On Friday I wrote about the death of a baby that occurred while Jan Tritten, Editor of the homebirth “journal” Midwifery Today, crowd sourced Facebook for suggestions for management of postdates with no amniotic fluid, but unruptured membranes.

Since then nearly, there have been approximately 25,000 visits to the post, and it is being discussed on a variety of message boards, Facebook pages and Twitter streams by lay people, doctors, skeptics and pretty much anyone else but homebirth midwives themselves. 329 people have signed the petition expressing revulsion.

Let’s listen for the reaction from the professional homebirth community. Do you hear what I hear?

That’s right … NOTHING!

Where is the Midwives Alliance of North America? Shouldn’t they be promising a public investigation of Jan Tritten for possible negligence and possible malpractice, not to mention serious unprofessionalism for crowd sourcing a life or death situation in real time?

Where is Melissa Cheyney, CPM, Director of the Board of Direct Entry Midwifery of Tritten’s state of Oregon? Shouldn’t she be promising a public investigation of Jan Tritten, as well as a root cause analysis to determine how to prevent future deaths?

Where is Ricki Lake, spokesperson for all things homebirth? Ricki was out there front and center defending an obstetrician who lost his hospital privileges and subsequently his right to practice because of egregious errors in the care of patients. Why hasn’t she come to Tritten’s defense?

Where is Aviva Romm, MD who recently confided this:

I will also readily admit that there are quite a few not so great home birth midwives contributing to not so great birth outcomes. In fact, in reaction to the problems found in medicalized birth settings, there’s a bit of a midwife ‘wild west’ out there – anyone can get “the calling,” attend some births, and call herself a midwife. Caveat emptor! It’s not black and white. A poorly planned home birth or a less than competent midwife (or physician, though most home births are attended by midwives), in the rare event of a complication, can be disastrous…

Ya think? So what are you going to do, Dr. Romm, when one of your homebirth buddies lets a baby die as the results of her grossly unethical actions? Will you be publicly condemning her? How about warning women to stay away from her. Or are you just going declare “caveat emptor” and let the tiny dead bodies fall where they may?

Where are the bloggers from the Lamaze blog Science and Sensibility? Will we be treated to cries of indignation from them, calls for investigation, calls for analysis of what went wrong?

Where are the homebirth bloggers, like Birth Without Fear, Monica Bielanko of Babble, Tracey Cassels of Evolutionary Parenting, The Feminist Breeder, etc.? When will they be discussing this tragedy and trying to learn from it?

Where is Jan Tritten? According to her pathetic attempts at backpedaling, this was supposed to be an opportunity for learning. Why did she delete the case just when we could have learned the most? When will be hearing from her on just what she learned from this tragedy and what other homebirth midwives can learn as well?

I’m going to go out on a limb and guess that we are going to hear from all these professional homebirth advocates and organizations at the exact same time …. NEVER!

And why will we never hear them demand an investigation, release the results, and condemn the mistakes?

Because homebirth midwives don’t care about safety. They only care about homebirth midwives.
The Midwives Alliance of North America has literally ZERO safety standards. Not only do they have no safety standards, they are quite explicit about this horrific stance. As far as MANA is concerned, it is up to each homebirth midwife to decide for herself what is safe. An official stance like that only makes sense if you are a lobbying organization, working tirelessly for the economic benefit of your members. What about the life and health of mothers and babies? They can fend for themselves and “own” the decisions that led to the deaths or permanent injuries of their babies or themselves.

But all is not lost. There is a way that the rest of us can learn from this preventable tragedy.

To any women contemplating homebirth, I ask you to imagine yourself in the situation of this mother:

• In the face of imminent disaster, her midwife assures her that doing nothing is the best course.
• In the face of imminent disaster, her midwife is so clueless that she is soliciting medical advice from her Facebook friends.
• When your baby dies she insinuates that it is your fault for listening to her.
• When confronted by others about her role, she pretends that your baby, his life and death, was posted on Facebook for the edification of everyone in the known world except you.
• And then she deletes even that, to cover up her own role in his death.
• Finally, as you make funeral arrangements, the homebirth community will rally around the midwife, not you. They will never investigate her actions; they will do everything possible to protect her.

Now ask yourself:

Is this what you want for yourself and your precious baby? A woman who calls herself a midwife, though lacking the most basic education and training, who cares more about her experience than whether your baby lives or dies?

As Dr. Romm, pointed out, “anyone can get “the calling,” attend some births, and call herself a midwife.” So take Aviva’s advice, caveat emptor, and choose hospital birth. Whatever the failings of the hospital may be, at least the professionals there care about whether you and your baby live or die.

As promised, here’s the Tritten post with comments so everyone can decide for themselves what actually went on and whether Tritten’s behavior was unprofessional and unethical.

Tritten thread

Sometimes I think the best argument against American homebirth midwifery is merely to expose their utter lack of ethics, their willingness to lie for their own ends, and the sheer stupidity involved in posting inappropriate behavior to the internet and then trying to deny what people can see right in front of their eyes.

At of this moment, 229 people have signed the petition to Jan Tritten, Editor of Midwifery Today, expressing revulsion as her grossly unethical, unprofessional behavior that resulted in the preventable death of a baby. The petition is being promoted even in some surprising places such as on the Facebook page of a homebirth midwife.

But Tritten still thinks she can absolve herself of moral responsibility in this baby’s death and she’s going about it in the most moronic possible way. Did she write that she was caring for this patient? Oh, she had nothing to do with the care of this patient. She was just writing in the voice of another midwife. I’ll let you decide.

Here’s what Jan originally wrote:

What would you do? Primip with accurate dates to within a few days who has reassuring NST at 42.1weeks, as well as reassuring placenta and baby on BPP, but absolutely zero fluid seen. 42.2 re-do of BPP and again, mom has hydrated well, but no fluid seen. Baby’s kidneys visualized and normal, and baby’s bladder contained normal amount of urine. We’re in a state with full autonomy for midwives and no transfer of care regulations past 42 weeks. Absolutely no fluid seen…what do we truly feel are the risks compared to a woman whose water has been broken and so baby/cord has no cushion there either. Cord compression only? True possibility of placenta being done although it looks good? Can anyone share stories/opinions? …

Here’s what she says now:

The questions on this page are messaged privately to me and put up anonymously. They are not my cases. This is to help mothers, midwives, doulas and physicians in their work. It is to opinions from many different practitioners and parents.

Really? Could have fooled me.

I see no indication anywhere that this was anything other than a case in which Jan was deeply involved, in real time, and was grossly unprofessional in crowd sourcing a life and death decision on Facebook. Jan can deny it as much as she wants, but her own writing says something very different, and very damning than what she is saying now in an attempt to save herself from public opprobrium, and worse.

For the time being, until Jan prevents actual evidence, not weasel words, I am taking her initial writing as the truth. She was involved in this case and she was morally, if not also legally, culpable in this baby’s death.

But Jan is hardly the only one back pedaling as fast as she can.

“Wanda Smith Midwife” was mentioned in passing on the my original post for her “advice” offered to Tritten:

Wanda Smith Midwife absolutely no experience with “0″ fluid, but have had two go quite over with very low fluid (under 5), one was 18 days over, quite uneventful home birth, and one was 19 days over with heavy mec and true knot, that did give a us a little trouble, but she stilled birthed vaginally (my emphasis)

But Wanda Smith Midwife suddenly remembered that her actions in both those cases violated midwifery regulations in Virginia where she practices.

Thinking quickly, this genius came up with the following:

Ladies may this be seen by everyone. I was the first to respond to the original post. Like many on this thread, I made an assumption. I assumed that this mom was in hospital or was being referred in. I assumed the midwife was seeking stories for outcomes, NOT seeking advice as to stay at home with an obvious dangerous situation. My answer was not thorough, and I am horrified by how I look by reading the docs blog. I gave two cases, one 18 days over and one 19 days over, both with a low AFI = not ZERO AFI. Each case was transferred into the hospital, because each had reached the end scope of my practice guidelines. Though each passed BPP guidelines, with an 8 out of 8. AFI was low but still WNL. We (Parents, OB, & Midwife) made decisions according to combined data, post dates pregnancy & LOW AFI, to induce labor with continuous EFM. My births had excellent outcomes. I have never been and will never be a do or die home birth midwife, and those that interview me know and I state, “if you are a do or die home birther, I am not the midwife for you.” Please, please do not assume that all midwives are uneducated, can’t read US reports, don’t know when to refer, don’t attend peer review, and don’t have practice guidelines. I also am not making the assumption that any midwife is sitting around waiting for internet responses instead of being proactive. None of us know exactly what happened to cause this death. It is tragic for everyone. I certainly will never respond on public forum again, for multiple reasons. (my emphasis)

Lying about it now just makes it worse, Wanda.

You wrote the following on the Facebook page associated with your own website, Gentle Birth Roanoke:

With JOY and tremendous ADMIRATION for one strong momma Gentle Birth Roanoke welcomes “SNOWbaby” Henry. He was born this morning at 9:14 am and weighed 8 lbs. 6 ozs. at 18 days over his due date. His wonderful parents are so pleased to be resting after two days of labor and hosting their midwife team overnight. Thankful for prayers, snowplows, and kind citizens who made it possible for us to safely get to and from this birth. w/Dawn & Cindy = pictures of our travels to follow. (my emphasis)

And the doula wrote about the birth, too.

Coincidence? I think not, but even if it were, it shows that Wanda Smith has violated the terms of her midwifery license.

Jan (and Wanda), I cannot thank you enough. You are working hard to demonstrate the fact that American homebirth midwives are not medical professionals. They have no safety standards. They violate the terms of their licenses and they lie about, too. Personally, I think that the worst thing about the lies is not that they are offered, but that homebirth midwives are as dumb as posts, imagining they can lie about what anyone can read for themselves and no one will notice.

Bad news, ladies: The days of getting your birth junkie highs while not giving a damn about the health and safety of your patients are coming to an end. Keep talking; keep violating your own practice standards; keep letting babies die and not offering a shred of remorse about your own involvement. You are doing my job for me.

People are disgusted and they are signing the petition to let you know.

Jan Tritten, stop the pathetic, self serving attempts to deny responsibility for the preventable loss of an innocent baby’s life; it’s sickening. Instead, start apologizing and begging forgiveness from the family you have harmed.

Yesterday approximately 10,000 people followed a Facebook thread where Jan Tritten, editor of Midwifery Today, crowd sourced a life or death obstetric decision at the exact same time that the baby suffocated to death. Judging by my private email, Facebook and Twitter accounts, many homebirth advocates and homebirth midwives were deeply distressed by the incident, Jan’s behavior, the baby’s death, Jan’s response, the desperation of some homebirth midwives to absolve Jan from accountability, and, of course, Jan’s deletion of the entire thread.

I could offer reams of statistics about the hideous death rate at homebirth, and I often do, but no one does a better job of demonstrating the ignorance, incompetence and gross lack of professionalism than homebirth midwives themselves. Jan Tritten exquisitely and painfully demonstrated my adage that homebirth midwives bury babies twice; first in little coffins in the ground, and once again by trying to erase their lives and senseless deaths from public consciousness.

There were some minor consolations to the thread. Homebirth midwives and advocates spent hours arguing and interacting with me, and others similarly outraged by Tritten’s behavior. No one was turned to stone, became radioactive or was otherwise permanently harmed by engaging with me. I daresay that some people actually learned some things.

To any homebirth midwives and homebirth advocates who were willing to engage or even just read along I offer this: You are welcome to post here anytime, with any questions, or even just to argue. Your comments will not be deleted. They will be addressed. We may be on opposite sides of the debate, but we’re on the same side when it comes to saving the lives of babies.

To them and to everyone else, I also offer this: A petition to express our outrage and revulsion at Tritten’s decision to crowd source a life or death decision on Facebook, the death of the baby, the utter absence of any attempt to hold anyone to account, and the immediate deletion of the thread that exposed Tritten’s grossly unprofessional behavior.

You can find the petition at Change.org.

It is addressed to Jan Tritten:

We wish to express our revulsion at your unprofessional behavior and the resulting death of a baby.

And goes on to explain:

Jan Tritten, Editor of Midwifery Today, crowd sourced a life or death decision on Facebook, and a baby died.

American homebirth midwives are the only healthcare providers who have literally no safety standards and, therefore, no accountability. Recent publications, including statistics from the Midwives Alliance of North America (MANA), the organization that represents homebirth midwives, reveal that homebirth increases the risk of death of the baby by 450% of more. High risk homebirths (breech, VBAC, twins) had even higher death rates.

Despite these hideous death rates, no homebirth midwifery organization or executive has made any recommendations to improve safety. Indeed, homebirth advocates in both Arizona and Hawaii are currently arguing to enlarge scope of practice to include the EXACT SAME high risk conditions that homebirth midwives have demonstrated in their own paper to be utterly unsafe at homebirth.

It is time for the leaders of American homebirth midwifery, including Jan Tritten in her role as Editor of Midwifery Today, to acknowledge the death toll of homebirth, to investigate why these deaths are occuring and to hold the midwives involved to account.

Please take a moment to sign the petition. Tritten will receive an email each time someone signs.

We had tremendous success with our petition to force MANA to release its homebirth deaths rates. Perhaps we can have equal success at preventing more homebirth deaths.

Jan Tritten is the Editor of Midwifery Today, the “journal” of homebirth midwives.

I’ve never had anything other than contempt for her, but now she’s taken it to a new level.

All the while she was busy crowd sourcing a life or death decision for a 42+ week baby with no amniotic fluid on ultrasound, the baby was dying.

What would you do? Primip with accurate dates to within a few days who has reassuring NST at 42.1weeks, as well as reassuring placenta and baby on BPP, but absolutely zero fluid seen. 42.2 re-do of BPP and again, mom has hydrated well, but no fluid seen. Baby’s kidneys visualized and normal, and baby’s bladder contained normal amount of urine. We’re in a state with full autonomy for midwives and no transfer of care regulations past 42 weeks. Absolutely no fluid seen…what do we truly feel are the risks compared to a woman whose water has been broken and so baby/cord has no cushion there either. Cord compression only? True possibility of placenta being done although it looks good? Can anyone share stories/opinions? …

Many of the suggestions are appalling:

Wanda Smith Midwife absolutely no experience with “0” fluid, but have had two go quite over with very low fluid (under 5), one was 18 days over, quite uneventful home birth, and one was 19 days over with heavy mec and true knot, that did give a us a little trouble, but she stilled birthed vaginally

Christy Birthkeeper Fiscer Fluid level readings can, and often are highly inaccurate at this point… yet often used now as indication for intervention. Can you FEEL fluid during palpation, or does baby have a “plastic wrapped” feel?

Erika Laquer Try a very good acupuncturist and midwife-friendly

Zuki Abbott-Zamora I would respect leaving things alone, and just because you cannot ‘see’ fluid does not mean there is none. I have seen babies come with as little as a tsp of fluids and be just fine.

Mary Bernabe Leave her be. I’ve had 3 bbs like that and all were just fine. Didn’t know till the birth though. All 3 were out of water births so I know for sure there was no fluid. Bbs did great and so did moms. Placentas were normal and healthy looking. She’ll go into labor when it’s time.

Has she tried stevia to possibly increase the fluid?

Lynn Reed what Zuki said:) Trust mom’s instincts too & who made up the 42 week law? Midwives or OBs scared of litigious times & distrust of mom’s owning their births

Jennifer Holshoe try a 1m dose of Natrum Muriaticum homeopathic to balance fluid levels. I have seen it work with one dose

There were other, reality based suggestions as well, including the recommendation to transfer care and induce.

And while Tritten and the rest of the midwifery stooges were contemplating reasons for ignoring the obvious signs of imminent death, the baby actually died.

Very sad? Very sad??!!

How about horrifically tragic and utterly preventable?

How about the completely avoidable result of mind boggling ignorance?

How about medical malpractice and criminally negligent?

Homebirth midwives are dangerous, witless fools and babies die as a result.

The CPM “credential” must be abolished and Jan Tritten is a perfect example of the desperate need to do so as soon as possible.

If I were able to address Melissa Cheyney, Wendy Gordon and the other executives of the Midwives Alliance of North America face to face (not likely, since they would run screaming from any possibility of appearing in the same venue as anyone with actual medical knowledge), I’d ask them one simple question:

How do you sleep at night?

How do you sleep at night when you know that you are deliberately concealing the hideous death rates of babies born at the hands of homebirth midwives?

I wonder how you rationalize it.

Are you like the executives at Merck who apparently rationalized hiding the deadly side effects of Vioxx by thinking of the profits to be made from unsuspecting patients?

Or do you think that the ends justify the means? Is it more important to you to protect that ability of self-proclaimed “midwives” to get their birth junkie fix, and get paid for it, than to protect the babies who die preventable deaths at homebirth?

Or maybe you simply pretend those dead babies don’t exist, so you don’t have to think about them. That tactic, as reprehensible a view as it is for any health provider to choose, would make me feel better about you than if I thought that you were merely callously ignoring them.

Have you convinced yourself that it is okay to lie about deaths at homebirth in both scientific papers and MANA publications because you believe in your heart of hearts that all the data that you and many other researchers have accumulated on homebirth deaths is actually wrong? That if you just keep collecting statistics long enough you will finally prove what you already “know,” that homebirth is safe?

I suppose that one thing that makes it easier for you folks is you insistence on surrounding yourselves with flunkies who are eager to agree with whatever lie you dream up. And it certainly makes it easier if the only people you have to convince about the safety of homebirth are people incapable of understanding the data for themselves.

I imagine that if you actually deigned to appear in a venue where you could be questioned by other medical professionals, not only would your claims be thoroughly eviscerated, but you might come face to face with the reality of what you have been facilitating, the deaths of babies who didn’t have to die. Maybe that would dent your resolve to keep hiding and lying.

Your latest gambit, the MANA statistics paper, does not seem to be working out very well.

I suspect that you thought that if you just hid the hospital death rate, you could convince everyone that the hideous homebirth death rate was actually an indication of safety. I guess you thought that they would promptly forget that you had been hiding those same numbers for 5 years, an indisputable indication that even you recognized the death rates as hideous. Maybe you figured you could send a few flunkies out to lie about the CDC Wonder database or anything else that it might be convenient to lie about. And no doubt you were relying heavily on the basic ignorance and seemingly endless gullibility of most homebirth advocates, professional or otherwise

But it hasn’t really worked, has it? Sure the gullible are willing to believe, but you knew that would happen. The problem is that no one else believes you. It was your misfortune to finally publish your data at the same time that other obstetricians published theirs. And although you hid the hospital death rate, they didn’t, thereby making it available to the public. And, unfortunately for you, the obstetricians found almost the same death rate at homebirth as you did; but they put it into the context of the hospital death rate making your claims look foolish at best and deliberately mendacious at worst.

You are going to lose this battle to hide accurate information from American women. Maybe not in the near future, but definitely in the not too distant future. It is inevitable that people are going to ask MANA why you hid those death rates in the first place. It is inevitable that people are going to ask MANA why you have no safety guidelines of any kind. It is inevitable that insurance companies will demand evidence of your competence before reimbursing you, and you won’t be able to provide it. In other words, it is inevitable that your hiding and lying is going to catch up with you.

Should you have a shred of conscience, you might want to contemplate this:

Since you’re going to be exposed as incompetent frauds eventually, might it make sense to create standards now to elevate your level of practice above that of incompetent frauds? Might it makes sense to abolish the ridiculous “portfolio” process that allows homebirth “midwives” to sidestep any real education or training? Does it make sense pay attention to preventable deaths of babies rather than bury those babies twice, once in the ground and then again in the public consciousness?

I guess it could all be summed up in one simple question:

Do you care more about whether babies die or do you care more about your wallet?

Your choice. Do let us know what you decide.

Can you guess who wrote this?

The usual diagnostic criteria in use nowadays invoke arbitrary standards of total duration of labor, beyond which abnormality may be considered to exist… Thus, for example, labors lasting longer than 24 hours are usually deemed to be abnormal and, therefore, to warrant consultative evaluation. This practice gained general acceptance, not so much because the criterion of duration is diagnostic (which I hasten to insist it is not), but rather because there is a relation between prolonged labor and increased fetal morbidity and mortality… [N]ot all labors which exceed these uncritical limits subject the fetus to comparable risk. The single guideline of duration, therefore, must be considered as much too coarse and insufficiently definitive to permit us to specify precisely which patients are at risk … (my emphasis)

How about this?

The physician is confronted by a wide range of normality in terms of patterns of contractility. At one extreme is the patient with negligible contractions; her cervix is dilating unobtrusively while we try to determine whether or not she is in labor… At the other extreme is the woman who suffers contractions of great intensity and frequency that may continue for many hours before cervical dilatation becomes apparent… Yet both are normal variants and the physician with enough experience will recognize their inherent differences. (my emphasis)

Or this?

Continued progress should be expected if patients with protraction disorders are properly managed in a conservative manner. The prognosis remains good as long as progress continues. There appears to be only a very small increase in risk to mother or infant from these conditions, provided no ill-advised measures for stimulation or-even more important- for traumatic delivery are undertaken. Expectancy is very strongly recommended. (my emphasis)

Or this?

Arrest of dilatation or of descent is a most serious abnormality and carries an especially poor prognosis for vaginal delivery. Many patients with these patterns ultimately require cesarean section because of disproportion. Where pelvic relations are adequate, the prognostic outlook for vaginal delivery is much better. One can determine the prognosis more carefully … if one compares the rate of progression … with the rate that occurs after treatment [with Pitocin] for the arrest… The more rapid the postarrest slope, the more likely is vaginal delivery. Patients whose postarrest slope is more than 2 cm./hr. greater than the prearrest slope should all be expected to deliver vaginally. None should require cesarean section unless it is indicated for some other reason, such as fetal distress… (my emphasis)

All of these statements come from a 1972 paper, An objective approach to the diagnosis and management of abnormal labor, by Dr. Emanuel Friedman of the eponymous Friedman Curve.

Surprised? You shouldn’t be. The new ACOG report on preventing primary C-sections is not a rejection of the Friedman Curve, but rather revisits first principles of the Curve is and how Dr. Friedman thought it should be used.

Why do professional natural childbirth advocates have such difficulty relating the results of scientific papers honestly?

First, following the lead of the executives of the Midwives Alliance of North America (MANA), Judith Lothian attempted to hide the fact that their data showed that homebirth increases the risk of perinatal death by a whopping 450%.

Now she’s come up with an equally misleading “interpretation” of the new ACOG report, Safe Prevention of the Primary Cesarean Delivery.

According to Lothian, the new report “change[s] the game.”

Sharon Muza, Editor of the Lamaze blog Science and Sensibility introduces the piece with her own bizarre spin:

I hope that readers of Science & Sensibility (and anyone working in the field of maternal infant health) are sitting down. Be prepared to be blown away. ACOG and SMFM have just released a joint Obstetric Care Consensus statement that has the potential to turn maternity care in the USA on its end. I feel like this blog post title could be “ACOG and SMFM adopt Lamaze International’s Six Healthy Birth Practices.” (Okay, that may be a little overenthusiastic!) I could not be more pleased at the contents of this statement and cannot wait to see some of these new practice guidelines implemented. Judith Lothian, PhD, RN, LCCE, FACCE summarizes the statement and shares highlights of this stunning announcement.

There’s just one teensy, weensy little problem. The report says very little that is new.

I ought to know. Nearly 30 years ago, I trained with Dr. Friedman himself (creator of the eponymous Friedman Curve). There very little in the new report that is different from what Dr. Friedman said back then and the standards that he set for our department.

Let’s take a look at the actual report itself, and you will see what I mean.

The report starts with a caveat:

The information … should not be construed as dictating an exclusive course of treatment or procedure.

ACOG isn’t changing the game, because ACOG starts with the premise that the correct treatment plan for an individual patient is best determined by the doctor caring for her in consultation with the patient, not by reports.

Let’s look at the recommendations in the report:

1. “Prolonged latent phase (eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women) should not be an indication for cesarean delivery”

Prolonged latent phase has NEVER been an indication for C-section.

Most women with a prolonged latent phase ultimately will enter the active phase with expectant management. With few exceptions, the remainder either will cease contracting or, with amniotomy or oxytocin (or both), achieve the active phase.

That’s the same thing that Dr. Friedman said decades ago, and that’s the way that I was trained to practice.

2. …“[A]s long as fetal and maternal status are reassuring, cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor . Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied.”

I was taught the the active phase typically begins at an earlier dilatation, especially for women having their second or subsequent child. However, I was also taught that the diagnosis of active labor should be made not by assessing dilatation, but by assessing the strength and frequency of contractions. It was recognized 30 years ago, and even before, that some women will not reach active phase until later than other women and that NO decision for C-section can be made before active labor begins, regardless of dilatation.

3. “Further, cesarean delivery for active phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.”

This is the one thing that is different and its different because authors recapitulated what Dr. Friedman did and found that in current practice, vaginal delivery can be achieved by waiting longer.

Dr. Friedman never set out to create hard and fast rules about labor. Quite the opposite. Dr. Friedman did the research that led to the curve because he was angry that obstetricians would make decisions based on nebulous criteria (e.g. “that woman looks like a Cesarean to me”). Dr. Friedman set out to define parameters that generally led to successful vaginal delivery. Before the Friedman curve, obstetricians DID perform unnecessary C-sections in latent phase; they DID perform unnecessary C-sections for supposed “arrest” of labor or “arrest” of descent when they simply hadn’t waited long enough to see what would happen. Dr. Friedman NEVER said that anyone who deviated from the curve needed prompt C-section or couldn’t ultimately have a vaginal delivery. He just defined the way that most successful labors progressed. If a woman deviated from the curve substantially, her chances of vaginal delivery were substantially lowered, but not zero or even close to zero.

Over the succeeding generations, the way that most successful labors progress has changed. Therefore, the recommendations OUGHT to change to reflect that.

Have some obstetricians converted the original Friedman curve into hard and fast rules? Yes, some have, but that was NEVER Dr. Friedman’s intention.

4. “… [B]efore diagnosing arrest of labor in the second stage and if the maternal and fetal conditions permit, at least 2 hours of pushing in multiparous women and at least 3 hours of pushing in nulliparous women should be allowed . Longer durations may be appropriate on an individualized basis (eg, with the use of epidural analgesia or with fetal malposition) as long as progress is being documented.”

Nothing new there, either. I routinely cared for women who pushed 3 or 4 hours, and as long as they were making progress, there was no need for any intervention.

5. “Operative vaginal delivery in the second stage of labor by experienced and well trained physicians should be considered a safe, acceptable alternative to cesarean delivery.”

Nothing new there. Forceps and vacuum have always been used and are still being used. Both have a greater potential to harm the baby, though, and that is a critical factor in determining how to proceed.

6. There are new methods for detecting and categorizing fetal distress, but the basic principle remains the same. If there is evidence of fetal distress, a C-section is the appropriate response.

7. “Studies that compare induction of labor to its actual alternative, expectant management awaiting spontaneous labor, have found either no difference or a decreased risk of cesarean delivery among women who are induced. This appears to be true even for women with an unfavorable cervix.”

Contrary to the claims of natural childbirth advocates, induction does NOT increase the C-section rate.

8. “Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned…”

C-sections are safer than vaginal delivery for breech babies.

9. “To avoid potential birth trauma, the College recommends that cesarean delivery be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes …”

This is not news. The research on which these recommendations are based was performed when I was in training.

10. “Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic/cephalic-presenting twins or cephalic/noncephalic-presenting twins should be counseled to attempt vaginal delivery.”

That’s what I was taught and that’s how I practiced.

11. The recommendation for C-section in the presence of active genital herpes is unchanged.

12. ACOG offers a nod to NCB proponents by recommending doulas.

I don’t see much that is new in this paper. In fact, I see much that harks back to Dr. Friedman’s initial recommendations and to the way he taught his residents and ran his department.

The one substantive change is the emphasis on waiting longer in active phase for making a diagnosis of arrest. That is likely to have an measurable effect on the C-section rate. The rest is old news.

Of note, ACOG is strongly in favor of fetal monitoring and recommends no alterations at all in standard labor and delivery care. ACOG mentions no support for 5 of Lamaze’s “Six Healthy Birth Practices.” ACOG offers no support for the notion that childbirth is inherently safe, that epidurals should be avoided, that interventions are “bad,” or just about anything else that is the hallmark of contemporary natural childbirth advocacy.

The new report reinforces one of the chief virtues of obstetrics. As a scientific discipline, it is always open to new evidence, always looking to improve outcomes, and always willing to change practice to reflect the latest research. Unlike natural childbirth and homebirth advocacy organizations, obstetrics doesn’t depend on unchanging beliefs, does not value process over outcome, and makes no value judgments about the “best” way to give birth.

If Lamaze wants to pretend, contrary to all the evidence, that they have changed minds at ACOG, it isn’t going to hurt any mothers or babies. The only thing their pretending hurts is their own credibility.

Jessica Grose, writing in this week’s edition of The New Republic, reviews a new book about the history of the Lamaze movement. The piece, entitled Why We’re So Obsessed with ‘Natural’ Childbirth; A new history of Lamaze explains the origins of the mythology reviews the book Lamaze: An International History by medical historian Paula A. Michaels.

Grose’s review explores many of the themes I have written about over the past few years:

The typical birth narrative that you read online is a tale of harrowing disappointment. The mother had “spent months—if not years—dreaming” about her baby and her pain-medication-free birth… But, by dint of fate and unhappy circumstance, these moms are forced by medical professionals—sometimes even midwives or doulas—to have C-sections or epidurals. They are “treated disrespectfully or without compassion at that most vulnerable time.”

As Grose notes, however, reality is quite different from the dystopian fantasies of natural childbirth advocates.

Indeed, it’s my experience that even at big, impersonal city hospitals, the language and protocol surrounding maternity care is sensitive and catered to a woman’s desires.

Grose also notes the pernicious influence of the father of the natural childbirth philosophy, Grantly Dick-Read:

… Dick-Read promoted some insanely retrograde ideas—that birth pain is psychological; that women of the upper classes should be the ones having lots of babies—but other parts of his philosophy sound like they could have been cribbed from crunchy mommy blogs. Birth, Dick-Read wrote, is “an ecstasy of accomplishment that only women who have babies naturally [i.e., without anesthesia] appreciate.”

In other words, NCB was created by a misogynist eugenicist as a way of convincing women of the “better” classes to have more children. NCB is not feminist, no matter how much its contemporary avatars, midwives and doulas, try to pretend that it is.

The leading exponent of contemporary natural childbirth philosophy is Lamaze International, and the history of the Lamaze movement is also surprisingly retrograde. Before it was popularized by a French obstetrician, the philosophy of Lamaze natural childbirth was created with the encouragement of the Stalinist government to paper over the horrific quality of Russian maternity services. Simply put, the Russian government couldn’t afford obstetric anesthesia, so they set out to convince women that non-pharmacologic methods of pain relief were both equally effective (which they knew was a spectacular lie) and “better,” a value judgment they felt compelled to promote rather than acknowledge the dire state of Russian medical care.

What is most striking to me is that the Lamaze method, just like Dick-Read’s philosophy, was a deliberate attempt to manipulate women into accepting the future that men wanted for them, or in the case of the Russian government, the only future they could afford to provide.

And in a nearly seamless transition, the philosophy of Lamaze has been adopted by midwives, doulas and childbirth educators for the same cynical reason is was invented in the first place. What does contemporary midwifery have in common with Stalinist Russia? Neither can provide effective pain relief for childbirth, so both resorted to hoodwinking women into thinking that pain relief is unnecessary, and that unmedicated childbirth is an accomplishment.

In other words, contemporary midwifery and Stalinist Russia tried to make a virtue of necessity. They couldn’t (in the case of the Russians) and still can’t (in the case of contemporary midwifery) provide effective pain relief. The Russians couldn’t afford it and the midwives don’t know how to do it and can’t bill for it. In both cases, women are manipulated into making a virtue out of necessity, literally.

There is nothing inherently better, healthier or safer in any way about giving birth without pain relief and there never was. The Russians made it up because they couldn’t provide pain relief, and contemporary midwives promote it because they can’t provide pain relief, either.

Effective pain relief for severe pain is a basic human right. Those who make a virtue of denying women pain relief or shaming them for wanting it and enjoying it should be recognized for what they are: selfish and manipulative individuals who praise what they can profit from and demonize anything they can’t.

Sometimes I really fear for the future of midwifery.

It has gone from being a noble profession, saving countless lives and always struggling to save more, to a bunch of clowns drumming up business and always struggling to drum up more.

The amount of stupidity and wishful thinking spewed by these fools is epic. Case in point: a post from the hilariously misnamed blog Midwife Thinking entitled The Curse of Meconium Stained Liquor.

Now you or I might think that the curse is that when excrement is inhaled into a baby’s lungs, it can result in severe respiratory illness and death. But for this midwifery clown, the “curse” is the potential loss of business. But never fear; the all purpose tool wielded by people who profit from homebirth is always available: it’s just a variation of normal!

Letting me repeat that: rather than lose business, Rachel Reed, Midwife (Not) Thinking, simply announces that breathing in excrement is just another variation of normal.

The motivation of the midwife is apparent from the very first paragraph:

Dear unborn baby,

Please consider holding your poo in until after you are born. The big people on the outside get very stressed about your poo and will want to change the way you are birthed if they find any evidence that you have failed to keep it in. Your mother will be told that you are in danger, and will be strapped to a CTG monitor. This will: reduce her ability to help you through her pelvis by moving; prevent her from using water to relax; and increase your chance of being born by c-section. Your mother will also have her time limits for labour tightened up. This may lead to labour being induced or augmented which will put both of you at risk of further interventions. You will be expected to get through your mother’s vagina quickly and if you take too long you will be pulled out with medical instruments…

Imagine that, those evil obstetricians will compromise the birth process for no better reason than to maximize the birth outcome: a healthy, live baby.

But Rachel Reed knows better. She has her priorities in order: it’s more important to have an intervention free labor than for a baby to be able to breathe or even survive.

Rachel is all over this:

MAS is the major concern when meconium is floating about in the amniotic fluid. It is an extremely rare complication – around 2-5% of the 15-20% of babies with meconium stained liquor will develop MAS (Unsworth & Vause 2010). Of the 2-5% of the 15-20%, 3-5% of babies will die. OK enough %s of %s – basically it is very rare but can be fatal.

Apparently both math and logical thinking are hard for Rachel, so let me make it easy for her. One in 5 babies will have meconium in the amniotic fluid. Of those 1 in 20 will become seriously ill (respiratory distress, mechanical ventilation, prolonged NICU stay, risk of death). Of those, nearly 1 in 20 will die. In other words, 1% of babies will have end up with a life threatening illness. That’s not rare. And that illness will kill 5% of those ill babies. That’s not rare, either.

Or, put another way, once a mother learns there is meconium in her baby’s amniotic fluid, there is a 1 in 20 chance of serious complications. And if her baby does experience severe complications, there’s a very real chance that he or she will die. In the US, that means that there are 25,000-35,000 cases of meconium aspiration syndrome (MAS) per year, and approximately 1500 deaths.

I would have thought that anyone with more than two functioning brain cells would recognize that excrement in the lungs is a bad thing, but not Rachel Reed. As far as she’s concerned, it’s not a big deal because:

Meconium is a mixture of mostly water (70-80%) and a number of other interesting ingredients (amniotic fluid, intestinal epithelial cells, lanugo, etc.).

You know what else is 70% water? Battery acid, and I suspect that even Rachel Reed would recognize that battery acid is very harmful.

It’s the other stuff in meconium (intestinal cells, hair, etc.) that makes it dangerous when it ends up in the lungs. What does it do?

This lecture for medical students explains how meconium damages a baby’s lungs:

Decreased alveolar ventilation related to lung injury, ventilation-perfusion mismatch and air-trapping.
• Pneumothorax or pneumomediastinum in 15-30% of cases
• Persistent pulmonary hypertension (PPHN) in severe MAS(increased pulmonary vascular resistance with right-to-left shunting)
• Fetal acidemia
• Chemical pneumonitis
• Surfactant inactivation caused by meconium’s disruption of surface tension

So meconium makes it much for difficult for a baby to expand his lungs, to absorb oxygen and can even lead to a hole in the lung causing it to collapse.

But meconium is not merely an irritant, it is a symptom of another serious problem, lack of oxygen getting to the baby during labor. The baby responds to the severe stress of lack of oxygen with a response similar to “fight or flight”: it defecates.

So there are two reasons to deliver a baby expeditiously once it has defecated in the amniotic fluid. First, the meconium itself is harmful to the baby’s lungs and the more meconium is sucked into the lungs, the worse the harm is likely to be. Second, a baby who has passed meconium is often a baby in distress, and the longer that oxygen deprivation lasts, the more severe the consequences are likely to be. Hence the desire to use whatever interventions are necessary to deliver the baby expeditiously.

This is not rocket science, but apparently it is too hard for Rachel to understand. She offers her bizarre take on meconium aspiration:

So you would think that the sensible thing to do if a baby has passed meconium (for whatever reason) is to create conditions that are least likely to result in hypoxia and MAS. This is where I get confused because common practice is to do things that are known to cause hypoxia, for example:

Inducing labour if the waters have broken (with meconium present) and there are no contractions or if labour is ‘slow’ in an attempt to get the baby out of the uterus quickly.
Performing an ARM (breaking the waters) to see if there is meconium in the waters when there are concerns about the fetal heart rate.
Creating concern and stress in the mother which can reduce the blood flow to the placenta.
Directed pushing to speed up the birth.
Having extra people in the room (paediatricians), bright lights and medical resus equipment which may stress the mother and reduce oxytocin release.
Cutting the umbilical cord before the placenta has finished supporting the transition to breathing in order to hand the baby to the paediatrician.”

The stupid, it burns. It’s the equivalent of approaching the situation of a child drowning in a lake by claiming that the best response is to avoid interventions like rescuing the child and, instead, wait patiently for its body to float to shore. It’s the equivalent of claiming that the “stress” of a frantic rescue with bright lights (oh, the horror!) is more damaging than the lack of oxygen in the child’s lungs.

Rachel’s entire piece is a monument to the stupidity and venality of homebirth midwives, but some parts are more idiotic than others. My personal favorite:

Avoid an ARM during labour so that any meconium present is not known about until the membranes rupture spontaneously …

That statement is a perfect illustration for a new motto for homebirth midwives:

Ignorance is power!

If that’s the case then midwife Rachel Reed is very powerful indeed.