Born in the USA (2 page)

Meanwhile, the neonatologist has determined that the baby is brain-dead, after nearly one hour without sufficient oxygen, due to the damaged uterus. The baby is rushed to the nearest neonatal intensive care unit, but dies twenty-four hours later. The mother is hemorrhaging from the ruptured uterus and receives a blood transfusion.

The outcomes of this story were tragic. A women nearly died and a family was left with a dead baby and no possibility of having another baby in the future. Most tragic of all, it need never have happened.

We doctors have a fancy word for the appalling outcomes in a case like this: they are
iatrogenic
, or caused by the doctor. Cytotec is a popular drug among obstetricians who use it to induce labor, even though it has not been approved by the drug manufacturer, or by the FDA, for that purpose, and to date there is no scientific evidence showing that it is safe for that purpose.
¹
On the contrary, in 1999, two years after this incident took place, studies proved conclusively that, while the risk of uterine rupture is higher than normal when Cytotec is given to “ripen the cervix” and induce labor, the risk of rupture is significantly greater still when it is given to a pregnant woman (like the woman in Oregon) who has had a cesarean section in the past and already has a weakness in the wall of her uterus at the scar.
²

Here is another story. This one is about a recent “normal” birth in Northern California.

Ms. C chose Dr. E, an obstetrician, to care for her during her pregnancy and birth. She wanted to have a natural birth and his printed flyers advertised that he “believes pregnancy is not an illness,” “works toward making pregnancy a happy experience,” and “provides natural delivery methods.”

A week before Ms. C's due date, Dr. E proposed that he induce labor with the powerful intravenous drug Pitocin. “Come to the hospital Friday at 7
A.M.
, and you'll have a baby by dinnertime,” he said. What Dr. E did not add was “and I'll be home for dinner.”

Inducing labor is medically indicated in rare cases, such as when the patient shows signs of preeclampsia (persistent, severe high blood pressure, edema or swelling due to an accumulation of fluid in the ankles, and protein in the urine)—or when the pregnancy is more than two weeks overdue and there are definite signs of fetal distress. In Ms. C's case, there were no medical indications for inducing labor. Ms. C and her husband refused Dr. E's offer and repeated their desire to let nature take its course.

A week later, Ms. C went into spontaneous labor and was admitted to the hospital at 11
P.M.
Dr. E was informed by phone, but perhaps because it was 11
P.M.
, he did not come in to examine her. Over the phone he ordered the nurse to start Pitocin in the morning to “augment” or speed up the labor, though there was no medical reason to do so, as Ms. C's labor had not slowed or stopped.

The next day, at 8:30
A.M.
, Dr. E visited Ms. C in the hospital for the first time, nine and a half hours after her admission and two hours after a nurse had started her on a Pitocin intravenous drip. During that time, no other doctor had seen Ms. C, and she was not told she was being given Pitocin.

At 8:40
A.M.
, and again at 8:43
A.M.
, there were signs of distress on the electronic fetal heart monitor. Ms. C's chart indicates that her nurses were aware of these signs, but there is no indication that a doctor was called.

When drugs such as Pitocin are used to induce or augment labor, the pain of labor typically becomes much worse than normal.
³
At 8:50
A.M
., an anesthesiologist gave Ms. C an epidural block to relieve her pain. Administering an epidural block is a delicate procedure that involves putting a needle into the spinal cord just far enough for the tip to be in the spinal fluid and injecting an anesthetic. An epidural blocks all sensations below the injection site, leaving the lower half of the body without feeling.

Nurses notes indicate that at 8:55
A.M.
, Ms. C was completely dilated—a sign that it was time for her to push the baby out. However, Ms. C was
not told that birth was imminent. A nurse called Dr. E, and on the phone he gave the order, “tell her don't push.” But the urge to push is spontaneous and out of the woman's control—like trying not to vomit when the urge to vomit comes. For the next hour and forty-four minutes, the nurses tried to keep the baby from being born before the doctor arrived by urging Ms. C not to push and by pushing on the baby's head to hold it back. Nurses' notes indicate that Dr. E was called several times during this period and urged to come quickly. Nurses also gave Ms. C oxygen while she waited and told her it was for the baby, so we can assume that they were aware that holding the baby back was putting the baby at risk.

Ms. C had made it clear to Dr. E before she went into labor that she and her husband wanted a natural birth without surgical interventions, such as an episiotomy (the practice of cutting the vagina open supposedly to create more room for the baby). During her labor, Ms. C reinforced this point. She repeatedly told a nurse, “I do not want an episiotomy.” Dr. E rushed in at 10:39
A.M.
, more than two hours since his last visit, and gave her an episiotomy, for no apparent reason and without telling her what he was doing. Since she was numb from the waist down, she did not know he was cutting her. When she reminded him that she did not want an episiotomy, he said, “too late.” Dr. E then used a vacuum extractor to pull the baby out—again, for no apparent reason. (Dr. E claimed the reason was “fetal distress,” but there were no signs of fetal distress on the electronic monitor just before the birth.)

These two birth stories—one with a disastrous outcome, one not at all unusual—illustrate many of the egregious errors that go on in maternity care in the United States. The fundamental flaw: in America, we have highly trained surgeons called obstetricians regularly “attending” normal, or low-risk, births.

The United States and Canada are the only highly industrialized Western countries in the world where this is true.
⁴
And Canada is rapidly converting to the system used in all other industrialized Western countries, including Australia, the Netherlands, Great Britain, all Scandinavian countries, Germany, and Ireland, and in many other countries, where more than 75 percent of all births are assisted by trained midwives. It is a midwife who provides prenatal care, a midwife who admits a woman to the hospital when labor begins (or goes to her home), a midwife who attends the labor, a midwife who assists at the birth, and a midwife who discharges the woman from the hospital. In these countries, obstetricians serve as specialists. They are essential members of the maternity care team, but they play a role only
in the 10 to 15 percent of cases where there are serious complications. Most women have babies without ever setting eyes on a doctor.

In the United States, the numbers are reversed. Obstetricians “attend” 90 percent of births and have a great deal of control, essentially a monopoly, over the maternity care system.
⁵
Obstetricians are taught to view birth in a medical framework rather than to understand it as a natural process. In a medical model, pregnancy and birth are an illness that requires diagnosis and treatment. It is an obstetrician's job to figure out what's wrong (diagnosis) and do something about it (treatment)—even though, with childbirth, the right thing in most cases is to do nothing. To put it another way, having an obstetrical surgeon manage a normal birth is like having a pediatric surgeon babysit a normal two-year-old. Both will find medical solutions to normal situations—drugs to stimulate normal labor and narcotics for a fussy toddler. It's a paradigm that doesn't work.

This book will show that by embracing a medical model of birth and allowing obstetricians control of our maternity care, we Americans have accepted health care for women and babies that is not only below standard for wealthy countries but often amounts to neglect and abuse.

Let's take a look at the stories above.

The birth certificate says that the obstetrician in Oregon “attended” the birth, but this is obviously a misstatement. It is a well-known fact among health care providers that in U.S. hospitals, “attending” obstetricians are almost never in attendance during a women's labor, except for occasional drop-in visits, and are often not even in the hospital building.
⁶
An episode of the award-winning TV series
ER
showed a woman in labor having convulsions. The emergency room doctor asks the nurse where the woman's obstetrician is. The answer: “Across town in his office seeing patients.” If a pregnant woman in America signs on with an obstetrician thinking she will have him around during her labor, she is almost certainly in for a rude awakening.

Doctors are not inclined to discuss the consequences of their absence, but a recent study shows a 12 percent increase in neonatal mortality in babies born between 7
P.M.
and midnight and a 16 percent increase in neonatal mortality for babies born between 1
A.M.
and 6
A.M.
. Researchers believe the increased deaths may be attributed to “the availability and quality of physicians, nurses and support personnel, as well as the accessibility of diagnostic tests and procedures.”
⁷

A review of litigation cases in obstetrics and gynecology, commissioned by the prestigious Institute of Medicine in Washington, D.C., reported that
nearly two-thirds of labor and delivery injuries were caused by problems in medical management—that is, failure to adequately supervise or properly monitor.
⁸
In the Oregon story, the obstetrician's “failure to adequately supervise and monitor” meant that treatment was delayed during a crisis—a crisis that was brought on by the use of Cytotec, a drug that has not been sufficiently studied to have been proven safe. Does that amount to neglect? I think it
is
neglect on at least two levels. To begin with, the physician ignored the most basic principle of medical practice:
First, do no harm
. Second, the woman was given a powerful drug, then left to go through the second stage of labor (when the risk of developing complications increases) without a doctor's continuous attendance but in the care of a nurse who was responsible for several women in labor and could check in only from time to time, as is usual in hospital maternity care,

It is no surprise that patients are neglected in a system where an obstetrician tries to be all things to all women. An American ob/gyn must be a primary care provider assisting normal, healthy pregnancies and births, a specialist in complications of pregnancy and birth, a counselor and family planning provider, a specialist in gynecological diseases, and a highly skilled surgeon. No other specialist anywhere in health care tries to maintain competence in so many areas. It is not humanly possible. Can an obstetrician do a major gynecological surgical procedure—such as a six-hour “pelvic clean-out” on a woman with extensive cancer—and then rush to his office and do a good job of quietly and patiently counseling a healthy pregnant woman about her sex life? Not likely.

In America, obstetricians' plates are full to overflowing. There is no way they can do it all. And of all the things they try to do, the most difficult thing to fit into their busy schedules is normal childbirth, which lasts twelve hours (on average) and, as we all know, can happen night or day, seven days a week. As in these stories, the actual attendant for the majority of births in the United States is a labor and delivery (L&D) nurse with a telephone.

On average, L&D nurses receive only six weeks of on-the-job training in L&D nursing after completing their basic nursing training. They have no autonomy, and so if problems develop they can do nothing without a doctor's orders. At the same time, L&D nurses are held responsible for accurately judging the moment of birth. If a nurse calls the doctor too soon, she may be accused of wasting the doctor's time. If she calls the doctor too late and the doctor misses the birth, the doctor is equally unhappy. It is no wonder that the thirty thousand L&D nurses working in American hospitals are frustrated and exhausted.
⁹

In most hospitals, L&D nurses are asked to closely monitor several women in labor simultaneously. Some level of neglect is inevitable in this situation. When you consider the fact that nurses work eight-hour shifts, the chance that a women in labor will receive continuous, one-on-one care in the hospital is reduced to zero. This is distressing, since many studies have shown that one-on-one, continuous care by the same person throughout labor means a shorter labor, less pain, fewer complications, and better safety for mother and baby.
¹⁰
Hospitals and health maintenance organizations (HMOs) say they don't have the money to provide continuous care to women giving birth. Yet somehow they
do
have the money to purchase and maintain expensive electronic fetal monitors and use them on all women—even those having low-risk births, without drugs to induce labor—despite the fact that there is no scientific evidence that routine electronic fetal monitoring improves birth outcomes.
¹¹
Most hospitals believe in machines, not bodies and not human contact, and that is where the money goes.

Now let's look at Dr. E's management of Ms. C's birth in the second story. There are many reasons it is justified to call it abusive. First, Ms. C was given Pitocin for no apparent reason other than the doctor's convenience. Speeding up labor with Pitocin induction has been shown to carry the risk of overly rapid uterine contractions, which can mean insufficient oxygen for the baby and brain damage, as well as another serious risk, uterine rupture, which can be fatal for the woman and the baby.
¹²
Because the risks are severe, women receiving Pitocin must be closely monitored by the doctor. Dr. E ordered the drug without even examining Ms. C and didn't see her until after she'd been on it for two hours. Furthermore, it is likely that it was the Pitocin that caused Ms. C's labor pains to increase to a level where she needed an epidural, which carries its own risks—such as a sudden fall in blood pressure (depriving the baby of oxygen) as well as the risk to the woman of paralysis or death resulting from the anesthesia.
¹³
The epidural also meant that Ms. C was robbed of the opportunity to feel the birth of her baby.