained in the design of birth is ignorant. And your efforts to play God are dangerous. Shame on you.

The birth world has been a buzz about the newly released consensus statement on preventing primary cesareans from ACOG (American College of Obstetricians and Gynecologists) this week. And rightfully so. This statement includes things that the scientific evidence has been supporting for some time now, but that have not been widely practiced by maternity care providers. Some of the new recommended guidelines in the Safe Prevention of Primary Cesarean Delivery statement, and what I believe are the biggest game changers include:

• Slow but progressive labor in the first stage of labor should not be an indication for cesarean.
  For nearly 60 years, maternity care providers have used a graph, known as the Friedman's Curve, published by Dr. Friedman of Columbia University to define a “normal” length and pace of labor. The Friedman's Curve is based on a study about the average amount of time it took laboring women to dilate and has been used to govern how providers manage a woman's labor. It is now recommended that the Constium on Safe Labor should be the new standard of managing labor. In short, this means that evidence is suggesting that laboring women don't always, or even often follow Friedman's Curve and should be given more time before performing a cesarean for “failure to progress.” Rebecca Dekker of Evidence Based Birth has put out a a great article, “Friedman's Curve and Failure to Progress: A Leading Cause of Unplanned C-Sections.”
  
  
• Adverse neonatal outcomes have not been associated with the duration of the second stage of labor.
  The second stage of labor is the pushing stage. It has previously been advised that first-time moms be given up to 3 hours to push their babies out and a multiparous woman (a mom who has already given birth before) be given 2 hours and to add an hour onto both of those numbers if the mom has an epidural in place. The evidence has not shown however, that longer pushing phases are affecting babies negatively. There is also discussion about whether the second stage begins simply at full dilation or once the mother begins to feel the natural urge to bear down. There also needs to be discussion about positioning during pushing.
  
  
• Instrument delivery can reduce the need for cesarean.
  There are concerns that many obstetric residents do not feel competent in doing a forceps delivery. Yes! More training and better training on the use of forceps can and will save many moms from going under the knife.
  
  
• Recurrent variable fetal heart decelerations appear to be a physiologic response to repetitive compressions of the umbilical cord and are not pathologic.
  There is a discussion of fetal heart-rate patterns and solutions other than cesarean. My opinion: maybe we shouldn't be continuously monitoring healthy, low-risk women. Read more about Evidence-Based Fetal Monitoring and Intermittent versus continuous electronic monitoring in labour.
  
  
• Induction of labor increases the risk of cesarean.
• Unnecessary induction of labor increases risk of cesarean section and other complications. Inductions should not be done prior to 41 weeks gestation without medical indication. (The previous recommendation was 39 weeks). There are also new guidelines about when induction should be considered a failure. Some babies need a bit more time on the inside than others and that's OK. Everybody knows that children develop at different rates. Two of my kids walked at 11 months old and one didn't walk until 14 months old. It was no big deal. Babies also develop at different rates in the womb. We need to stop forcing them out before they are ready. 
  
  
• Ultrasound done late in pregnancy is associated with an increase in cesareans with no evidence of neonatal benefit. Macrosomia is not an indication for cesarean.
  Macrosomia is the medical term for a big baby. Those who know me, know that I am a big believer that your body will not grow a baby too big for it to birth. Ultrasounds in late pregnancy are not a good indicator of baby's size. And even if they were, cesareans should not automatically be done just because the baby is big. Your body grew it, your body can birth it.
  
  
• Continuous labor support, including support provided by doulas, is one of the most effective ways to decrease the cesarean rate.
  A Chochrane Review published in 2012 by Hodnett and colleagues states that when continuous labor support is provided by a doula, a woman experiences a 28% decrease in the risk of cesarean. Improving Birth's fact sheet titled Doulas and Healthcare Providers: Working Together for Better Maternal and Infant Outcomes lists other benefits of doula support. And Rebecca Dekker of Evidence Based Birth has an article about the the medical evidence of a doula's presence titled What is the Evidence for Doulas?
  
  

These new guidelines offer great hope for lower cesarean rates and safer births for both mother and baby. But, it will be a big challenge to change the culture surrounding birth and obstetrician's attitudes about labor management. History has shown us that once new guidelines have been posted, it takes anywhere from 10-20 years before they are widely practiced. I don't want to wait that long. I'm afraid to wait that long. Our cesarean rate has been increasing steadily. Our maternal mortality rate has doubled in the last 25 years. We are ranked very low among developed nations in infant mortality and morbidity, yet we spend an obscene amount of money on maternity care...the most in the world.

We need these changes to happen soon. How can maternity care consumers facilitate these changes?

• Hire a doula. If I am unavailable or not the right doula for you, the Omaha Doulas Association has many lovely doulas.
• Have a discussion with your provider about things such as their cesarean rate, their induction rate (and reasons for performing both of them), their practices of labor management (do they expect their patients to follow the Friedman's Curve?), their practices during the second (pushing) stage of labor, their competency in the use of forceps, their policy about continuous electronic fetal monitoring, etc. The Coalition for Improving Maternity Services has put out a great list of 10 Questions to Ask your provider. 
  
• Stop giving your business and money to providers that are unwilling to practice evidence based maternity care. There are providers in the area that practice evidence based care. If you change providers because of their practices, write them a letter to let them know why you've left. 
  
• Own your birth. Realize that you are ultimately in charge of your birth. Your doctor/midwife is an educated consultant for your care. Your doctor/midwife and the hospital staff work for you. You are the boss. This is your body, your baby and your birth. With that ownership comes responsibility. Educate yourself. Research. Take a good quality private childbirth education class. Learn your rights as a patient and consumer of maternity care. Advocate for yourself and your baby.