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Noyac

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my niece is in a graduate course as a counselor in which a midwife was brought in to "educate" the class on midwifery. My niece, being an intelligent individual, saw straight through the midwifes bullsh*t. Now she is asking me for some data to present to her class. This midwife repeatedly bashed hospitals and doctors. She also blamed epidurals for failure to breastfeed and substance abuse in later life. Wtf, substance abuse in later life? Now that's even new to me.

I'm going to arm my niece with some hard facts but I decided that I can help her more by enlisting those of you that might know some sites or online accurate information that I am not aware of.

Thanks

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Well, first I think you need to get a hold of the midwife's "evidence," if only for pure comic relief. It's probably from a really good blog that we can all enjoy.

Expertise is no longer valued in our society, but nowhere is it more evident than in parenting. There is an enormous market for charlatans and snake oil salesmen in raising a child.
 
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Expertise is no longer valued in our society, but nowhere is it more evident than in parenting. There is an enormous market for charlatans and snake oil salesmen in raising a child.
See that is why I posted this. I knew I would get some gems from you people.
 
Midwives as well as many other biased practitioners can do "studies" that demonstrate whatever outcome they are looking for. I did a quick google search and read an article that was severely biased against the use of epidurals. Reading the logic in it was severely flawed. One example was the statement that epidurals decrease adrenaline release which is needed to give an extra energy boost to get the baby out. While I agree that adrenaline (epinephrine) release is likely less in epidurals (because epi is released in response to pain), what that has to do with getting the baby out is irrelevant.

Here is a link to the study that the midwife association put out with some statistics.

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

If you look, it is very difficult to find published mortality data for home births and midwife deliveries. Why do you suppose that is? If they truly believe they are equivalent providers they should publish outcomes to prove it. The associated study is proclaimed to prove equivalency, but the death rates are higher. Here is a physicians study and assessment

http://www.mdedge.com/familypractic...-finds-increased-infant-mortality-home-births

The midwives seem to have higher mortality despite having a lower risk population. Also, any home birth gone wrong gets dumped on the hospital. If their are complications at home, but they get mom to the hospital before the birth (but likely after the damage is done), the death counts against the mortality count for the hospital.

"When we calculate the excess total neonatal deaths associated with home birth, we arrive at 9/10,000," he said during an interview. "If the trend of increasing home birth holds over the next few years, in 2016 we could have 32 excess neonatal deaths per year – a whole school class of children."

"It’s possible these risks are even higher," he added, because any babies born in the hospital after an emergency transfer from home are counted as hospital births.

I'm not sure if any of this helps. The midwives think they are better. Any OB or anesthesiologist will tell you that they have seen routine deliveries go wrong unexpectedly and without immediate attention the outcomes would not have been good. Mid levels are only equivalent when there aren't any complications, but they run immediately to the experts when things get real.
 
You should give the midwife a call and have a chat with her.
 
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To be honest, I don't think facts and figures will help convince your niece's classmates that doctors provide better care than midwives. It'll come off as defensive and potentially attacking midwives and nurses (the true patient advocates! /s)

You need to appeal to emotion. Maybe an anecdote of how an epidural allowed a woman to give birth naturally or some other emotionally BS story. Then shout MAGA! at the end and you are sure to get some standing ovations!
 
Midwives as well as many other biased practitioners can do "studies" that demonstrate whatever outcome they are looking for. I did a quick google search and read an article that was severely biased against the use of epidurals. Reading the logic in it was severely flawed. One example was the statement that epidurals decrease adrenaline release which is needed to give an extra energy boost to get the baby out. While I agree that adrenaline (epinephrine) release is likely less in epidurals (because epi is released in response to pain), what that has to do with getting the baby out is irrelevant.
Since adrenaline (epinephrine) is a uterine relaxant, epidurals must be helpful for pushing out the baby, even according to their "science". :p
 
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Anesth Analg. 1998 Oct;87(4):864-9.
The tocolytic effect of catecholamines in the gravid rat uterus.
Segal S1, Csavoy AN, Datta S.
Author information

Abstract
Maternal catecholamines increase dramatically in labor because of pain and emotional stress. Because the uterus is richly endowed with both alpha- and beta-adrenergic receptors, catecholamines could alter uterine activity. We assessed the effect of clinically encountered concentrations of these catecholamines on uterine activity and modeled the effect of the abrupt reduction in circulating epinephrine that occurs during effective labor analgesia. Term pregnant rat uteri were excised, and cross-sectional rings were mounted for isometric force recording. Log concentration-response curves for epinephrine, norepinephrine, and their combination on uterine activity were constructed from 10(-12) to 10(-6) M. Catecholamine responses were repeated in the presence of phentolamine, an alpha-adrenergic blocker or propranolol, a beta-adrenergic blocker. The abilities of oxytocin and of washout of catecholamines to reverse catecholamine-induced changes in uterine activity were also assessed. Epinephrine caused dose-dependent reductions in uterine activity, blocked by propranolol. Epinephrine concentrations in the clinical range(10(-9) to 10(-8) M; 100-1000 pg/mL) decreased uterine activity to 49.6% +/- 6.6% (mean +/- SE) of control. Norepinephrine caused a dose-dependent increase in uterine activity, which was blocked by phentolamine. In the clinical range (10(-8) M), uterine activity was 139.2% +/- 13.40% of control. The combination of both catecholamines, however, was nearly as tocolytic as epinephrine alone. Oxytocin antagonized catecholamine-induced tocolysis, and washout of epinephrine or both catecholamines increased uterine activity. We conclude that mixed catecholamines are significantly tocolytic at concentrations encountered in laboring women. In this in vitro model, reduction in epinephrine concentration, comparable to that which occurs during effective analgesia, significantly increases uterine activity.

IMPLICATIONS:
Maternal catecholamines increase in labor, but epinephrine decreases dramatically after regional analgesia. In this study, we found that norepinephrine and epinephrine together decrease uterine contractile activity and that decreased epinephrine causes significantly increased uterine activity.
 
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Since adrenaline (epinephrine) is a uterine relaxant, epidurals must be helpful for pushing out the baby, even according to their "science". :p

The effect of maternal catecholamines on the caliber of gravid uterine microvessels. - PubMed - NCBI

CONCLUSIONS:
The results demonstrate that EPI, in concentrations found in the plasma of laboring women, vasodilates uterine resistance vessels and attenuates NE-induced vasoconstriction. This observation may have implications for changes in uterine blood flow that may accompany the onset of labor analgesia in human parturients, as effective analgesia is accompanied by an acute decrease in circulating EPI levels.
 
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To be honest, I don't think facts and figures will help convince your niece's classmates that doctors provide better care than midwives. It'll come off as defensive and potentially attacking midwives and nurses (the true patient advocates! /s)

You need to appeal to emotion. Maybe an anecdote of how an epidural allowed a woman to give birth naturally or some other emotionally BS story. Then shout MAGA! at the end and you are sure to get some standing ovations!
She isn't trying to defend anyone. The class is having a discussion about it. She wanted to be prepared if she calls this charlatan out for what she is.
 
There's a few families with dead kids I've seen over the years due to poor midwife care that I wish would start a nonprofit with commercials educating the public about what happened to them. Ignorance kills.
 
She isn't trying to defend anyone. The class is having a discussion about it. She wanted to be prepared if she calls this charlatan out for what she is.

Why can't she do her own research? She's in a graduate class for heaven's sake!

SDN isn't for homework advice.

:prof:
 
my niece is in a graduate course as a counselor in which a midwife was brought in to "educate" the class on midwifery. My niece, being an intelligent individual, saw straight through the midwifes bullsh*t. Now she is asking me for some data to present to her class. This midwife repeatedly bashed hospitals and doctors. She also blamed epidurals for failure to breastfeed and substance abuse in later life. Wtf, substance abuse in later life? Now that's even new to me.

I'm going to arm my niece with some hard facts but I decided that I can help her more by enlisting those of you that might know some sites or online accurate information that I am not aware of.

Thanks

It's good for women to suffer the pain of a natural birth, says senior midwife

A senior midwife in the UK believes we can eliminate epidurals with yoga, massage and hypnosis.

Also, here is an article from live science showing epidurals increase the risk in a recent study in a major obstetrics and gynecology journal:

Epidural May Prolong Labor More Than Thought



Of note: "In the new study, in women who were having a baby for the first time, the second stage of labor took 336 minutes with epidural, and 197 minutes without epidural — a difference of 2 hours and 19 minutes."

This argument can easily be used to state that epidurals are possibly increasing C section rates.

Also, I think the worry about addiction is the exposure of fentanyl placed in the epidural during the hours of labor. I can't find any studies confirming or denying this assertion.

So, the midwife can cite the above article in livescience to prove their assertion and add the discussion about opioid usage crossing the placental barrier with the usage of epidurals that really hasn't been studied much in the literature.

Can you counter these claims?
 
Midwives as well as many other biased practitioners can do "studies" that demonstrate whatever outcome they are looking for. I did a quick google search and read an article that was severely biased against the use of epidurals. Reading the logic in it was severely flawed. One example was the statement that epidurals decrease adrenaline release which is needed to give an extra energy boost to get the baby out. While I agree that adrenaline (epinephrine) release is likely less in epidurals (because epi is released in response to pain), what that has to do with getting the baby out is irrelevant.

Here is a link to the study that the midwife association put out with some statistics.

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

If you look, it is very difficult to find published mortality data for home births and midwife deliveries. Why do you suppose that is? If they truly believe they are equivalent providers they should publish outcomes to prove it. The associated study is proclaimed to prove equivalency, but the death rates are higher. Here is a physicians study and assessment

http://www.mdedge.com/familypractic...-finds-increased-infant-mortality-home-births

The midwives seem to have higher mortality despite having a lower risk population. Also, any home birth gone wrong gets dumped on the hospital. If their are complications at home, but they get mom to the hospital before the birth (but likely after the damage is done), the death counts against the mortality count for the hospital.

"When we calculate the excess total neonatal deaths associated with home birth, we arrive at 9/10,000," he said during an interview. "If the trend of increasing home birth holds over the next few years, in 2016 we could have 32 excess neonatal deaths per year – a whole school class of children."

"It’s possible these risks are even higher," he added, because any babies born in the hospital after an emergency transfer from home are counted as hospital births.

I'm not sure if any of this helps. The midwives think they are better. Any OB or anesthesiologist will tell you that they have seen routine deliveries go wrong unexpectedly and without immediate attention the outcomes would not have been good. Mid levels are only equivalent when there aren't any complications, but they run immediately to the experts when things get real.

In defense of midwives, big pharma and most medical journals do the same thing.
 
my niece is in a graduate course as a counselor in which a midwife was brought in to "educate" the class on midwifery. My niece, being an intelligent individual, saw straight through the midwifes bullsh*t. Now she is asking me for some data to present to her class. This midwife repeatedly bashed hospitals and doctors. She also blamed epidurals for failure to breastfeed and substance abuse in later life. Wtf, substance abuse in later life? Now that's even new to me.

I'm going to arm my niece with some hard facts but I decided that I can help her more by enlisting those of you that might know some sites or online accurate information that I am not aware of.

Thanks

Here is more from Medscape:


Epidural Prolongs Second Stage of Labor by More Than 2 Hours
Laurie Barclay, MD

February 05, 2014


Duration of second-stage labor was more than 2 hours longer when epidural anesthesia was given during labor for both nulliparous and multiparous women, according to a retrospective cohort study reported in the March issue of Obstetrics & Gynecology. The duration of second-stage labor observed in the study is twice as long as typically estimated for epidurals in clinical guidelines.

"Minimizing primary cesarean delivery is a priority," write Yvonne W. Cheng, MD, PhD, from the Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, and colleagues. "Two common indications of cesarean during labor are active phase arrest and arrest of descent."

The study goal was to compare the duration of second stage of labor with and without epidural anesthetic given during labor, using an historical sample of 42,268 women who delivered vaginally with normal neonatal outcomes. The investigators compared median durations and 95th percentiles of second stage of labor for women given or not given epidurals, with stratification by parity. The Kruskal-Wallis test and Kaplan-Meier survival analysis allowed statistical comparisons.

Epidural Associated With Longer Second Stage


For nulliparous women, the 95th percentile duration of second-stage labor was 197 minutes without epidural and 336 minutes with epidural, a significant difference of 2 hours and 19 minutes (P < .001). The difference for multiparous women was 2 hours and 54 minutes (81 minutes without epidural and 255 minutes with epidural; P < .001).

The duration of labor became progressively longer in more recent years for unclear reasons. However, the study authors suggested that this might be attributed to changing obstetric characteristics, such as higher proportion of induced or augmented labor, less frequent forceps and high station operative deliveries, and increased prevalence of obesity and gestational weight gain.

"Although recommendations for intervention during the second stage of labor have been made based on a 1-hour difference in the setting of epidural use, it appears that the 95th percentile duration is actually more than 2 hours longer with epidural during labor for both nulliparous and multiparous women," the study authors write.

Prolonged Labor May Need to Be Redefined

They note that according to use of current definitions of prolonged labor, nearly one third of nulliparous women receiving an epidural would be labeled as having abnormal labor, which would likely result in potentially unnecessary interventions.

"Although the majority of obstetrician–gynecologists subscribe to the clinical guidelines of giving 1 additional hour to account for epidural use, it appears that the differences from epidural at the 95th percentiles may be approximately double," the study authors write. "Thus, the current definition of prolonged second stage of labor may be too stringent."

Limitations of this study include missing data or inaccurate information, potentially creating bias; long study period; and analysis of data from a single academic institution, which could potentially limit generalizability.

"Although labor norms should not be established based on this study alone, our findings, along with those of others, suggest that current definitions of prolonged second stage of labor in the setting of an otherwise reassuring fetal status may be insufficient," the study authors conclude. "There exists a need to establish proper second stage of labor norms to reflect modern obstetrics."


The study authors have disclosed no relevant financial relationships.


Obstet Gynecol 2014;123:527-535.


Notice all the midwives talking in the comment sections. This is what they will argue.

Not that easy to rebut as previously thought.
 
I looked over that article, but I don't understand the endpoint. The endpoint is the 95th percentile duration. Are they saying that the 95th percentile is the length of labor where 94% are shorter. That's how I'm interpreting it. If that is the case then there is some logical sense to be made that epidural labors are longer because most women laboring that long without an epidural are going to either A) give up and ask for one or B) demand a c/s. I only skimmed the article, but it makes logical sense that a woman can tolerate a longer labor with an epidural in place vs without. The cause and effect relationship here is unclear to me. I don't think there is any way they made women with a prolonged labor remain in the non-epidural group until delivery just to make the study valid. If women with long periods of labor could then switch into the epidural group, regardless of whether or not they added that data point to the epidural group, it skews the results. I personally don't care either way. I just want my epidural pts to decide during daytime hours and not call me in the middle of the night.
 
But the midwife was not quoting studies talking about the prolongation of labor by an epidural. That's a legitimate debate that we continue to have in our profession. The midwife was talking about epidurals causing the failure to breastfeed and drug addiction in the child later in life. This is more concerning to me because these vultures are preying on legitimate anxieties that new mothers have. Midwives and anyone who promotes these natural birth ideas have found a way to make money on people's fear. Look at the shelves of books and ridiculous blogs dedicated to giving parents bad information...all in the name of some huckster making a few bucks. It's charlatans like these midwives that give rise to dangerous ideas like the anti-vaccine movement.
 
But the midwife was not quoting studies talking about the prolongation of labor by an epidural. That's a legitimate debate that we continue to have in our profession. The midwife was talking about epidurals causing the failure to breastfeed and drug addiction in the child later in life. This is more concerning to me because these vultures are preying on legitimate anxieties that new mothers have. Midwives and anyone who promotes these natural birth ideas have found a way to make money on people's fear. Look at the shelves of books and ridiculous blogs dedicated to giving parents bad information...all in the name of some huckster making a few bucks. It's charlatans like these midwives that give rise to dangerous ideas like the anti-vaccine movement.

Well they are going to argue its the fentanyl you put in the epidural that is causing addiction. We know opioids can cross the placenta and we know opioids from the epidural space goes into the bloodstream of the mother. So there is a logical inference that the fetus is exposed to opioids.

With the concerns about narcotics these days, it wouldn't be that hard to try to argue that its bad for the fetus to exposed to opioids for hours before even being born.

Dunno if there are any studies on the subject that I can find. Without studies to refute this, they will continue to argue that point.

I see multiple articles discussing opioid exposure for addicted mothers: Prenatal Exposures and Short and Long Term Developmental Outcomes: Prescription Opioids in Pregnancy and Birth Outcomes: A Review of the Literature

So they will just extrapolate these ideas to even hours of exposure with an epidural.
 
I looked over that article, but I don't understand the endpoint. The endpoint is the 95th percentile duration. Are they saying that the 95th percentile is the length of labor where 94% are shorter. That's how I'm interpreting it. If that is the case then there is some logical sense to be made that epidural labors are longer because most women laboring that long without an epidural are going to either A) give up and ask for one or B) demand a c/s. I only skimmed the article, but it makes logical sense that a woman can tolerate a longer labor with an epidural in place vs without. The cause and effect relationship here is unclear to me. I don't think there is any way they made women with a prolonged labor remain in the non-epidural group until delivery just to make the study valid. If women with long periods of labor could then switch into the epidural group, regardless of whether or not they added that data point to the epidural group, it skews the results. I personally don't care either way. I just want my epidural pts to decide during daytime hours and not call me in the middle of the night.

It matters if it is increasing the C section rates due to prolonged labor and "failure to progress". This is very common in OB.
 
But the midwife was not quoting studies talking about the prolongation of labor by an epidural. That's a legitimate debate that we continue to have in our profession. The midwife was talking about epidurals causing the failure to breastfeed and drug addiction in the child later in life. This is more concerning to me because these vultures are preying on legitimate anxieties that new mothers have. Midwives and anyone who promotes these natural birth ideas have found a way to make money on people's fear. Look at the shelves of books and ridiculous blogs dedicated to giving parents bad information...all in the name of some huckster making a few bucks. It's charlatans like these midwives that give rise to dangerous ideas like the anti-vaccine movement.

I agree. I guess I deviated a bit discussing perhaps the only questionably valid argument against epidurals. I have no idea where they got the idea that epidurals would cause failure to breastfeed. The idea that it would cause drug addiction is ..... well I have no idea where it came from but it is a new level of idiocy. Perhaps they are taking the "blame anesthesia" approach to a new level.
 
It matters if it is increasing the C section rates due to prolonged labor and "failure to progress". This is very common in OB.

I can see the concern with increased c/s rates. My point is that the cause/effect relationship is unclear. Are epidurals actually prolonging labor or do women with prolonged labor end up with epidurals more commonly? It seems reasonable that a woman who labors for 2 hrs would be far more likely to tolerate labor without an epidural than those who labor for 18 hrs.
 
I agree. I guess I deviated a bit discussing perhaps the only questionably valid argument against epidurals. I have no idea where they got the idea that epidurals would cause failure to breastfeed. The idea that it would cause drug addiction is ..... well I have no idea where it came from but it is a new level of idiocy. Perhaps they are taking the "blame anesthesia" approach to a new level.

There are other arguments that are powerful if you want to think women can "handle the pain" of birth through "yoga, hypnosis, etc". These include:

A) Invasive method compared to alternative. Potential for nerve injury/hematoma. Articles in popular media include: Irrum Jetha PARALYSED after saying ‘Yes’ to epidural to ease agony of childbirth | Daily Mail Online

B) Exposure to potential toxicity from local anesthesia and potential for intrathecal spread that can cause patient to stop breathing. If not closely monitored, inadvertent "wet taps" can lead to a higher spinal that can be very dangerous to a patient.

C) Exposure to opioids in the epidural that have been shown to cross the placenta barrier. I have seen no studies that confirm/deny the level of exposure to the fetus from this method.

D) Clearly failure to progress can be a big problem increasing C section rates dramatically with significant morbidity/mortality associated with unneeded surgery compared to avoiding the epidural. This is likely particularly relevant during early stages whereby there is little dilation of the cervix.

E) Potential for infection in the hospital environment with exposure to the spine. The OB room isn't often the most sterile environment considering the patient traffic in these areas.


Im sure there are others I can think of pretty quickly if needed.
 
I can see the concern with increased c/s rates. My point is that the cause/effect relationship is unclear. Are epidurals actually prolonging labor or do women with prolonged labor end up with epidurals more commonly? It seems reasonable that a woman who labors for 2 hrs would be far more likely to tolerate labor without an epidural than those who labor for 18 hrs.

Often epidurals are placed well before true labor has even started. Patients will often demand them well before 4cm of dilation for the cervix and true labor being noted.

Very rarely are they going through a longer labor process and then getting an epidural as a result in real life. If they are that progressed, anesthesiologists usually do a CSE to get the medication in far faster due to the later stage of labor.
 
Often epidurals are placed well before true labor has even started. Patients will often demand them well before 4cm of dilation for the cervix and true labor being noted.
Well yes but thanks to ACOG we are expected to place the epidural as soon as it is requested.
 
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Often epidurals are placed well before true labor has even started. Patients will often demand them well before 4cm of dilation for the cervix and true labor being noted.

Very rarely are they going through a longer labor process and then getting an epidural as a result in real life. If they are that progressed, anesthesiologists usually do a CSE to get the medication in far faster due to the later stage of labor.

To reiterate some of what Pharmado was saying.
  1. Why are we even talking about the difference in 95th percentile durations of active labor? The article you quoted said they compared both MEDIAN and 95th percentile durations, but they only reported (in the article) the (obviously more dramatic) 95th percentile duration differences. Even without the epidural the 95th percentile duration was over 3 hours. Most OBs I work with would have long decided to do a cesarean by that point. And why wasn't the median difference in duration times reported? Isn't that what most studies report? Or maybe I could report a study deeming cardio exercise bad for everyone because there was a higher incidence of MI in patients with 95th percentile coronary stenosis doing cardio compared to healthy patients doing cardio.
  2. You're "important" end point (cesarean rate) is fair. However, they didn't report that. Why not? Isn't that what's more important? Is it because there was no difference in cesarean rates?
 
Well yes but thanks to ACOG we are expected to place the epidural as soon as it is requested.


Contrary to the conclusion of the Cochrane meta-analysis of EA compared with narcotic analgesia, EA given before the active phase of labour more than doubles the probability of receiving a CS. If given in the active phase of labour, EA does not increase rates of CS. Meta-analysis can be helpful and timesaving for busy practitioners, but we need to be vigilant about which studies get into the meta-analyses and ask ourselves if they make clinical sense. And, unfortunately, we need to continue to read the individual studies that make up meta-analyses—especially if they are likely to actually change practice—to determine whether study conditions represent our clinical reality.

Does epidural analgesia increase rate of cesarean section?
 
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Key points


  • The effects of neuraxial labour analgesia on the progress of labour and labour outcomes have generated considerable controversy.

  • The evidence indicates that effective labour analgesia does not increase the rate of Caesarean delivery.

  • Effective labour analgesia can prolong the second stage of labour, and might also increase the rate of instrumental vaginal delivery.

  • The potential benefits and risks of neuraxial labour analgesia must be tailored to the needs of each parturient.

Labour analgesia and obstetric outcomes | BJA: British Journal of Anaesthesia | Oxford Academic
 
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The obsession with decreasing the rate of Caesarean delivery is not evidenced based. There is, of certainty, a rate at which going any lower is detrimental.
 
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The obsession with decreasing the rate of Caesarean delivery is not evidenced based. There is, of certainty, a rate at which going any lower is detrimental.
I think we have fewer evidence-based C-sections than evidence-based vaginal deliveries.

To me, a vaginal delivery is evidence-based by definition (nobody does things better than Nature, most of the time), unless there is evidence that it would harm the patient/baby. While many C-sections are either elective or malpractice avoidance-based.

We need better fetal monitoring, not more C-sections. First do no harm. Every intervention of ours produces some harm, at least temporarily, even that 25G spinal needle. The fact that we have not been able yet to link back pain in the elderly to h/o spinals/epidurals doesn't mean that it doesn't exist. It only means that the first generations who got epidurals for labor are still relatively young, and nobody has done a cohort study.
 
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I think we have fewer evidence-based C-sections than evidence-based vaginal deliveries.

To me, a vaginal delivery is evidence-based by definition (nobody does things better than Nature, most of the time), unless there is evidence that it would harm the patient/baby. While many C-sections are either elective or malpractice avoidance-based.

We need better fetal monitoring, not more C-sections. .

You are slipping into the Appeal to Nature or Perfection of Nature fallacy.

The same misunderstanding of nature that gives rise to the idea that natural delivery is best, "nobody does things better than Nature", is the same misunderstanding that gives rise to the "breast is best" feeding fallacy, and to antivax beliefs.

Nature, and natural selection, is an inherently wasteful process, where only a small percentage of offspring survive to reproduce. In undeveloped parts of the world infant mortality is as high as 150 deaths per 1000 live births, and maternal mortality exceeds 1,200 per 100,000 live births.

Birth balances the optimum outcome for the baby's wellbeing (develop in utero as long as possible) against the optimum outcome for maternal wellbeing (get the baby out as soon as possible).

The earlier delivery occurs, the more likely the mother survives the process, and the earlier the mother can go on to reproduce again. The later the delivery occurs, the more likely that baby will be capable of surviving outside the womb, assuming it survives through the birthing processs.

In humans, that balance is right around 39 weeks, and we clearly need to work towards all deliveries occurring in that window, if our goal is minimizing combined maternal and fetal morbidity and mortality on a population level. This is evidenced based.

What is not evidenced based is the speculation that, in identically risked pregnancies, c-sections have a higher level of combined maternal and infant morbidity and mortality. What studies exist are heavily skewed by selection bias with the c-section group having exponentially higher baseline risk.

We need only to look at Brazil where 85% of private hospital births are by c-section (with no clear increase in fetal/maternal morbidity and mortality) to begin to question whether the international targets for c-section rates are more driven by the fallacy of the Appeal to Nature, rather than hard data and true evidence.
 
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You are slipping into the Appeal to Nature or Perfection of Nature fallacy.

The same misunderstanding of nature that gives rise to the idea that natural delivery is best, "nobody does things better than Nature", is the same misunderstanding that gives rise to the "breast is best" feeding fallacy, and to antivax beliefs.

Nature, and natural selection, is an inherently wasteful process, where only a small percentage of offspring survive to reproduce. In undeveloped parts of the world infant mortality is as high as 150 deaths per 1000 live births, and maternal mortality exceeds 1,200 per 100,000 live births.

Birth balances the optimum outcome for the baby's wellbeing (develop in utero as long as possible) against the optimum outcome for maternal wellbeing (get the baby out as soon as possible).

The earlier delivery occurs, the more likely the mother survives the process, and the earlier the mother can go on to reproduce again. The later the delivery occurs, the more likely that baby will be capable of surviving outside the womb, assuming it survives through the birthing processs.

In humans, that balance is right around 39 weeks, and we clearly need to work towards all deliveries occurring in that window, if our goal is minimizing combined maternal and fetal morbidity and mortality on a population level. This is evidenced based.

What is not evidenced based is the speculation that, in identically risked pregnancies, c-sections have a higher level of combined maternal and infant morbidity and mortality. What studies exist are heavily skewed by selection bias with the c-section group having exponentially higher baseline risk.

We need only to look at Brazil where 85% of private hospital births are by c-section (with no clear increase in fetal/maternal morbidity and mortality) to begin to question whether the international targets for c-section rates are more driven by the fallacy of the Appeal to Nature, rather than hard data and true evidence.
Breast IS best. That's been proven again and again. Ask an experienced pediatrician (I have one in my family) and she will tell you that the healthiest babies have been breastfed.
Breastfeeding is associated with infant health benefits, such as fewer childhood illnesses, lower blood pressure and cholesterol levels, lower prevalence of obesity, and improved intelligence as adults [24, 25]. Maternal benefits of breastfeeding include faster involution of the uterus and lower risk of haemorrhage after birth, in addition to lower a lower lifetime incidence of type II diabetes, and breast and ovarian cancer [26]. These studies have suggested that the benefits of breastfeeding act in a dose response relationship, whereby increasing breastfeeding duration results in more infant health benefits [2426]
The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum

I wouldn't trust Brazilian medicine with outcome measurements. In the US, we know that pre-existing uterine scars are associated with at least an increased risk of placental insertions and uterine rupture.

Most intelligent doctors know the value of the old Latin maxim "medicus curat, natura sanat" (the medic cares [for the patient, but] nature heals). The older I get, the more desperate cases I see, the more I recognize this (and I am not a religious or fatalist person). Regardless, I am a strong believer in "first do no harm", so I find any for-profit medical procedure unethical unless proven to be better than its less profitable alternatives.
 
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I think we have fewer evidence-based C-sections than evidence-based vaginal deliveries.

To me, a vaginal delivery is evidence-based by definition (nobody does things better than Nature, most of the time), unless there is evidence that it would harm the patient/baby. While many C-sections are either elective or malpractice avoidance-based.

We need better fetal monitoring, not more C-sections. First do no harm. Every intervention of ours produces some harm, at least temporarily, even that 25G spinal needle. The fact that we have not been able yet to link back pain in the elderly to h/o spinals/epidurals doesn't mean that it doesn't exist. It only means that the first generations who got epidurals for labor are still relatively young, and nobody has done a cohort study.

Totally agree with FFP. It's much more expensive for a c-section and there's significant more morbidity associated (especially for repeat partituents). We have had several "crash" c-sections where we even skipped neuraxial opting for GA for prolonged fetal distress... APGARs of 9 and 9 many times (anecdotally). We absolutely need better fetal monitoring, or at least a better understanding of its limitations and implications.
 
Benefits of breast feeding are marginal at best. Fed is best and many women find out the hard way that, contrary to the browbeating of lactivists, not all women are capable of producing sufficient milk.
 
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Before someone tries to go there, statistical arguments against c-section are as ridiculous as statistical arguments for home birth. Anyone who has done work on a OB floor understands that the problems are risked out of vaginal delivery, just like they are, or at least should be, out of home birth.

The statistics tell us exactly what we expect. It is significantly safer for a cohort of low risk women to deliver than it is for a cohort of higher risk women.

Until we have a truly randomized study, based on intention to treat, we will be stuck with comparing a lower risk cohort of vaginal deliverers with a higher risk cohort of patients who deliver by c-section
 
Breast IS best. That's been proven again and again. Ask an experienced pediatrician (I have one in my family) and she will tell you that the healthiest babies have been breastfed.

"Ask an experienced pediatrician" for an anecdote is expert opinion at best.

There are confounding reasons why breastfed babies might be healthier or appear to be healthier than non-breastfed, that have nothing to do with calories, nutritional value, immune benefits, etc.
 
Benefits of breast feeding are marginal at best. Fed is best and many women find out the hard way that, contrary to the browbeating of lactivists, not all women are capable of producing sufficient milk.
Nope. Nothing beats maternal antibodies, especially in the first 6 months of life, while infants "suck" at defending themselves against infectious agents. That's why those babies are healthier.
 
"Ask an experienced pediatrician" for an anecdote is expert opinion at best.
And that's why I posted a quote to an article that referenced a systematic review.
There are confounding reasons why breastfed babies might be healthier or appear to be healthier than non-breastfed, that have nothing to do with calories, nutritional value, immune benefits, etc.
There are also very logical reasons, such as maternal antibodies being passed to the babies. As in the case of C-sections, there is a huge for-profit industry trying to prove that breastfeeding is non-superior, so they can peddle their products to busy moms. Also, adjustments for women who breastfeed cost corporations a lot of money, so there is a big lobby for artificial feeding. As with C-sections (and most medical "research"), just follow the money!

I am not the activist here. ;)
 
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It's much more expensive for a c-section

We are discussing morbidity and mortality, not cost.


and there's significant more morbidity associated

In identically risked women? We don't know that.


We have had several "crash" c-sections where we even skipped neuraxial opting for GA for prolonged fetal distress... APGARs of 9 and 9 many times

I'm not even sure what your point is. If we are doing c-sections appropriately, we should expect this. If our crash c-sections are having all APGARS of 3 and 4, then we clearly aren't pulling the trigger fast enough. If they are 100% 9 and 9, then, perhaps, we are pulling the trigger too fast. However, the entire point is to err on the side of having a few unnecessary c-sections. So, even a 100% 9/9 APGAR rate doesn't necessarily mean you are doing it wrong
 
Nope. Nothing beats maternal antibodies, especially in the first 6 months of life, while infants "suck" at defending themselves against infectious agents. That's why those babies are healthier.

You know what beats maternal antibodies? A baby that is eating and gaining weight. Women that struggle to breast feed and have babies falling behind growth curves shouldn't fixate on the breast milk, they should fixate on making sure the baby is eating. A breast fed failure to thrive baby is not better off than a bottle fed normally growing baby.
 
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We are discussing morbidity and mortality, not cost.
Make the incentive for C-section as low as for a NSVD, and you'll suddenly notice fewer women "needing" C-sections. Money is very important. ;)
I'm not even sure what your point is. If we are doing c-sections appropriately, we should expect this. If our crash c-sections are having all APGARS of 3 and 4, then we clearly aren't pulling the trigger fast enough. If they are 100% 9 and 9, then, perhaps, we are pulling the trigger too fast. However, the entire point is to err on the side of having a few unnecessary c-sections. So, even a 100% 9/9 APGAR rate doesn't necessarily mean you are doing it wrong
In an ideal world, we would do NSVD only in situations where NSVD is the best alternative, and C-sections where the C-section is the best one. Each of them has risks and benefits, and the role of the physician is to quantify those for the mother.
 
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