Birth as the Ultimate Collaboration
By Richard N. Waldman, MD
The Lamaze International Annual Conference is being held October 11-13, 2013 in New Orleans, LA. “Let the Good Times Roll for Safe and Healthy Birth” is the theme and there is a fabulous line up of speakers and events planned. Birth professionals who serve women and babies in all capacities will find many sessions of great interest to them. Dr. Richard Waldman, former President of ACOG, is one of the two keynote speakers preparing to speak to those in attendance. Today, on Science & Sensibility, Dr. Waldman shares his thoughts in a blog post on communication and collaboration amongst caregivers and other professionals to achieve a healthy outcome for mother and baby. Learn more about Dr. Waldman in my interview with him published a few days ago.
Three years ago I had the honor of being inducted as the President of the American Congress of Obstetricians and Gynecologists. I titled my talk on that day “Together We Can Do Something Wonderful” and I discussed many issues surrounding childbirth that impact mothers and families. My title was partially borrowed from Mother Teresa who stated it so well when she said: “What I do you cannot do; but what you do, I cannot do. The needs are great and none of us, including me, ever do great things. But we can all do small things, with great love, and together we can do something wonderful.” This is so true today.
(A section from Dr. Waldman’s Induction as President of ACOG, June 2010. Additional segments available here.)
It is appropriate for me to address families concerned with childbirth and childbirth educators because you are so important to the future of birthing.
We have been changing the culture of birth without Nature’s permission in so many ways that are really troubling. For instance, the distribution of births to a lower gestational age has been developing in the last two decades. There has been a sharp decline in deliveries occurring after 39 weeks with a concomitant sharp increase in births occurring particularly between 36-38 weeks gestation. There are many reasons for this and sometimes delivering a baby early can be life saving.
In the early part of my career it was not unusual for pregnancies to go beyond 43 weeks. Although I was a naturalist at heart and did not easily embrace inductions just past 42 weeks, I was impressed by the decrease in morbidity that I encountered. For instance, I do not miss seeing babies who suffered with meconium aspiration syndrome, I still see a family whose baby boy died shortly after birth from meconium aspiration syndrome. Every time I see her I think of their family’s tragic birth experience. You never forget those losses.
There is no question that the wonderful care in the neonatal nursery has made some maternity care providers complacent. However, we often overreact. If delivering at 42 weeks is a good idea why not deliver at 41 weeks? If we are delivering our prior cesarean patients at 39 weeks, why not deliver them at 38 weeks? The babies will do well will they not? I once gave a talk for ICEA entitled “Deliver Us from Technology?” My point was that some technology, used as a fine instrument only when it is clearly indicated, can be lifesaving but technology used too frequently and without clear indications can be a real problem. Good practitioners walk a tightrope with nature on one side and technology on the other.
On other hand, physicians are sometimes under great pressure to deliver their patients before their due dates. Women have been led to believe that delivering early is not going to harm the baby and they put tremendous pressure on their care providers to “end their misery” or deliver the week before their due date because “that is the only week that mom can fly in from California.” The March Of Dimes has a wonderful program called “Healthy Babies are Worth the Wait” but they cannot do it alone.
Induction of labor is a similar and related problem. If you are planning to deliver early then you have to do so by inducing labor or by doing a cesarean section. Over 20% of pregnancies resulted in an induction of labor in 2007, representing a 140% increase since 1990. In one hospital report 44% of their patients were induced. Pregnant women who are induced are 37% more likely to require cesarean compared to those with spontaneous labor. If a ripening agent is used they are nearly three times more likely to undergo a cesarean. Nulliparous women undergoing elective induction of labor with an unripe cervix (low Bishop Score) face almost a 50% risk of cesarean delivery.
Now those are the facts, but how do we educate the women in this country so that they can ask the right questions and make the best birthing decisions? We all need to work together to convince families that delivering early is not good for mother or baby unless there are clear medical indications and that inductions of labor may lead to unnecessary cesarean sections but knowledge in itself is not enough. Perhaps we should regard birth as the ultimate collaboration. In order to have successful collaboration, the participants need to communicate as equals. I know that our maternity suite at our hospital is so much happier place to work since we instituted a non hierarchal formal communication system.
While I was President of ACOG I made “collaborative intelligence” a top priority of our college. We worked very hard at our communication styles with other organizations (specifically the ACNM) to overcome trust issues and we had amazing results. It seems to me that facts are facts but how educators and doulas, families and caregivers communicate with each other is equally important and can have a tremendous impact on a birth outcome. Collaboration and formal communication are not easy to learn and are recursive processes that require time and effort. But resolving conflicts in labor and delivery are worth it, because in the end, what we all really want is what is best for both mother and baby.
About Richard Waldman, MD
Dr. Richard N. Waldman is a diplomat of the American Board of Obstetrics and Gynecology, and is the past president of the American College of Obstetricians and Gynecologists (ACOG), a premier private, not-for-profit organization dedicated to the advancement of women’s health care through continuing medical education, practice and research. Dr. Waldman is the president-elect of the Medical Staff at St. Joseph’s Hospital Health Center in Syracuse, NY, and a member of the Board of Trustees. Dr. Waldman is a Senior Medical Consultant at OB Consult. Among other things, he established the first hospital-based midwifery practice in central New York. He served as the president of ACOG from 2010-2011. He has lectured extensively on pregnancy and childbirth across the United States and has also lectured internationally. He has published several articles in peer review journals and recently co-edited an issue of Obstetrics and Gynecology Clinics of North America dedicated to collaborative practice.