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Andrew Kotaska MD, FRCSC Yellowknife, NWT

Combating coercion in maternity care: does modern obstetrics deserve a wooden club as well as the wooden spoon? Canadian Association of Midwives 7 th Annual Conference Vancouver B.C, Nov 2 nd , 2007. Andrew Kotaska MD, FRCSC Yellowknife, NWT. Archie Cochrane 1909-1988 “He was always ready

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Andrew Kotaska MD, FRCSC Yellowknife, NWT

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  1. Combating coercion in maternity care: does modern obstetrics deserve a wooden club as well as the wooden spoon?Canadian Association of Midwives7th 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 obstetricssuccesses - 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 @ delivery • Routine delivery in lithotomy position • Routine twilight sleep/ GA for delivery

  4. Evidence-based obstetricssuccesses - 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 obstetricsfailures – 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. X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

  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 Jehovah‘s 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 @ home with breech or VBAC

  17. Early TBT Results(Hannah M, et al. Lancet 2000; 356:1375-83) ~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. 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 External validity??

  21. TBT: 2-year infant F/U results(Whyte H. AJOG 2004;191:864-71) * 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 TBT‘s 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 StudyPREsentation et MOde D’Accouchement(Goffinet F,et al. AJOG 2006;194:1002-11) • 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 2006;194:1002-11) • 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 2006;194:1002-11) • 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 2006;194:1002-11) PREMODATBT • Pelvimetry: 82% 10% • CEFM: 100% 33% • Active 2nd stage > 60min: 0.2% 5.0%

  28. PREMODA Study: Results (Goffinet F,et al. AJOG 2006;194:1002-11) VB:C/S: • Neonatal Apgar5 < 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 women’s 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 1953;8(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 1953;8(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 Steiβlage (Management of the Breech). Zentralblatt für Gynaekologie 1938;62:1735-6

  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 < 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 < 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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