“Artisanal obstetrics” is deadly folly

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At the turn of the 20th Century, obstetricians were deeply concerned about the inherent dangers of childbirth. Both infant and maternal mortality were approximately 10X higher than they are today. Obstetrics Prof. Joseph De Lee thought that preventive care was the answer and recommended routine use of forceps. The result of that hubris was disaster.

Based on a theory that childbirth is inherently ‘pathogenic,’ prominent American obstetricians recommended sweeping reforms. Leaders exhorted their colleagues to mitigate the perils of childbirth by performing operative deliveries prophylactically — a leap that resulted in catastrophic suffering…

Sadly, we don’t seem to have learned much about the dangers of hubris in obstetrics. Based on the theory that childbirth is inherently normal, a prominent American obstetrician is recommending sweeping reforms. He exhorts his colleagues to mitigate poor outcomes in childbirth by reducing the C-section rate — a leap that has resulted elsewhere (the United Kingdom) in catastrophic suffering.

There’s not much daylight between artisanal obstetrics and the deadly Campaign for Normal Birth.

That American obstetric leader is Neel Shah, MD, and ironically, he is the one who wrote the quote above.

Recently he recently had this to say on Twitter:

The best obstetricians I know *are* artisans, using their hands, minds, and hearts to solve for the gray zones in our field

The opposite of artisanal is industrial…

Not exactly. According to Oxford Dictionaries, artisanal means “a product made in a traditional or non-mechanized way.“

In that sense, the opposite of artisanal is modern and as between the two, modern obstetrics is far safer than traditional practice.

Dr. Shah’s Team Birth Project aims to reduce the C-section rate by practicing artisanal obstetrics.

Avoiding C-sections is also better for many moms. With Cesareans, there’s a longer recovery period, a greater risk of infection and an association with injury and death. And most are not medically necessary, says Dr. Neel Shah, who directs the Delivery Decisions Initiative at Ariadne Labs.

“We’re fairly confident that when you look nationally the plurality — if not the majority — of C-sections are probably avoidable,” says Shah.

Such beliefs probably sound familiar; midwives, self-proclaimed avatars of “traditional” childbirth practices, have been promoting them for decades.

No doubt Dr. Shah believes this every bit as fervently as Dr. De Lee believed in the need for widespread use of forceps. But this belief — that C-sections are “bad” and mostly unnecessary, was the foundation of the Royal College of Midwives’ Campaign for Normal Birth and we all know how that turned out.

Sadly, there’s not much daylight between artisanal obstetrics and the deadly Campaign for Normal Birth. Both focus on process (C-section rates) and assume that good outcomes (low perinatal and maternal mortality) will inevitably follow.

That’s not what happens. The RCM was forced to shutter their campaign in August of 2017 after tens, possibly hundreds, of babies and mothers died preventable deaths in the pursuit of lower C-section and intervention rates.

Overall:

Tens of thousands of mothers and babies in England were harmed by potential lapses in maternity care in the past two years, the BBC has learned.

More than 276,000 incidents were logged by worried hospital staff between April 2015 and March 2017 – the equivalent of one mistake for every five births.

Most were minor or near misses, but almost a quarter of the incidents led to the mother or baby being harmed – and in 288 cases there was a death.

The cost has been astronomical.

Maternity is also the biggest cause of clinical negligence payouts, accounting for half of the cost of all claims.

Last year, £1.9bn of claims were made – a rise of 91% since 2004-05.

Is this what we wish to emulate? Apparently so since Dr. Shah has publicly aligned himself with UK midwifery leaders and their Normal Labour and Birth Research Conference.

There’s an additional reason why artisanal obstetrics is likely to be deadly. That’s because failing to follow guidelines leads to maternal deaths. The US maternal death rate is viewed as a scandal and the State of California lauded as the only state that has lowered its mortality rate.

What did they do in California?

…[I]mplementing large-scale interventions by integrating providers with public health services, begins with a bundle, a quality improvement toolkit defining best practices and the creation of learning collaboratives. The largest of CMQCC’s learning collaboratives, which includes 99 hospitals that collectively report more than 250,000 annual births, reduced severe maternal morbidity among women with hemorrhage by 20% using an obstetric hemorrhage toolkit.

A cornerstone of their approach is:

Hospitals must implement and sustain a standardized approach to managing known obstetric complications and emergencies involved in pregnancy and childbirth.

That is the exact opposite of artisanal obstetrics. A standardized — modern and industrialized —approach saves lives!

Artisanal obstetrics is deadly folly. It’s already been tried on a large scale in the UK and it has led to tremendous tragedy. Failing to follow standardized protocols is known to be a factor in preventable US maternal deaths. It’s an affection; it plays off the American upper class obsession with artisanal products, which is fundamentally a way to flaunt status not a reflection of quality.

Obstetricians have learned this lesson the hard way. A century ago, very little in obstetric practice was codified. Care was artisanal, variable, and sometimes dangerous.

Why go back to that?

Dr. Shah would do well to heed this warning and hopefully he will, since he is the one who actually wrote it.

  • Angharad

    When my first was born, her heart rate started dipping into the 70s with each push. She was born with the assistance of forceps. I was BADLY torn up (the OB said she felt like she was putting Humpty Dumpty together again and took over an hour stitching me back up), and it was over a year before I stopped having constant pain from it. I mentioned this to my L&D nurse when I was in labor with my second. She told me I should be grateful that I hadn’t had a C-section. I’m not a doctor, and I trust that my OB made what she felt was the safest and best decision for the situation we were in, but I would take 100 C-sections over another forceps delivery.

  • mabelcruet

    What is annoying me today…

    There is a website for doctors in the UK called, not surprisingly, Doctors Net UK. It has over 100 000 registered medical practitioners of all different specialities, has large numbers of active discussion fora and provides a lot of CME/CPD educational modules. They are currently touting their ‘breast feeding’ training module aimed at GPs (family doctors) and trainee paediatricians. The objectives, as listed, are:
    1. An understanding of the process and physiology of normal breastfeeding
    2 . Awareness of the benefits of breastfeeding and the risks of formula feeding
    3 . Knowledge of the main reasons mothers stop breastfeeding before they intended
    4 . The ability to recognise and treat common breastfeeding problems
    5 . Awareness of sources of help for breastfeeding mothers
    6 . Understanding of the principles of safe prescribing in breastfeeding

    There isn’t a single mention about the benefits of formula feeding and the dangers of breast feeding. Most of the multiple choice questions continue to peddle the benefits as increased IQ, lower risk of leukaemia, and peddles the ‘breast feeding is free’ argument:

    Direct quote: ‘Increased breastfeeding rates would result in reduced healthcare costs. For example, a report commissioned by UNICEF UK estimated that moderate increases in breastfeeding would save up to £40 million in NHS expenditure as a result of fewer GP consultations and hospital admissions (UNICEF UK, 2012 [pdf]). The report also highlighted savings to the family as there would be no need to buy formula’

    This is on a medical website with no access to the general public, not even other affiliated health care staff like nurses are allowed to join, so I would have expected a far more robust and objective evidence based discussion, not a toe the party line fudge.

    • Chi

      Of course they’re not going to discuss the benefits of formula, not when they’ve clearly stated that formula feeding has ‘risks’, thus immediately making it clearly inferior to breastfeeding.

    • maidmarian555

      One of the things that really irritates me is the ‘mothers stopping bf before they intended’ thing.

      Most of us do. Even when it works well. We are repeatedly told that we should bf for specific periods of time (i.e. 3 months, 6 months, 1 yr, 2 yrs). These arbitrary targets help nobody because babies are people with needs and wants, and they aren’t interested in targets. I’ve got friends who’ve bf for over 2 yrs who would describe the moment it stopped as ‘before they intended’. Not because something went wrong, but because the child decided they didn’t want to bf any more.

      I do know that sometimes we stop before we intend because of issues that could potentially be addressed. But if we weren’t given all these targets to aspire to, maybe the right time to stop (for either party) wouldn’t be considered to be such a negative thing.

      • RudyTooty

        I’d read that ‘stopping before they intended’ thing and was irritated for a slightly different reason.

        Women might say they intend to breastfeed while in the hospital (to please the doting nurses and lactation consultants), and then they go home and change their minds. At the point they stop breastfeeding because [insert any reason here], they INTENDED to stop breastfeeding.

        I was irked because it comes across as if women are too stupid to do what they intend to do. No, when they stop, they are intending to stop, for whatever reason. Let’s respect that and stop pitying women for making choices that are best for them in those moments. GAH.

        • space_upstairs

          Unfortunately, many women internalize the notion that they are too stupid, or weak, to do what they intended…or worse, too stupid or weak to intend a morally valid thing in the first place. And society condones that attitude, insofar as playing by the rules is a feminine gender role and the attitude doesn’t interfere with other such roles like, say, smiling and taking care of others. Yet caring too much about the rules often does interfere with those very things. So it’s all one big trap, and until society evolves, I guess we all have to choose which flack we’re best equipped to put up with and fight it the best we can.

        • demodocus

          I “intended” to breastfeed as long as we both wanted to, but that doesn’t fit well on their “but that means 2 years, right?” way of thinking

    • PeggySue

      Grrrrrrr…. I really hate junk science.

    • Elizabeth A

      Breastfeeding is free only if you discount the value of a woman’s time.

      When my first was small and I was receiving an hourly wage in my profession (exempt from minimum breaktime requirements), the work time lost to pumping cost me $130/week. (Staying late was out of the question – daycare closed when it closed.)

    • demodocus

      I got a phone call from some cancer group calling about breast cancer awareness. I struggled to not say “okay, I’m aware, now go away.” The same applies to breastfeeding. (I can go with, yes I’m aware because of my sister, who is a survivor and works for another group and no I do not have enough money to be donating to both.)

  • Forceps Mom

    Long time lurker here who felt compelled to post because I have such strong feeling about Dr. Shah. During my pregnancy, I read much of the writing by him and others in the mainstream media about how terrible C-sections are. The WHO stat of an ideal C-section rate of 10-15 percent was cited everywhere. So I checked the Leapfrog scores of my hospital. Did tons of preparation and research for birth. And the picture painted to me was that C-sections were to be avoided if at all possible because of the many short-term, long-term, and unknown risks to me and the baby. I read about the microbiome and seeding, accreta, uterine rupture rates after VBAC, wound infections, etc. The info about the risks of C-sections was everywhere and I was terrified to have one, and there was precious little info anywhere about operative delivery or its risks—and I read many birth books, took 8 hours of childbirth classes, had a doula, etc. I went into delivery believing the greatest risks of forceps and vacuum were injuries to the infant and lacerations, and I figured that was just tissue that could be sewed back together. And all the books said operator skill would minimize these risks. Little did I know. I ended up with a badly managed labor, prolonged second stage, and then forceps. I now have been living with levator avulsion, bladder prolapse, pelvic pain, sexual dysfunction, and diminished bowel control as a result for the past several years, as well as PTSD. I never knew any of this could happen from forceps assisted vaginal delivery, and I can’t be fixed. My quality of life is horrible. I can hardly walk without discomfort now. Sex is rarely pleasant and almost always hurts. I can’t jump or run or wear tampons or do vigorous exercise. Sitting too long causes pain. I worry often about accidents. I cannot live the life I want or be the mom or wife I want to be. I feel like an old woman. And I am so very angry at people like Dr. Shah who have such control of media dialogue and yet he refuses to acknowledge this kind of suffering, which is largely invisIble because we women are so ashamed that no one knows. It was only after my delivery that I learned about the high incidence of irreversible pelvic floor muscle trauma with forceps—injuries which cannot be corrected surgically. I read recently a stat that 40 percent of women who delivery by forceps will get irreversible pelvic floor muscle trauma. So how can it be that no one is talking about this, and people like Dr. Shah continue to rail against C-sections? I wonder every day if my life would have been different if I had one, and feel betrayed by all the providers I trusted who didn’t inform me of the real risks. And every time I see news stories about the high C-section rate or my friends lament their emergency C-sections (yet can still chase their kids and exercise) I am triggered.

    • Who?

      That is so awful, I’m sorry to hear it.

      This idea that we can manage birth if we only do enough research is so dangerous and literally, damaging.

      It would be a good thing if people were properly informed about the risks of vaginal birth, and the risks of forceps deliveries.

    • Montserrat Blanco

      I am so sorry about your suffering. You are absolutely right in everything you say. The level of misogyny that women have to endure while pregnant and in childbirth is just amazing. How we end up after birth hardly matters at all.

      And you are right, had you had a CS, especially an elective one and you would be running marathons, enjoying sex and not worrying about continence because your pelvic floor would be intact. How can we expect women to take the right decisions for themselves? How can we expect them to know they prefer a CS scar and recovery instead of risking pelvic floor damage? They are not intelligent enough!

      If you get gallbladder surgery everybody trusts your ability to make informed decisions. If it is birth, then, well, apparently you can not be trusted.

      I had a CS. Got really sick with preeclampsia and my son was premature. It is true that I did not get to the late pregnancy stages when the weight on top of the pelvic floor sometimes damages it. I was running three weeks after my CS. Running. I did a 10 k race when my son was 7 months old. My CS hurt. A lot. For a few days. I do not like the scar. Those are the problems I have had. I wanted a vaginal uncomplicated delivery, got a CS and I am truly happy I did. To be clear my CS was performed for my son, he could not have endured a vaginal delivery and I probably would not have any long term damage from such a small baby. I am still happy I had a CS.

    • Amy Tuteur, MD

      I’m am so sorry that you have had to deal with this. I wonder if at least some of the damage can be repaired with surgery. Have you seen a urogynecologist for a second opinion?

    • Sue

      So sorry to hear of this terrible experience. Ironically, one of the reasons for increased use of Cesarean delivery is the evidence of the harm of forceps on the structures of the birth canal.

      Your story is consistent with this evidence.

      That’s why we need clinical practice to be informed by evidence, not just based on individual opinions.

    • Amazed

      God, I wish you the best urogynecologist around for Christmas and yes, it’s a sad thing that women should resort to Christmas wishes. But when media and worse, doctors treat them like children?

      So sorry to hear about your ongoing struggles. Stories like these always make me remember the first time I saw my parents’ godson – one of the best looking young men I’ve seen in my LIFE. But when I first saw him as a baby, I asked, “Mommy, who beat him?” The forceps bruise was literally 2 mm away from his eye. His mom has been left to push long after it had become clear that no delivery was happening. Yes, I suppose one might say the location of the bruise is indicative of the artisanal skills of the obstetricians. To me, it’s so, so terrifyingly close. A near miss.

    • Sarah

      You should be angry. He’s a cumrag.

    • fiftyfifty1

      Hi ForcepsMom,
      Sorry to hear about your damage. I also had a levator ani avulsion (one sided) and have pelvic organ prolapse and iffy bowel control. In my case it wasn’t forceps, it was just a difficult regular vaginal birth. It sucks.
      I know that feeling of it seeming like the birth turned me into an old lady overnight. The first few years were the worst, but then things gradually have gotten better. I no longer have any actual pain. I do have pressure and discomfort at times, but no pain. The iffy bowel control I deal with by keeping an extra pair of pants and undies in my car at all times just in case, although truthfully, I have seldom used them, because when I do have bowel accidents they usually occur at home or near home (like if I go on a walk, feel the urge, and can’t make it back.) The tampon thing is a pain. For a couple of years I couldn’t wear them at all. Now I can wear OB brand. Because of the tissue damage and the low-hanging uterus, my vagina is wider and shorter that it was. OB tampons are shorter than other brands, so I can fit them in. I do have to wear a pad at the same time because of bleed-around. I definitely do not jump. I have gone jogging a few times so technically can do it, but it was uncomfortable, so I choose not to, I walk instead.
      The sex part took a lot of adjustment. Feeling old and damaged was a big mental barrier. I was finally able to make the mental leap that even though sex was going to be different, that I still deserved to have sexual enjoyment. Part of what helped me was knowing a number of patients with disabilities that had way bigger hurdles than mine who were able to create happy sexual lives for themselves.
      I did go on to have another baby, and had a maternal request CS. The recovery was super easy, and so I finally got to enjoy a postpartum experience where I could enjoy by baby rather than be in so much pain, not be able to sit, struggle to walk etc.
      It’s true the levator ani can’t be fixed. But the pelvic organ prolapse can often be surgically improved. I haven’t done it yet, but I know I will.
      I am sorry you and I are in this club. I will say, however, that I have met a lot of outstanding women in this club who have become my friends.

    • PeggySue

      I am so sorry for what happened to you. It sounds really awful.

    • demodocus

      egad. *hugs* that sounds so horrible to deal with.

    • KeeperOfTheBooks

      I’m so sorry you have all that to deal with. I don’t have anything useful to add, just my sincere sympathy.

  • Amazed

    The moment I see a skill described as “artisanal”, my trust in the professionalism of the person making the comment wavers. Unless it’s something about real art, praise like this has nothing to do with professionalism. He sounds like a homebirth midwive gushing over her “hobby”. But then, he’s best buddies with these, isn’t he?

    Usually, when I hear an editor explaining excitedly how they “read books and get paid for this” and it’s such a pleasure to treasure art, I do my best to avoid providing this person with any translations of mine to edit. Reason: I don’t want artistry and enjoyment, and awe of the process. At least, I don’t want those blurring the fact that it’s a job, first of all. It demands accuracy and precise judgment, not this person’s feelings.

    Artisanal obstetrics sounds like “the kind of obstetrics that I admire over any other because it’s so much better that no other can possibly compare”.

    • demodocus

      Artisanal brain surgery?

  • Spamamander ctrl-alt-right-del

    OT but I just found out today a woman I work with is planning a home waterbirth with her daughter. What’s worse, I’m pretty sure the “midwife” she is using is Sherry Lee Dress. (I was told the “midwife” in question was in trouble in Washington for delivering babies without a license. We’re on the WA/ OR border, and my co-worker lives in OR. This would be square where Sherry Lee Dress practices). She originally was very much pro hospital birth, but she is Seventh-Day Adventist and her family is pushing the homebirth narrative. Apparently this “midwife” delivered most of her husband’s family. I’m absolutely horrified. She is about 26 and this is her first child. I guess she told some of my other co-workers that “you only hear one side of the story in the news, and she made me feel very comfortable” etc. Pulling my hair out a bit…

    • PeggySue

      So scary, and there is really nothing you can do.

      • Spamamander ctrl-alt-right-del

        I hate that there is nothing I can do. That’s the frustrating part. She’s basically the age of one of my own kids and I can’t stand the idea she is putting herself and her baby at so much risk. 🙁

        • Daleth

          You could at least talk to her a bit and see if she’s open to hearing, um, reason. She did start out pro-hospital birth, after all.

  • Zornorph
    • I like to see things explode just as much as the next hamster, but these Facebookable gender reveal moments just have to go.

      • AirPlant

        Hey, nothing will ever beat the look of flooding disappointment on my meat head brother in law’s face when they pulled out that slice of pink cake.

        • swbarnes2

          If you aren’t going to be overjoyed at whatever result you get, why would you show the world that publicly?

          Though I think a “surprise, we are having twins” reveal would be worthy of dragging people to a party over.

          • demodocus

            I did see one where even the twins were a reveal, revealed by having both blue and pink whatevers

      • Lilly de Lure

        I’ve been wondering – what do they do if the scan doesn’t actually reveal the baby’s gender (I know several people whose 20 week scan left them none the wiser as the baby’s leg, arm or umbilical cord was in the way) – do they have a special colour for “sorry, your baby is bashful” or do they get given some kind of discreet call telling them that the party they’ve been planning is going to have to be called off or how does it work exactly?

        • Heidi

          I guess wait a few weeks for another scan or make everything yellow? Ha.

          My kiddo was like, “Hey, here’s my penis!” My untrained eye figured that one out at the 20 week scan. He’s still kinda like that.

    • AirPlant

      but… was it a girl or a boy?

      • Zornorph

        I read several articles trying to find out, but none of them would say.

        • AirPlant

          Then why even have a forest fire?

    • PeggySue

      I commented elsewhere that this guy is a Darwin Award in the making. Tinder-dry conditions, firearms, exploding targets–what could possibly go wrong? It’s really a miracle of location that no homes were destroyed or people killed or injured, but the damage, gosh.

  • Krista

    My father in law told me a horrible forceps story about a friend he went to school with. His father was the ob that delivered him. He got stuck and forceps were used, which likely saved his life but also badly gauged his eyes. His friend was blind but otherwise fine. Granted, it was the forties and it was probably the best that could be done in a difficult situation, but I’m pretty sure a nice easy c-section would have been preferable for everyone.

  • Lee McCain MD

    We always had a saying in training that forceps separated the family practice physicians from the true Obstetricians. Not sure why you are so insecure towards operative obstetrics particularly forceps. Your passive stance in modern Obstetrics is destroying the art that I hold near and dear. We are training a generation of physicians who cannot do forceps, who cannot do breech deliveries, and who are terrified of delivering twins vaginally. I guess you believe we should just cut our way out of every difficult delivery. Maybe you have forgotten but a second stage arrest of labor section on a patient who has been pushing 2 plus hours is fraught with complications.

    • The Computer Ate My Nym

      Higher perinatal adverse outcomes seems to me to be a very good reason to not do breech deliveries. As for forceps, most of the literature seems to support use of c-section and vacuum rather than forceps in the majority of situations. There’s nothing wrong with abandoning an outmoded treatment technique. Few oncologists use, say, single agent nitrogen mustard for treatment of HL but I’ve yet to see anyone complain about oncologists these days and their inability to do old fashioned oncology. Why is OB different?

      • Lee McCain MD

        Actually forceps have long been shown safer and more effective than vacuum in numerous RCTs. As for breech deliveries I think one has to be judicious. I had 8 last year; three second twin and the others on multiparous patients gravida three or greater. Would I ever delivery a primip breech by choice? Absolutely not! My point is there are situations where a vaginal breech is best. Case in point the other night my young partner called me in at midnight for a patient where the fetus flipped to breech in labor. He was trained to section her but knew I would back him up. The patient was gravida six. Ultimately the baby delivered in the bed. Would I put forceps on a patient with gestational diabetes that had been pushing two plus hours. Not a chance. My overall point is the there are guidelines for forceps, for vaginal breechs, for twins; and if you stay within those then your outcomes will be equivalent to a c-section. There is nuance. But just to say lets do forceps to lower your section rate when precious few know how to do forceps anymore is lunacy. Conversely to say all forceps or breech deliveries are dangerous is naively dismissive but alas that is where our profession is regressing.

        • The Computer Ate My Nym

          Do you have a reference re forceps versus vacuum? The cites I found seemed to suggest the opposite, but I’m not an expert in the field and don’t know the totality of the literature like you do.

          It’s my understanding that the recommendation for singleton breech births where version isn’t desired or practical is c-section. Not correct?

          • Lee McCain MD

            You are correct. All my breech deliveries recently have been multips who have presented with advanced cervical dilation that I elected to delivery vaginally vs doing a circus go to the OR stat c-section. But I trained 26 years ago when vaginal breech deliveries especially second twins was still routine. Hell I was a vaginal breech. I am just stating that nothing in Obstetrics should be sacrosanct as long as one is judicious in picking the right circumstance. As for the safety of forceps vs vacuum found a few articles. The big difference is maternal trauma with forceps vs fetal trauma with vacuum. I also linked ACOGs 2015 stance on operative delivery.

            https://academic.oup.com/aje/article/153/2/103/118370

            https://www.ajog.org/article/S0002-9378(04)01608-4/abstract

            https://www.medscape.com/viewarticle/853132

          • FormerPhysicist

            Thanks, after reading these articles, I’ll take a MRCS, a bikini scar, and a poufy tummy instead of an injured mother or baby. I do not see what’s so bad about a CS, or why I should take vaginal trauma to save my baby instead of nice, neat bikini scar. I happen to like continence and marital sex, TYVM.

          • Lee McCain MD

            Well there are some academics who use your arguments to suggest we should section every pregnant patient for your very valid reasons! I certainly could get on board with that because the beauty of a c section is that you take all the unknowns out of the equation. And I absolutely despise Leapfrog and WHO for making arbitrary goals for section rates that have no basis in any scientific fact. All patients should be free to choose with informed consent what they want be it section or forceps or whatever. I never counter a patient that wants a primary elective c section. If I convince them otherwise and the vaginal delivery is less than perfect then I am the worst doctor on earth. Most of my points are philosophical on what makes an Obstetrician. But I truly believe two decades from now obstetrics will be laborist and midwives running L&D with NPs and MFMs running the clinic and us generalist long gone.

          • RudyTooty

            “But I truly believe two decades from now obstetrics will be laborist and
            midwives running L&D with NPs and MFMs running the clinic and us
            generalist long gone.”

            This is interesting – and I suppose it depends on the area of the country where one works. I am a CNM, and I see my role as becoming completely superfluous. L&D requires intensive 1:1 nurse to patient ratios. And L&D requires a physician who can perform operative vaginal deliveries and cesarean sections 24/7. What unique role does the APRN or CNM provide? Lighting candles, providing foot massages and waterbirth?

            The pregnant patient population is not becoming more low-risk, nor do they request natural birth (you know, of the waterbirth and candlight variety) in large numbers.

            From my viewpoint, the CNM is branding itself out of business – and that might be why they lobby so hard for ‘natural, physiologic’ birth. I could see a niche for CNMs/APRNs providing laborist and/or nursing care to the most at-risk patients in L&D. I don’t see any push to do that, though. Maybe it’s happening in other areas.

            What are the trends that make you think it’s going the other direction – to an NP/CNM and a MFM specialist model? None of the MFMs I know want to be up at night!

          • Sue

            Interesting perspective, RudyTooty. In the Australian and UK midwifery model, the midwife provides both nursing care and labor/delivery care for the majority of births in the public hospital system, consulting with obstetrics as required. I don’t see that model becoming obsolete.

          • I agree with you. I am autonomous up to a point, but when certain parameters are reached, I then become part of a team. Is my more advanced knowledge less useful as a result? I don’t think so. And I think the patient benefits from continuity of care, if the CNM also is involved in antenatal and postpartum care [as it was when I was in the UK long ago]

          • RudyTooty

            The model is different in the US than it is in Europe and Australia. The L&D nurse would never become obsolete. The labor assessment piece is necessary.

            A CNM in the American model assumes the role of the physician or provider – essentially coming to the bedside for the delivery. A CNM may labor-sit if preferred and the patient census allows – but the duty of monitoring and assessing the patient during labor is the responsibility of the RN. The CNM is ‘extra.’

            It seems like the maternity care model of Europe and the UK combines a labor nurse and nurse-midwife. Which makes some sense. I don’t know if it’s one that would ever be adopted here – though I can see some benefits.

          • FormerPhysicist

            It didn’t sound like you would be at all in favor of MRCS, and I appreciate your clarification.

          • Elizabeth A

            I was asked to provide informed consent for ventouse delivery in mid-labor. It added about two hours to the pushing phase (they had to stop as I howled through contractions, my epidural had failed), and all I remember is that people were talking at me.

            Informed consent for mid-labor events is a joke. Either you get it in advance or it’s meaningless.

        • Anna

          I think youre singing to the choir here. No-one is saying no forceps or breech ever, we’re saying women should be fully informed and have a right to opt for c-sec if they wish, particularly if they are high risk for a poor outcome vaginally, which these days is far more common. Breech is a reasonable option for some but we have elevated vaginal to such a level that some think breech is safer even for primips, lga babies, overdue, high bmi Mums, at home, in water etc etc Thats when things go horribly wrong.

    • Amy Tuteur, MD

      I was trained by Dr. Friedman of the Friedman curve who was convinced that forceps harmed babies. There is a role for outlet forceps but mid-forceps and mid-forceps rotations have serious side effects including fetal death and permanent maternal injury. When I practiced I had a C-section rate of 16% so I certainly didn’t feel it appropriate to cut my way out of difficult deliveries.

      • When I trained in the 60s, mid and high forceps were completely off the table already. Outlet forceps were not uncommon, but ours was a teaching hospital and we had real experts. But it is a dying art — in Israel the doctors who are best are from Eastern Europe where C/S is often an impossibility.

        The statistics show conclusively that the risks of vaginal breech delivery are not warranted, and I can’t tell you how many times, after an easy first twin vertex delivery, it’s a mad rush to the OR because of potentially lethal and unanticipated complications with the second.

        The ART of obstetrics is knowing when the appropriate intervention is indicated, and knowing how to perform it.

        • AnnaPDE

          Where in Eastern Europe are C/S often an impossibility? Maybe I’m in the wrong social stratum, but at least for everyone I knew in Hungary and for my Polish and Ukrainian friends, C/S was a very normal way. So much so that the last vaginal birth in my family happened in 1955, since then non-emergency C/S all around. My oldest childhood friend only found out when her (allegedly male) hamster unexpectedly gave birth overnight that there is a way of babies getting out of mummies’ tummies that doesn’t involve a doctor cutting them out… she was 12 at the time.

          • Most particularly during the Caucescu regime in Romania when OB facilities were very primitive. But many hospitals in the former USSR didn’t have enough anestheologists or ORs to be able to perform emergency C/Ss, and doctors had to resort to forceps, or let the baby die. It depended a lot on where one was. Baku or Tashkent wasn’t Moscow or Warsaw.

            One professor who had been the Head of OB at a major Petersburg hospital confessed that there was so much bureaucracy involved in getting permission to do an ultrasound that he did fewer per month than he did weekly in Israel. To be licensed in Israel, despite being in his 50s, he had to repeat his residency, and he said he was amazed at how much he learned. Like me, who trained back in the “Bad Old Days” before monitors and ultrasounds were invented, he however had immensely skilled hands.

          • Amazed

            They used to be… not impossible but kind of rare anyway in Bulgaria as well. Especially in the country. At least in the last two decades before Communism fell. We’re talking about a big regional hospital who had ONE ultrasound (officially) and this one was broken, so my mom went without one after an obstetrician sent her there to see how many babies there were since she gained like 50 pounds well before the end of her pregnancy. The nurse said, “Do you know the head doctor?” “Would it have changed something if I did?”, my mom replied. OF COURSE it would have. Because there was likely a second machine, for the “rightholders” (yes, this was actually a word and it included… well, everything you can imagine.) For the smallfolk (thanks, GRRM!) there were not enough materials in pur public healthcare system. Letting things go vaginally and operatively, unless it was a true, grave emergency was a way to cut down costs. Plus, at the time C-section around here only included a vertical incision so doctors were understandably more reluctant to use them liberally.

            I’ve written before how there was no baby formula at the market. A deficit. God, how I hate this word! I especially hate the memory of deficit of toilet paper.

            Romania was even worse off than us at the time. I imagine c-sections and related costs weren’t in vogue there either.

      • Lee McCain MD

        Well then I am trying to figure out the point of your article. ACOG came out in 2015 urging more operative deliveries to lower the section rate with technical bulletin 154. Is that wrong? Is that “artisanal”? And I agree wholeheartedly mid forceps and Keillands should be relegated to the dustbin of history. But your article argues operative vaginal deliveries ie artisanal is the root cause of maternal morbidity and mortality and that we in the U.S. should avoid such misadverterous follies. In fact I would argue if you take away operative obstetrics then you might as well let the midwives run the show and we can be relegated to consultant Gynaecologist whose only function is to do C-sections at the behest of said midwife. You want to reduce maternal mortality? Quit training residents to think delivery at 37 weeks is heresy and that 39 weeks is inviolate. Maybe then we would stop letting patients progress to HELLP syndrome before we felt the delivery was indicated.

        • Amy Tuteur, MD

          Yes, I believe that urging more operative deliveries to lower the C-section rate IS wrong. We should always focus on outcome, NOT process.

          In this piece I am not arguing against operative deliveries per se. I’m arguing against the idea that C-sections are “industrial” and vaginal births are “artisanal.”

    • Neya

      Well, I don’t really care about the art you love. You certainly did not have to deal with the tears and pain that came with forceps extraction the way I did — which by the way, still didn’t prevent a c-section. This is so ridiculous. If I wanted art, I would have gone to a museum. But, now I can’t, at least not without wearing a pad.

      • Amazed

        I wish you a complete recovery as fast as possible.

      • demodocus

        *hugs*

    • BeatriceC

      I just had surgery to repair the damage done to me by a forceps delivery 19 years ago. I’ve been bringing up the issue with doctors all this time, but got blown off every time, until one single GYN finally took my issues seriously. 19 years I suffered when I didn’t have to. I could have had a c-section. I did have two c-sections after that delivery and have zero long term complications with them. Actually, I had zero short term complications with them. Even my “smash and grab” style c-section was a less traumatic recovery than my forceps assisted vaginal delivery. When I finally got referred to a urgogyn, she said I was one of the worst cases she’d ever seen, yet doctors like you told me to suck it up and deal with it. You are what’s wrong with women’s healthcare. There’s a safer alternative less likely to lead to long term complications yet you refuse to let go of it. Quit. Get out of the business. We don’t need doctors like you making any more women suffer like I did.

      • demodocus

        All healed up from the surgery? Hooray! Did you make the adult child buy you a popsicle? 😉

    • Amazed

      Yes! Please cut your way out of MY difficult delivery! I’ve been an object of art and it was fun. I need to clarify that it was a sculptor’s art. I am so not interested in becoming an object in your maintaining your skills in your art. When I go to a doctor, I want him to choose the way that is best for ME and MY baby. Not HIS chance of practicing his art.

      I am not interested in having an obstetrician pat himself on the back and say, “Well, I did it!” I want a peaceful, calm delivery with the best chance of no long term complications. The idea of a doctor doing a vaginal breech or twins delivery on me is horrifying. Why invite the risk?

    • Sue

      If I needed gallbladder surgery, I would not care how good you were at open surgery, I would want a person skilled at laparoscopic surgery, because that is state of the art, associated with a lower complication rate and a more rapid recovery. In this case, DON’T cut me – even if you love the art of a good laparotomy, because that is not contemporary or best practice.

      It’s not Dr Tuteur’s blog that is changing obstetric practice – it;s the good evidence of the harm of instrumental delivery to women. We have the relatively minor and short-term risk of wound infection in a Cesarean scar (easily treated) vs complex pelvic floor damage (not easily treated). At the same time, we know that Cesarean deliveries are better for babies – more frequent short-lived TTN vs much more serious injury or hypoxia. What evidence is there, then, that favours forceps? (other than the specific indications discussed elsewhere, which are not disputed).

    • Elizabeth A

      There are many provlems with the art you hold near and dear and one is this:

      No one wants to be the target of anyone’s first try with the forceps. In order to learn and practice, doctors have to determine that it is fine for some women and some babies to risk (and actually experience) permanent injury and fetal death. Sing all the praise you want of experienced hands on forceps, the fact remains that in order for that experience to occur, thousands of parients have to have any gosh darn trainee messing around their intimate anatomy with hard edged tools.

      Do you care about art or do you care about patients?

      • demodocus

        the first resident sewing up tears didn’t do nearly as good a job as the second. He even left a little pocket-like gap. It’s been gone since she sewed me back up. I think it was experience in large part. The 2nd was in late spring and the 1st in the fall.

        • Elizabeth A

          I can’t like your post – it’s too painful to think about.

          C-sections are far easier to teach and to check than…a whole he’ll of a lot of other OB procedures.

          • demodocus

            Eh, at least it wasn’t a 4th degree tear, and it was corrected. And I had an epidural. Now I only have to worry if I sneeze or cough with a full bladder.

  • BeatriceC

    Totally off topic: MK has moved back home! I am beyond thrilled to have all my kids together again. After living with his dad for two years, he wanted to come back, and I wanted him here, so the move was made. He arrived a week and a half ago. I couldn’t be happier.

    • attitude devant

      He’s your skater, right? Is he still skating? Glad he’s home!

      • BeatriceC

        He had to quit competitive skating because of his health issues, though he still skates for fun.

        • KeeperOfTheBooks

          Seriously OT as well, but I thought it might make you smile to hear that my first CS kid is about to start figure skating lessons after becoming enamored of Olympic figure skating last year. She’s homeschooled, and if she sticks with this long-term, I plan on doing as you described here a few years ago…I’ll pay for ice time, but she has to do her lessons with no fussing about it in exchange. (Goodness, I hope that was you I remember posting about that…)
          I’m so glad your kiddo is home, and while I’m not on here very often anymore, it’s nice to “see” that you’re still here. 🙂

  • AnnaPDE

    “Artisanal” is only good when the standardised approach is the low-quality, easily automated, and optimised for cost savings one.
    But not when the standard is set at the level of the competent, experienced and skillful artisan who is willing to invest time and effort into a good outcome. In this case, the standard is a protection against the not so successful practices of the lower end of the artisan spectrum — and when the “not so successful” outcome is not just a loaf of rubbery bread, but an injury to someone, that protection is very important.

  • RudyTooty

    Quoting him is brilliant.
    Can’t he remember all the way back to January?

    • demodocus

      My memory of January is pretty fuzzy, honestly. But that’s me.

      • Sarah

        Well yes, but I don’t see you shitting nonsense all over twitter.

        • demodocus

          Very true

  • This is troubling on many fronts and yet again relegates women to a world where they don’t get to make the decisions with respect to their care. If a woman desires a low intervention birth and has been informed of the risks and benefits, that’s one thing. If she’s been subjected to one, that is quite another. Its hard to think that having been reasonably informed of the risks and benefits of a course of action, that women are any less capable of making a decision on a care plan that best meets their needs. That includes a care plan for a planned cesarean.

    Further – there’s a lot of work on the data side to be done before declaring that a retrospective diagnosis is best! One must look at the data from an “intention to treat” perspective – and then control for a variety of factors that may influence that intention. Further, we need to have more data on longer run consequences of pregnancy and birth – after all, most pelvic floor issues are addressed long after the event.

    • Mel

      I doubt that Dr. Shaw or any of the NCB crowd or the people who wring their hands over the CS rate of a country have worked out the informed consent form needed to implement their “most CS are unnecessary” end goal.

      Their assumption is that most women will prioritize an easier recovery and lower rate of infection for themselves over an increased risk of morbidity or mortality for their kid.

      I might be a raging optimist, but most women I know would trade off a rough recovery and infection risk to keep their baby in a lower risk of mortality or morbidity

      The pessimist in me remembers the moms in the NICU who were recovering from vaginal births gone wrong. Recovering from a CS can be rough – but we weren’t having to cushion everywhere we sat down for weeks.

      • rational thinker

        After i had my first I had to sit on an inflatable inner tube for two weeks, not fun!

      • FormerPhysicist

        Depends on the relative risk, and what that risk is. I.e. The percentages of incidence and the severity if it happens.

        What does infection even mean? My third C/S incision got “infected”. We had to squeeze a little pus out of 1/4 the incision, and apply a topical antibiotic. Does that count in their stats? Nothing opened, nothing was major, and PPPE was still my major problem. Would I trade that for a forceps delivery? No how, no way.

        Recovery from 13 hours of labor, then a c/s. Hard.
        Recovery from 5 hours of pre-E labor, c/s, then PPPE. Really Hard. Especially with two young kids at home, as well as the baby.
        Recovery from a planned c/s. I got to move gingerly for four weeks. I was sitting and nursing most of the time anyhow. Wasn’t a big deal.

  • fiftyfifty1

    The liberal use of forceps resulted in many injuries and so Dr. Shah criticizes it. And yet liberal and experienced use of forceps is what kept the CS rate low until the practice was abandoned. Dr. Shah loves to harken back to to these good old days of low CS rates to “prove” that our current CS rate is too high. Sounds like he wants it both ways!

    • Anna

      The efforts to lower c/s rates in Australia has resulted in more use of forceps and no decrease in c/s. Midwives say the only answer is to give them more power and if a few babies die, oh well.