Friday, June 09, 2006

Emily Litella

If you are as old as I am, you may remember Emily Litella, the character that Gilda Radner portrayed in the early years of Saturday Night Live.

Emily Litella was supposed to be a television commentator who ranted against various abuses. Trouble was, she was always ranting against things that weren't happening, because she had misunderstood.

A typical rant might be about banning violins on television. Emily would go on and on about what wonderful instruments violins are and why no one should ban them from television. Finally, Jane Curtin or Chevy Chase would interrupt: "Emily, it's violence on television, not violins. They want to ban violence on television." And Emily would always stare into the camera and say sweetly, "Never mind!"

What's the connection with homebirth advocacy? Homebirth advocates often claim that they are not taken seriously in scientific debates about obstetric practice in general and homebirth in particular. One of the reasons why is that they are constantly railing against things that they have misunderstood or made up. When this is pointed out to them, the response is a rhetorical "Never mind!"

This happens all the time on this website. The most recent example is a homebirth advocate railing against the use of Accutane by obstetricians. Accutane is an acne medication and it causes serious birth defects. Accutane is a category X drug, which means that it should NEVER be given to pregnant women because it causes birth defects. Obviously, that means that it is NEVER used by obstetricians.

Nonetheless a homebirth advocate just insisted that I should explain why obstetricians routinely use the drug. Of course, they don't. I know what happens next. "Never mind!"

21 Old Comments:

Just stick with the SHOULD NEVER part of your statements- as you do not know what everyone does.
Yea I read the list too and though this is coming off the top of her head and maybe instead of DDT she meant DES... we are almost at the end of that population huge generational effect.
As for misoprostol ( Cytotec) she nailed that-- have you read the ACNM article on VBAC ? - the article tiers out the different risk categories in vbac- to add misoprostol in the mix it elevates the risk of uterine rupture.
so with the increased use of misoprostol ( no studies on this to begin with just word of mouth off label use) and then more uterine ruptures than expected- what happens some docs see the correlation and DC using it and the DRUG company certainly sees the danger and correlation and what do we get over all ? New recommendations about VBAC- infact no VBACs in many places - what is used to for study- a big insurance company evaluation not even a good study. Tell me Amy how do you feel about misoprostol being used at a birth center? how about at home? --- I mean for hemorrhage silly not for induction.... the misuse of misoprostol is chilling indeed.
I am still curious about the use of drugs for resuscitation by the physicians in the Canadian study, do you think this has to do with the kind of epidural they use? What else I have found is standing in the hospital at 1 minute they are very generous about the apgar score the tone in the baby I would almost always count 1 off for and 1 for color so most of the time something they would call 9 -10 I would call and 8 so if there is a problem , the numbers would be skewed.
I also think boy oh boy we will be having this ongoing discussion for the next 7-8 years until there is enough information to be real.
As far as studies go we have been proven with the episotomy and the delayed cord cutting.

By Anonymous Anonymous, at 10:04 AM  

Yes, use that broad brush to extrapolate what one person on the internet wrote to paint the whole group.

Another example of how your debate points hold no water. (Notice I'm not condemning the whole group based on your shortcomings.)

By Anonymous Anonymous, at 11:16 AM  

Have you considered just renaming this blog: "Homebirthers are Idiots: a Medical Opinion?"

There doesn't seem to be much allowance for debate outside of the comment boxes. Have you considered inviting guest bloggers to write posts contrary to your opinion?

This last post is a good example of what I call the jaundiced eye. Not all homebirthers are uninformed ninnies and not all doctors are right. I would surmise that you have had a lot of bad experiences with this particular group because of the nature of your job, but consider that there are plenty of women you never see because things go well and not by accident.

And even if I do agree that the risks of homebirth are unnecessary why swath the rest of mothers who desire less medical intervention in the same cloth? Birth is a pivotal experience. Wanting the best outcome for yourself and your child is not unusual or dumb. Many of your arguments just seem very hasty and mean-spirited.

By Anonymous Anonymous, at 11:52 AM  

I suggest that Amy is a manipulator. A manipulator of statistics, a manipulator of women (look at her book exerpt on episiotomy which fails to recognize alternatives to tearing -- I know I've had three, one with a big head and NO TEARS. why? I was on my own feet to give birht, and I pushed at my own will with no direction), and a manipulator of your own reality.

Amy -- you state your position but NEVER really support it. You just state and restate your position. That is not debating. It is poor form.

If you don't know how to prevent tearing other than cutting, does that make you a manipulator by ignorance?

By Anonymous Anonymous, at 12:07 PM  

"As for misoprostol (Cytotec) she nailed that"

I don't know why you say that.

What is misoprostol? How does it work? Why is it used? Who discovered and tested it? What are its benefits? What contraindications are associated with its use? Who figured that out? What are the current clinical guidelines for its use?

If you are so sure that it is a debacle, tell everyone else why.

What always impresses me in these types of discussions is the fact that the only people in America who think obstetricians are different from other human beings and should be expected to be perfect are homebirth advocates. And when obstetricians are not perfect, their fury knows no bounds.

How exactly do you propose to solve any problems in medicine without ultimately testing things on human beings? There are 3 official phases of testing for any medication, but then there is an unofficial fourth phase. The fourth phase occurs when the medication or procedure goes into general usage. Risks that were too low to be detected in the original studies will come to light when large numbers of people start using the drug or procedure.

You sound absolutely scandalized that such a thing can happen. I'd love to know what you think is the alternative. Should we just let postdates babies die "naturally" rather than induce labor?

DES is another example. DES was prescribed to prevent miscarriages. I assume that you agree that miscarriages are a terrible disappointment to those who have them. I also assume that since 20% of pregnancies end in miscarriage, you would agree that it represents a significant problem for women. Finally, I assume you agree that if we could find a way to prevent miscarriages, we should.

So, how exactly do we go about doing that and simultaneously assure that no one suffers any side effects or complications? Doctors, at least, were trying to solve the problem. I haven't noticed midwives or anyone else making any headway on the issue. Furthermore, at the time DES came into use, no one understood the concept of medication induced birth defects because it had never been described before. Certainly no one had any idea that a drug could have an effect on a baby 20 years down the line.

The story of DES is unfortunate on so many different levels.

Even today, when we understand that most miscarriages are caused by genetic defects, women still beg their obstetricians for something to take or do when they start bleeding in early pregnancy. Obstetricians would be thrilled to have something better to offer than throwing up their hands and saying nothing can be done.

It is unfortunate because there was so little good data at the time that obstetricians should not have given in to patient demands by trying DES, reasoning that it wouldn't hurt.

Finally, it is most unfortunate that exposure to DES during several critical weeks of pregnancy changes the development of the squamo-columnar junction of the cervix in such a way that it predisposes to rare cervical cancers.

You can criticize obstetricians for not waiting for better data, but it is hard to criticize them for anything else. They were trying to help. They thought they were helping. They had no idea about what could happen because nothing similar had ever been described. Furthermore, they did not profit from DES in any way.

Finally, this is part of the "marketing" campaign to denigrate doctors. The thinking is supposed to be that since doctors, being only human, make mistakes, then everything they do is a big mistake or should be assumed to be a big mistake until proven otherwise.

I think, however, that MOST people recognize that doctors are only human beings, and can and will make mistakes. They also realize that in most instances these mistakes were made in the process of lowering mortality rates and treating disease. I'm sorry that homebirth advocates can't seem to recognize it, too.

By Blogger Amy Tuteur, MD, at 6:14 PM  

'You can criticize obstetricians for not waiting for better data, but it is hard to criticize them for anything else. They were trying to help. They thought they were helping.'

Oh Pleeeeeze, Amy! This sounds like a 2 year old throwing a tantrum.

And this paragraph is exactly what you accuse midwives of doing.

By Anonymous Anonymous, at 11:15 PM  

I guess the very first thing I want to know if I am in a drug trial- or you are using an experimental drug on me that I have that in writing and it is made clear to me. Off label use is the same thing.
--Amy wrote:
"What is misoprostol? How does it work? Why is it used? Who discovered and tested it? What are its benefits? What contraindications are associated with its use? Who figured that out? What are the current clinical guidelines for its use?"

Originally a drug used for ulcers/ ulcer prevention in people who take NASAIDs- Cox 2 (synthetic prostaglandin)
for women of child bearing age take day 2 or 3 of period- trying to avoid problems with pregnancy

used in a 2 step process for very early abortions
( RU-486)- 80-90% effective
20-40 minute half-live-- is absorbed systemically

I think that there is a current labor study-
50-100mcg of misoprostol against cervidil for ripening and induction.
the misoprostol for the trial is in a slow release insert-- I am pretty sure though that the trial has some cavats-- not for preterm, no uterine scar, no multiples- not grand multip ( in other words any one who might be at a higher risk for uterine rupture) and no other things that would counter-indicate the use of a prostaglandin
use for postpartum hemorrhage would have to look back at the lit - info on that was oral worked as fast as the rectal -
couldn't tell you who invented it... could look it up I guess.

By Anonymous Anonymous, at 1:09 AM  

you fault midwives for not being perfect-- look at your language all along- and you propose for us to just consume your product and no other kind in any other fashion-- I don't want a surprise experiment.
You are the one with infinitives in your language-- notice you start this off telling us how stupid the other poster is-- and that ALL doctors know better-- you can speak for one doctor that is you- you may also know what is recommended, and you probably know what a few of your friends/co-workers do- your information is anecdotal ...
I really don't expect you to be perfect- not in any way - but do not posture in a superior position -

By Anonymous Anonymous, at 1:24 AM  

Acta Obstet Gynecol Scand. 2006;85(5):579-82.

Bishop score and the outcome of labor induction with misoprostol.

Szczesny W, Kjollesdal M, Karlsson B, Nielsen S.

Department of Obstetrics and Gynaecology, Sykehuset Innlandet Hospital Trust,

BACKGROUND: The aim of the study was to retrospectively identify possible
factors for predicting the outcome of induction with misoprostol. METHODS: Fifty
micrograms of misoprostol were administered intravaginally every 6 h during the
first 2 days of induction, up to a maximum of 4 doses. The Bishop score,
indication for induction, gestational length, maternal age, and parity were
analyzed. The study involved 99 patients (47 primiparous and 52 multiparous) at
term (>36 weeks of gestation) with unripe cervices. RESULTS: Forty-five per cent
of the patients achieved ripening of cervix and went into labor after a single
dose of misoprostol; a further 45% required 2 doses. Nine patients received more
than 2 tablets. Ninety-seven per cent of all vaginal deliveries occurred within
the first 2 days of induction. Ninety-five per cent of the patients delivered
vaginally when the Bishop score was >3, compared with 75% of those with a Bishop
score of < or =3 (p=0.003). Among factors creating the Bishop scoring system, in
logistic regression analysis effacement of the cervix was the only independent,
significant predictor of cesarean section (p=0.003, OR = 0.16) even after
adjusting for maternal age, which also was a significant predictor in the
regression analysis. Eleven patients had previously had a cesarean section; one
of them had a uterine rupture with a fatal outcome for the fetus. All women with
a previously scarred uterus are now excluded from misoprostol treatment.
CONCLUSION: Misoprostol 50 microg administered intravaginally every 6 h
according to this protocol is highly effective for inducing labor in carefully
selected patients with unripe cervices.

PMID: 16752237 [PubMed - in process]
Acta Obstet Gynecol Scand. 2006;85(6):706-11.

Effectiveness and safety of a new vaginal misoprostol product specifically
labeled for cervical ripening and labor induction.

Cecatti JG, Tedesco RP, Pires HM, Calderon IM, Faundes A.

Department of Obstetrics and Gynecology, School of Medical Sciences (FCM),
University of Campinas (UNICAMP).

Objective. The purpose of this study was to evaluate the effectiveness and
safety of misoprostol in two different formulations: vaginal tablets of 25
microg and one-eighth of a 200-microg oral tablet, also administered
intravaginally, for cervical ripening and labor induction of term pregnancies
with an indication for that. Methods. A single-blind, randomized, controlled
clinical trial was carried out in 120 pregnant women who randomly received one
of the two formulations. The main dependent variables were mode of delivery,
need for additional oxytocin, time between beginning of induction and delivery,
perinatal results, complications, and maternal side effects. Student's t,
Mann-Whitney, chi 2, Fisher's Exact, Wilcoxon and Kolmogorov-Smirnoff tests, as
well as survival analysis, were used in the data analysis. Results. There were
no significant differences between the groups in terms of general
characteristics, uterine contractility, and fetal well-being during labor,
cesarean section rates, perinatal outcomes, or maternal adverse events. The mean
time between the beginning of cervical ripening and delivery was 31.3 h in the
vaginal tablet group and 30.1 h in the oral tablet group, a difference that was
not statistically significant. Conclusion. The results showed that the 25-microg
vaginal tablets of misoprostol were as effective and safe for cervical ripening
and labor induction as the dose-equivalent fraction of 200-microg oral tablets.

PMID: 16752263 [PubMed - in process]
and a novel way to use it that sounds promising

Gynecol Obstet Invest. 2006 May 25;62(2):115-120 [Epub ahead of print]

Role of Misoprostol in Overcoming an Unsatisfactory Colposcopy: A Randomized
Double-Blind Placebo-Controlled Clinical Trial.

Aggarwal R, Suneja A, Agarwal N, Mishra K.

Department of Obstetrics and Gynaecology, University College of Medical Sciences
and Guru Teg Bahadur Hospital, Delhi, India.

Objective: To assess the effectiveness of vaginal misoprostol in overcoming an
unsatisfactory colposcopy and to analyse the factors that might influence the
response to misoprostol, i.e. age, menopausal status, duration of menopause and
cervical characteristics. Study Design: A randomized double-blind
placebo-controlled clinical trial. Methods: Forty patients with unsatisfactory
colposcopy were recruited from the colposcopy clinic and were randomly allocated
to receive either 400 mug misoprostol or similar-looking placebo tablets
vaginally. Repeat colposcopy was performed after 6 h noting the side effects, if
any. Results: One patient was excluded from the misoprostol group because
postdrug colposcopic examination could not be done due to a technical fault. Of
the 19 patients in the misoprostol group, 15 (78.9%) had satisfactory
examination compared to only 6 of the 20 (30%) patients in the placebo group.
This effect of misoprostol was statistically significant (p = 0.004).
Misoprostol in the present study averted 3 cone biopsies and 12 endocervical
curettages. The side effects of misoprostol were comparable in both groups. The
slit-like external os and the posterior cervical lip as the site of
unsatisfactory colposcopy had better conversion rates compared to pinhole os
(66.6 vs.81.2%) and anterior lip involvement (85.7 vs.100%). Conclusion: Four
hundred micrograms of intravaginal misoprostol is an effective and safe method
to convert an unsatisfactory colposcopy into a satisfactory one. Copyright (c)
2006 S. Karger AG, Basel.

PMID: 16735793 [PubMed - as supplied by publisher]

By Anonymous Anonymous, at 4:12 AM  

I am also old enough to remember those broadcasts. Remember when Dan Akroyd would rant against his co-host with, "Jane! You ignorant sl*t!" There might be a loose association with that portion of the skit as well (no pun intended).

By Anonymous clever ID, at 1:15 PM  

Thanks for the articles about misoprostol. People can see that misoprostol is a synthetic prostaglandin. It is used in a variety of settings, but the reason it is used in obstetrics is to "ripen" the cervix so it will thin and soften in preparation for labor induction. Induction with pitocin does not always work if the cervix is not soft enough.

So misoprostol has a legitimate medical use. Misoprostol was discovered and tested by scientists and physicians. The complications of misoprostol were also discovered and described by physicians. Women who have had a prior C-section are at increased risk of rupture of the uterus if they are induced following administration of misoprostol. It is therefore no longer used for induction in women with previous C-section.

It is not surprising that misoprostol might cause problems in that setting because many physicians believe that a women who has had a prior C-section should never be induced with any medication because of the risk of rupture of the uterus.

Ina May Gaskin jumped on this issue as being emblematic of what is wrong with obstetrics. She inflamed the debate by accusing doctors of using an ulcer drug which had not been approved for use in labor. Of course, what she neglected to mention is that prostaglandins are used in a variety of circumstances in medicine and it wasn't as though some obstetricians suddenly decided to irrationally dose women with ulcer medication.

The bottom line is that misoprostol is a medication that can increase the chances of successful induction for women who need induction. Doctors discovered and described a known complication of its use and stopped using it in that way. So it is hardly some sort of debacle that demonstrated the incompetence and lack of concern of obstetricians.

By Blogger Amy Tuteur, MD, at 3:59 PM  

Well, of course this has nothing to do with the homebirth debate (though we do use it for postpartum hemorrhage with good results), but Amy, it's not as simple as that. You are correct in everything you say. But cytotec can also cause problems in women without a scarred uterus -- see case examples at http://www.midwiferytoday.

Unlike most midwives, I actually think cytotec has a place as an option for informed choice. We induced a woman with it this week, in hospital. She read everything about cytotec and accepted the risks of it, so that she could avoid intermittent monitoring and still labor in the tub. As HBAC has risks, so does cytotec, but I think women should be able to make informed decisions for themselves.

By Anonymous maribeth, CNM, at 4:09 PM  

Oops, meant avoid continuous EFHM.

By Anonymous maribeth, CNM, at 5:50 PM  

I never once thought it was an ineffective , but that it was used off label- most likely after the studies for completing abortions--and the hint would have been there from the trials for ulcers.
But I know that many women were not informed when it was being used what it was and that it was off label -- and unfortunately I do think it has put us in the negative vbac arena we are in today-- so there are some bigger social implications. I also know of doctors in my own town still using it on vbacs maybe they are compulsive gamblers--

probably the coolest thing is the use for cervical dysplasia -- there has been atleast one study out that showed an improvement in in dysplasia and HPV after vaginal delivery-looks like part of the improvement is prostaglandins.. hummmmmm

By Anonymous Anonymous, at 12:55 AM  

My problem is this:

doctors are allowed to choose the risk set. the whole discussion of "informed consent" seems ludicrous to me, since my experience (and experience of many of my friends and acquaintances , not just in childbirth) is that it's really difficult to find a doctor that doesn't paternalistically make decisions on their patients' behalf without really enrolling the patient in the decision-making process.

I'm not sure what region you're in, but it must be drastically different than where I live, if you're telling me that women were fully informed and decide wha risks they prefer in childbirth (because there are risks no matter what approach you use, and I believe they are equal in infant mortality at home and lower for the mother at home).

Plus, even after the plural of anecdotes that cyotec was very dangerous for vbacs, and increased risk even in moms w/o a scar, many prominent doctors insisted it was still safe -- flying in the face of reality. It was a heated debate -- even on national TV. (did you see that?)

God forbid, but if I've been in a terrible car wreck or have a heart attack, you bet I want a good doctor making decisions. But about inducton of labor or other major pregnancy and childbirth decisions? I'll choose. Thank you.

See, in your example of risk of fetal demise for post dates -- you're using extremes as an example of what doesn't really happen. Many many inductions occur before 40 weeks, and many many many more before 42. Plus, I would add that home birth midwives help women avoid or at least reduce calcifiation, thus lowering some of the risk.

Why not let the mom choose the risks she's most comfortable with? Why do doctors have to cajole and shame women into taking the risks that the doc feels comfortable with?

I can tell you, though, that I would not want to go 42 weeks with the average doctor, because I don't think doctors know how to support women to give birth spontaneously, and the bigger the baby, the less silled I see docs as. Active management of labor and birth is not safer. That's not what made childbirth safer, no matter how many times it's incorrectly asserted.

(BTW -- I'm referring to the American medical system; I suspet some countries are more evidence based in their approach to various things -- especially pregnancy and birth)

By Anonymous Anonymous, at 10:22 AM  

"Why not let the mom choose the risks she's most comfortable with?"

I absolutely agree. That's why I am so adamant on the point that homebirth advocates have an ethical responsibility to their own patients to represent the risks truthfully. Being truthful would involve removing the statement "scientific studies have shown homebirth to be as safe as or safer than hospital birth" from their websites and publications.

It is irrelevant to the practice of midwives whether doctors offer appropriate informed consent. DEMs do not need the permission of doctors to follow appropriate ethical rules.

By Blogger Amy Tuteur, MD, at 11:07 AM  

Being truthful would involve removing the statement "scientific studies have shown homebirth to be as safe as or safer than hospital birth" from their websites and publications.

What has the response been when you've made this point to the various websites you refer to? Have you inquired as to the validity of the statement in their point of view? I would think if you are truly seeking "truth in advertising" for the legions of women who may choose home birth you would focus your attention on those sites, not on this small isolated spot on the internet.

By Anonymous clever ID, at 12:30 PM  

"What has the response been when you've made this point to the various websites you refer to?"

I have not approached them.

I posted some of the data on a discussion at NHS Doctor and Angela Horn of the UK Homebirth Reference Site publicly stated that she was unaware that the studies she quoted might not actually say what she thought they did. She said that she was going to obtain copies, read them for herself, and modify her site if necessary.

There are hundreds of homebirth advocacy websites and it would take a long time to write to them all. It is far easier to post my own website as a corrective, and let people question me or other website providers in order to make informed decisions.

By Blogger Amy Tuteur, MD, at 2:03 PM  

"Amy Tuteur, MD said......Angela Horn of the UK Homebirth Reference Site publicly stated that she was unaware that the studies she quoted might not actually say what she thought they did. She said that she was going to obtain copies, read them for herself, and modify her site if necessary."

Heh. Does anyone else see this response as very, very, odd?

I wonder how many people went to Angela Horn's page and dutifully assumed the papers said what Angela implied they said.

Wouldn't they be surprised (or shocked) to know that Angela apparently never READ the papers she posted on her site? Something tells me she didn't have a "by the way, I haven't read these" disclaimer. I tried to imagine posting things on my site I hadn't read, but I couldn't.

And for those who have been following this: It's a boy! My wife wasn't looking forward to a natural delivery of a 9 pounder... so she (and midwife) were more than a little surprised to deliver an 11 pound baby :)

By Blogger sailorman, at 9:35 AM  

I'd love to know what you think is the alternative. Should we just let postdates babies die "naturally" rather than induce labor?

So are you saying that inductions are mostly for women that are past 42 weeks and that there are NO other alternatives for inducing labour then to put the woman at risk?

I have yet to meet one woman that was with an OB that was "allowed" to go past her due date... I would also have to say that MOST women that go into the hospital will be induced (if not a planned C/S of course)...

By Anonymous aUCmom, at 12:27 PM  

aUCmom said...
So are you saying that inductions are mostly for women that are past 42 weeks and that there are NO other alternatives for inducing labour then to put the woman at risk?

No, that's not what she's saying. Which is why sie didn't say that.

I have yet to meet one woman that was with an OB that was "allowed" to go past her due date...
Wow, you must hang with an interesting crowd. I know several. In any case, this is anecdotal evidence.

Are you trying to claim that OBs routinely advise induction as soon as mom hits 40 weeks? This is contrary to medical protocol.

What DOES happen in my experience is that many OBs will agree to induction more readily after 40 weeks because they are reasonably sure the baby will be healthy. And many, many, mothers would rather induce and get it over with.

Is this a good thing? Dunno. But it's their choice.

I would also have to say that MOST women that go into the hospital will be induced (if not a planned C/S of course)...

OK, let's see if you're speaking English or "home birth English."

"Most" has a meaning which is equivalent to "the majority of." So are you claiming that over 50% of women who enter the hospital will be induced to begin labor, or will have an elective C section?

I really doubt it. Why? Well, by your reading, over half of women who present at the hospital aren't in labor at all. Kind of looks funny when you think of it that way, huh?

Of course, you may be using "induce" to mean "receive any pitocin." But there's a big difference from getting pit to modify or assist with an already active labor on the one hand, and getting pit to START labor on the other hand.

And of course, you may be using "most" to mean "more than I'd like." Don't be surprised if you get misunderstood.

By Blogger sailorman, at 12:29 PM