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Combating coercion in maternity care: does modern obstetrics deserve a wooden club as well as the wo

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Routine twilight sleep/ GA for delivery. Evidence-based obstetrics. successes ... Anaesthesia & Paeds at all deliveries. Truly experienced practitioner ... – PowerPoint PPT presentation

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Title: Combating coercion in maternity care: does modern obstetrics deserve a wooden club as well as the wo


1
Combating coercion in maternity care does modern
obstetrics deserve a wooden club as well as the
wooden spoon? Canadian Association of
Midwives 7th Annual Conference Vancouver B.C,
Nov 2nd, 2007
  • Andrew Kotaska MD, FRCSC
  • Yellowknife, NWT

2
Archie Cochrane 1909-1988 He was always ready
to challenge medical (and non-medical)
authorities to provide better evidence about
the basis for their diagnoses and
treatments. - Iain Chalmers 2006
3
Evidence-based obstetrics successes - stopping
  • Routine pre-delivery enemas
  • Routine pre-delivery shave preps
  • Routine episiotomy
  • Elective forceps delivery
  • Routine post partum chest x-ray
  • No partner/support person _at_ delivery
  • Routine delivery in lithotomy position
  • Routine twilight sleep/ GA for delivery

4
Evidence-based obstetrics successes - starting
  • Corticosteroids for premature fetal lung
    maturation
  • Magnesium sulfate for pre-eclampsia/eclampsia
  • Oxytocics for post-partum hemorrhage
  • Prophylactic antibiotics for cesarean section
  • VBAC instead of routine repeat cesarean section
  • Prostaglandins for cervical ripening
  • Antibiotics for PPROM
  • Vacuum vs. forceps for operative vaginal delivery

5
Evidence-based obstetrics failures disproven,
but still routine
  • Continuous fetal monitoring in low-risk women
  • Lack of doula support
  • Placental function tests
  • Induction/cesarean section for macrosomia

6
Culture of Risk
  • 1/1 - Certain
  • ½ - Likely
  • 1/10 - Common
  • 1/100 - Uncommon
  • 1/1,000 - Rare
  • 1/10,000 - Very rare
  • 1/100,000 - Negligible
  • 1/1 million - Theoretical

7
"One in a thousand club"
  • Stillbirth risk from 41 to 42 weeks gestation
  • Risk of perinatal death with selective vaginal
    breech delivery using routine U/S and CEFM
  • Risk of newborn GBS sepsis if mother is GBS ve
    without risk factors and does not receive
    antibiotics (risk of neonatal death 1/20,000)
  • Composite risk of perinatal death or hypoxic
    ischemic encephalopathy with VBAC

8
One in a thousand - comparisons
  • Yearly risk of all cause mortality in a 40
    year-old non-smoking male in Canada
  • Stillbirth risk simply being pregnant for ten
    days near term
  • Likelihood of an infant with trisomy 21 in a 31
    year old woman
  • One fifth the risk of miscarriage associated with
    genetic amniocentesis (1/200)

9
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10
Modern obsterical interventions
  • Skilled maternity care provider
  • Basic prenatal care
  • The occasional BP and urine dip
  • Aseptic technique
  • Ebolics for PPH
  • Antibiotics for infection
  • Intermittent auscultation to monitor the fetus
  • Lower segment cesarean section for CPD.

11
Coercion The act of compelling by force of
authority
12
Risk reduction imperative at what cost?
  • Unmeasured side effects
  • Immediate (amniotic fluid embolus)
  • Delayed (placenta accreta, uterine rupture)
  • Under-appreciation of harder to quantify benefits
    of non-intervention
  • Empowerment
  • Neonatal immune activation
  • Ignoring maternal values and autonomy

13
Maternal choice or coercion?
  • Routine induction at 41 weeks
  • Routine antibiotics in GBS ve women without risk
    factors
  • Advising against homebirth
  • Not offering VBAC
  • Not offering vaginal breech delivery

14
Values and Risk
  • A Jehovahs Witness refuses blood transfusion in
    face of an imminently fatal hemorrhage
  • Potential risk 1/1
  • Medical approach explain risks obtain
    consent try our best to save her life without
    using blood
  • A mother wishes to labour with a breech or prior
    C/S
  • Potential risk 1/1000
  • Medical approach threaten to abandon her by
    not offering to care for her in hospital
    unless she consents to a cesarean section

15
Not offering not allowing threatening
abandonment coercion
16
Not offering
  • Condescending
  • Not woman-centered
  • Forces most women to accept intervention
    (cesarean section)
  • Causes displacement and distress for those
    motivated enough to find care elsewhere
  • Higher risk to those who birth unattended and/or
    _at_ home with breech or VBAC

17
Early TBT Results (Hannah M, et al. Lancet 2000
3561375-83)
1/20 chance of having a dead or damaged baby
with TOL
18
TBT Problems
  • Internal validity limitations
  • Quality of care issues
  • External validity difficulties
  • Lack of generalizability to all breeches
  • Lack of generalizability to all maternity units
  • Encouraged practitioners to exceed their baseline
    level of comfort bias of license
  • Surrogate short-term outcome

19
Quality of Care? Standards not required by TBT
protocol
  • Universal ultrasound
  • Breech type? IUGR? Flexed head? EFWt?
  • Continuous fetal monitoring in labour (33)
  • Immediate availability of rapid C/S
  • Anaesthesia Paeds at all deliveries
  • Truly experienced practitioner
  • Meticulous attention to labour progress
  • Allowed 0.5 cm/hr 1st stage 3.5 hr 2nd stage

20
External validity??
  • Hospital A
  • Swiss tertiary care unit
  • Pre early labour U/S
  • CEFM
  • 24/7 Paeds Anaesth
  • Consultant with 100 VBB available to come in
  • Hospital B
  • Romanian community hospital
  • Clinical assessment only
  • Intermittent auscultation
  • Call-in Paeds Anaesth
  • Junior staff or Senior Resident for delivery

21
TBT 2-year infant F/U results (Whyte H. AJOG
2004191864-71)
97 chance of having a normal 2 year-old,
either way p 0.02
22
Short- vs. long-term results poor surrogate
marker
  • How meaningful was serious neonatal morbidity
    when
  • 17/18 infants with serious neonatal morbidity
    were neurologically normal at 2 years of age?

23
Conclusion Even with the TBTs limitations, in
low PNM countries, planned TOL vs. C/S
  • No difference in perinatal mortality
  • Greater risk of short-term infant morbidity
  • Lower incidence of childhood medical problems,
    not otherwise specified
  • Same chance of a normal 2 year old (97)

24
PREMODA Study PREsentation et MOde
DAccouchement (Goffinet F,et al. AJOG
20061941002-11)
  • Sentinel study for the estimation of contemporary
    risk of cautious breech birth
  • Sentinel study for the utility of meticulous
    prospective audit (cohort study) for researching
    complex phenomena

25
PREMODA Study (Goffinet F,et al. AJOG
20061941002-11)
  • Non-randomized, prospective study
  • 174 French and Belgian maternity units
  • 8105 women with singleton breech fetus at term
  • All eligible women with breeches included
  • Audit of current practice no modifications
  • Meticulous, comprehensive data collection
  • Intent to treat analysis
  • Primary outcome similar to TBT

26
PREMODA Study Results (Goffinet F,et al. AJOG
20061941002-11)
  • Planned C/S for 5579 (69)
  • Planned vaginal birth for 2525 (31)
  • Vaginal birth in 1796
  • 71 of women planning vaginal birth
  • 22.5 of all women with a breech (vs. 33
    pre-1998)
  • 0.6 of ? planning C/S had vaginal birth (vs. 10
    in TBT)
  • Vaginal birth rate variable for different
    centres
  • Allowed for patient choice (motivated or not?)
  • Allowed for varying practitioner expertise
    comfort

27
PREMODA Study Results (Goffinet F,et al. AJOG
20061941002-11)
  • PREMODA TBT
  • Pelvimetry 82 10
  • CEFM 100 33
  • Active 2nd stage gt 60min 0.2 5.0

28
PREMODA Study Results (Goffinet F,et al. AJOG
20061941002-11)
  • VB C/S
  • Neonatal Apgar5 lt 4 0.16 0.02
  • Perinatal mortality 0.08 0.15
  • PNM serious NN
  • morbidity 1.6 1.45
  • (TBT 5.7 0.4 )
  • N 8105 only significantly different outcome

29
With a cautious approach
  • Universal pre early-labour ultrasound
  • Breech type? IUGR? Flexed head? EFWt?
  • Continuous monitoring in labour
  • Immediate availability of rapid C/S
  • Anaesthesia Paeds at all deliveries
  • Truly experienced practitioner
  • Meticulous attention to labour progress
  • Not required by TBT protocol

30
ACOG RCOG 2006 Breech Guidelines Informed
Consent?
  • No longer sufficient to simply inform women with
    a breech at term that they should undergo a
    planned cesarean section.
  • Strong ethical and legal obligation to give a
    more complete view of the evidence

31
Informed Choice.
  • If a unit is unable to offer the choice of a
    planned vaginal breech birth, women who wish to
    choose this option should be referred to a unit
    where this option is available. (RCOG
    Breech Guidelines, 2006)
  • Larger and experienced centres should
    re-establish systems to care for women desiring
    vaginal breech birth and offer regionalized
    breech service to women from other centres unable
    or unwilling to do so

32
Informed Choice
  • The new ACOG and RCOG guidelines will help women
    and their advocates allay the fears of
    obstetricians and hospitals reluctant to allow
    opportunities for planned vaginal breech birth.
    The principles of autonomy and informed consent
    will make it increasingly difficult for them not
    to do so.
  • Supporting womens autonomy by reestablishing
    vaginal breech birth as a mainstream choice will
    be a sign that the obstetrical community does not
    deserve a wooden club

33
  • Evidence-based medicine has been expropriated
    from its original intention. Useful concepts such
    as relative risk (RR), absolute risk reduction
    (ARR), and number needed to treat or harm (NNT/H)
    have become risk-focused jargon that eclipse the
    normalcy of birth, replacing optimism and joy
    with fear and control. These concepts emphasize
    small, narrowly quantifiable short-term risks and
    neglect harder to quantify long-term risks and
    psychosocial benefits.
  • Even for motivated women and clinicians, it is
    hard to combat the coercion of science-based
    obstetrics we need some conceptual lynchpins to
    help put EBM back in its place. Perhaps for
    phenomena such as VBAC and breech birth,
    reasonable risk (RR) should replace relative
    risk, since for many the empowerment to risk
    ratio (ERR) will justify a trial of labour,
    especially when the number needed to transform
    (NNT) with a normal birth is one.

34
Illusion of no risk, or a balanced faith in
physiology
  • Evidence-based medical terms
  • RR Relative Risk
  • ARR Absolute Risk Reduction
  • NNT/NNH Number Needed to Treat/Harm
  • Physiological based birth terms
  • RR Reasonable Risk
  • ERR Empowerment to Risk Ratio
  • NNT Number Needed to Transform ( 1 for most
    normal births)

35
  • Bibliography
  • Enkin M. Beyond the evidence the complexity of
    maternity care. Birth 2006 33(4)265-259
  • Kotaska A. Combatting Coercion Breech birth,
    parturient choice, and the evolutioin of
    evidence-based maternity care. Birth 2007
    34(2)176-180
  • Klein MC. Enkin MW. Kotaska A. Shields SG. The
    Patient-Centered (R)evolution. Birth 2007 34(3)
    264-266

36
Vaginal Breech Birth 1953 A Skill in Evolution
  • The more manipulation is performed and the
    earlier this manipulation is instituted, the
    greater is the fetal mortality and morbidity, to
    say nothing of maternal injuries.
  • As a well established principle based upon
    numerous analyses from clinics all over the
    world, the dependence of fetal mortality upon
    manipulation is uniformly accepted.
  • The efforts of the obstetrician should be
    directed toward cutting down the time and extent
    of manipulation and to avoid the necessity of its
    employment.
  • Plentl A, Stone R. Obstet Gynecol Survey
    19538(3)313

37
Spontaneous Vaginal Breech Birth
  • The art of waiting is a difficult one, and not
    many obstetricians have either the courage or the
    patience to sit idly by while the breech delivers
    spontaneously this becomes even more difficult
    if the impatient obstetrician has a century of
    tradition as well as the words and writings of
    contemporary teachers behind him.
  • Plentl A, Stone R. Obstet Gynecol Survey
    19538(3)313

38
Spontaneous Vaginal Breech Birth
  • The largest reduction in vaginal breech perinatal
    mortality (PNM) ever published was by Bracht in
    1938
  • Baseline breech PNM 3.2
  • Bracht method PNM 0 (206 births)
  • Bracht E. Zur Behandlung der Steißlage
    (Management of the Breech). Zentralblatt für
    Gynaekologie 1938621735-6

39
Netherlands Database Study (Rietberg C, et al.
BJOG 2005)
  • Retrospective cohort of 35,000 singleton Dutch
    term non-anomalous breech births
  • 33 months before and 25 months after TBT
  • Vaginal delivery rate went from 50 ? 20 within
    4 months of publication of TBT results
  • (C/S)
  • PNM 0.35 ? 0.18 NNT 590 (175)
  • AG5 lt 7 2.4 ? 1.1 NNT 77 (23)
  • NN trauma 0.29 ? 0.08 NNT 500 (150)

40
Netherlands Database Study (Rietberg C, et al.
BJOG 2005)
  • Currently, with 20 VBB rate
  • PNM now 1.8/1000 (similar to low-risk cephalic
    births)
  • AG5 lt 7 now 1.1
  • NN trauma 0.08
  • Remaining 20 of vaginal births constitutes a
    selection of the breech population better suited
    for vaginal delivery (i.e. multips faster
    labours smaller babies, frank breech)
  • Remaining 20 of vaginal births delivered in
    centres with more interest (and expertise?) in
    VBB
  • 20 vaginal birth rate similar to PREMODA (22.5)

41
Netherlands Database Study (Rietberg C, et al.
BJOG 2005)
  • Increasing the breech C/S rate above 80 is
    unlikely to lower the PNM further
  • Lower perinatal risk must be balanced against
    increased maternal morbidity and mortality due
    to C/S and an increased maternal and fetal risk
    in subsequent pregnancies, especially uterine
    rupture and placental invasion of the uterine
    scar.
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