ACOG Issues New Guidelines on Managing Stillbirth

Yesterday, ACOG released new guidelines on managing stillbirth.

Overall, it's a generally solid, informative, although very clinically-driven, piece that gives a run-down of the known stats and evidence currently available.

What really struck me was the section on Management. Stillbirth is universally devastating for new mothers and families. They've spent at least 5 months (since stillbirth is deemed to occur after 20 weeks) pregnant feeling this child grow inside them and anticipating its birth, only to have their worst fears realized.

In token appreciation to this great loss, the ACOG guidelines state:

After a stillbirth, sensitivity to the family's emotional state is important. Parents should be given the opportunity to hold their baby and perform cultural or religious activities, such as baptism.

In response to this tragedy and its overwhelming impact on the mental and emotional health of their patients, clinicians are advised in a brief, single sentence to be sensitive to the family's emotional state.

The other 3.5 paragraphs are devoted on how to get a family to agree to an autopsy or get their consent for a number of additional tests if they can't be talked into a full autopsy, citing this reasoning:

"Parents want answers when they have a stillbirth, so clinicians should not be afraid to request an autopsy. Without a thorough evaluation it will be difficult to counsel women on their risk of having another stillbirth," said Dr. Fretts.

While I agree in principle, in practice, far too many families are so emotionally blindsided, they can't see the benefit of the autopsy or testing at the time. Perhaps its due to the lip service physicians are instructed to pay to the family's emotional state, wrapped up in a single sentence with a few token activities thrown in.

Perhaps the guidelines could read, "families should be allowed to hold their babies for as long as they like, call whatever family members they wish to come support them, dress the baby and take pictures, as needed. Families should be moved to a location off the maternity floor to avoid painful contact with other families experiencing the joy of their new babies if they so wish".

It would seem to me that by truly showing empathy to the emotional needs of the family, it would be easier to broach painful topics such as autopsy and post-mortem testing.

Expanded Midwifery Care in Ireland

Here's a positive article on the expanded use of midwives in Ireland.


It's a good read that highlights many of the benefits of midwifery care. Enjoy!

Good Article on VBAC

Here's a well-written article on the soon-to-be lost option of VBAC that does a great job of highlighting the erroneous reasons hospitals and doctors report on why they don't offer VBAC.

This is one of my favorite parts:

In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be "readily available" during a VBAC to "immediately available." "Our goal wasn't to narrow the scope of patients who would be eligible, but to make it safe," says Dr. Carolyn Zelop, co-author of ACOG's most recent VBAC guidelines.

I wonder how much longer it will take before ACOG realizes that in their efforts to "make it safe", they'd caused more harm than help.

Unfortunately, I don't think it will be any time soon.

Campaign to Change Hospital Policy Against Midwifery Care

I received this email from an expectant father seeking help in changing a local hospital's policy on midwives attending births. If you live in the area (and even if you don't), please consider making a phone call or sending a letter/email to the hospital administrator to heighten awareness of the issue and hopefully change hospital policy for the benefit of mothers and babies:

My wife and I are expecting our first in September. We are eager and excited to work with a specific midwife/nurse practitioner who works in a woman's health office near our home. This office is connected with Holy Cross Hospital in Silver Spring, Maryland. For this reason, we can not work with our midwife during birth because Holy Cross does not allow midwives to help women deliver in their hospital. They are the only hospital in our region that does this horrible practice. I was hoping you could help get the word out and help me to begin a campaign with the hospital leadership.


The president of the hospital is:

CEO and President: Kevin Sexton

Holy Cross Hospital

1500 Forest Glen Rd.

Silver Spring, MD 20910

301-754-7010
E-mail Address: sextok [at] holycrosshealth.org

~~~~~~~~~~~~~~~

If you've never phoned, written or emailed such a letter, here are some sample scripts with talking points to include:

"My name is ____________________. I live in _______ near ________ hospital. I wanted to share with you how the lack of access to midwifery care at ________ hospital has affected me and other women and families in the vicinity. (List 1 or 2 examples from the list below or add your own).

• I chose to travel ____ miles rather than give birth in this hospital due to the lack of midwifery care providers


• I had to choose a provider I'm not comfortable with because of the lack of midwifery care at this hospital


• Parents have the right to choose how, where, and with whom their children will be born.


• Women deserve to have access to all the nationally certified maternity care providers that women in other states, like Wisconsin and Minnesota, can choose from -- including CPMs


• Midwives are known to do an excellent job working with under-served populations, including undocumented worker populations, who are more accustomed to midwifery care in their home countries


• With obstetricians leaving that profession, midwives can help fill the gap for normal births in a cost effective fashion


• With their unique out-of-hospital training, Certified Professional Midwives can be a vital part of emergency services in times of epidemics, natural disasters or terrorist attacks (when hospitals might be overwhelmed with actual medical emergencies), allowing obstetricians to oversee the cases that required their surgical expertise


• I want the option of midwifery care available for my children,
  when they start to have children of their own

(You should pick the talking points that make the most sense in your situation and/or best represent your point of view or comfort level.)

"I hope that in light of these factors, you will reconsider your policy and allow midwives to have privileges within this hospital to attend to birthing women and their families. Thank you for your consideration in this matter."


Please spread the word to help this and other families in the area gain full access to the care providers of their choice.

Time to Take a Page from the NHS Book...

The National Health Service (NHS) Institute for Innovation and Improvement recently released a new initiative and toolkit to "to assist maternity units in achieving low caesarean section rates while maintaining safe outcomes for mothers and babies."


According to this article, after only 18 months, c-section rates dropped from 24% in 2007 to a mere 16% in November 2008.


The idea of a 16% c-section rate is the US seems like a dream. That is half our current c-section rate and very close to the World Health Organization's (WHO) target rate of 10-15% or less.


The truly intriguing aspect of the toolkit is that it is one of introspection. The NHS created a tool to help providers and maternity care units self-evaluate their practices against evidence-based standards, to see how their actions impacted the number of cesarean births and how altering those practices could help or hinder birth outcomes.


The American College of Obstetricians & Gynecologist's (ACOG) has stated that they are "committed" to reducing the number of c-sections. However, their approach, in sharp contrast to the NHS, has been to simply blame the mother - we're too fat, too lazy, too old, too small, or even "that's what they wanted" and so on and so forth...ad nauseam...


If ACOG is truly committed to lowering c-section rates nationwide, it's time for them to take a page from the NHS's book: start implementing the necessary steps to create the change you want to see.


Namely, start practicing evidence-based medicine and the rest will follow...