Uncertainty in the diagnostic methods of the obstetrician

by Henry Dorn, MD

In 1974, the noted obstetrician Marcus Filshie published a review of the relatively new electronic fetal monitoring in the British Journal of Hospital Medicine. He stated, somewhat fatefully:

Now that the appropriate technology is available, the obstetrician may virtually eliminate intrapartum stillbirths and reduce morbidity to a minimum.

Similar statements were made in the United States by leaders in the obstetrical community and headlines were created. Although there was significant evidence that spoke to the limitations of this technology, the obstetrical community and the general public leapt to embrace this new found “cure” for adverse neonatal outcomes.

Certainly in an age in which man could travel to the moon, computers were becoming commonplace in academic settings and nuclear energy a reality, doctors should be able to reliably detect fetal distress and act upon it safely, sparing parents the grief of the past.

Likewise, ultrasounds have allowed us to peer into the womb, and into the bodies of our unborn children, allowing us to anticipate not only the gender of our babies, but also see things as subtle as heart or spine defects. Yet everyone knows a story of the girl who turned out to be a boy, despite our best imaging efforts, and the mixed feelings that that surprise engenders (pun intended).

Molecular biology has allowed us to go even further, and examine the blueprints of life in utero, allowing parents to prepare for a child with chromosomal issues, or reassuring those with family histories of hereditary disorders.

Altogether, ever advancing science has created a sense of control over what once had been a very insecure time for families and their caregivers. The idea that following the current best medical evidence will virtually guarantee best outcomes is an appealing extension of that new found power over nature, but is a belief system that is inherently flawed, and that fact is often not appreciated by those who are captivated by its seduction.

Joseph Campbell, the comparative mythologist noted that cultures which are the most subject to the variable forces of nature, such as seafaring peoples, have the most rituals, in order to exert some sense of control over the uncontrollable. The obstetrical community must fit that model, insisting on specific rituals of care, even in the absence of absolute evidence of their efficacy, in order to gain a sense of control and mastery of the birthing process. The fetal heart rate tracing is poured over like tea leaves or cast bones, and the doctor becomes the shaman.

This belief system has been preached to future physicians and  obstetricians, who passed it along to their students until the whole culture of childbirth medicine became steeped in a religious-like belief in the power of the fetal monitor, labor curves, ultrasound measurements and the like. This belief is similarly conveyed to patients who are assured that if their pregnancy was managed according to the protocols developed by trusted researchers, their babies would be delivered without fail and without harm.

Reality, however, has proven otherwise. Despite close and continuous monitoring in labor by the best trained and most capable staff and doctors, babies still die suddenly, or are born with unexpected asphyxia, or unanticipated illness. Families feel bewildered and betrayed and seek explanation and often recourse. If the latest technology was employed, then certainly human error must have been the cause.

Trial lawyers turn physician’s own promises against them and win huge lottery-like settlements, setting precedence, and further convincing the public that the fault was not in the system but in the individual caregiver.

If, however, one looks critically at the myriad of diagnostic methods, and treatments used by the modern obstetrician, it becomes quite clear that there is much that is uncertain and much we cannot control. Most experienced practitioners know this, but are often resistant to admit this to their patients and the public, but this lack of disclosure has a tendency to backfire.

This is not to say that modern obstetrics with all of its technologies and oft maligned “interventions” is without value. Huge numbers of babies and mothers have been saved by modern medical care, but the failure to admit to ourselves and the patients we serve that we cannot guarantee perfect outcomes does a disservice to us all. Bad things do happen to good doctors (and nurses, and midwives etc) and the sooner everyone understands this, the sooner we can start practicing evidence-based medicine as opposed to ritual-based medicine.

Conversations need to start with recommendations and explanations of their rationale, but leave room for the ever present uncertainty of outcomes as well as factoring in the patients desires and apprehensions. I believe that “I don’t know” are three of the most powerful words in medicine and should be used more often. Patients who don’t want to hear this need to realize that any practitioner who believes that they truly KNOW anything for certain is more dangerous than the one that makes allowances for the great amount of variability that life entails.

This more open communication should certainly help to restore the trust patients once had in their providers, and begin the process of reducing costs due to defensive medicine, as well as lessen patients’ sense of betrayal that sometimes occurs with unexpected bad outcomes.

Henry Dorn is an obstetrician-gynecologist and can be reached at Henry Dorn MD OBGYN & AssociatesThis post originally appeared on The Unnecesarean.

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  • Smart Doc

    Uncertainty in OB?

    There is not the slightest “uncertainty” in the liar-for-hire expert witness testimony paid for by the Trial Lawyer Industry asserting that blameless obstetricians caused cerebral palsy in their plaintiff because he/she did not perform a caesarian section 20 minutes earlier.

    Followed by a $2 million jackpot juistice payout and $250,000 malpractice insurance premiums in some states. The John Edwards of the world made vast millions off of this “uncertainty.”

  • http://myheartsisters.org Carolyn Thomas

    “…the power of the fetal monitor….” indeed! Almost 35 years ago, before fetal heart monitors were becoming a routine practice in hospital obstetrics, I gave birth to my first baby. Even back then, pregnant women were being warned in our Lamaze classes that the fetal heart monitor can indicate fetal distress precisely because the mother is wearing the monitor – because she must lie so very still with the full weight of the baby putting pressure on blood vessels that show – quelle surprise! – fetal distress. And fetal distress means increased likelihood of undergoing a C-section.

    Instead, we were advised to move around during labour. Walk around, take a shower, sit up, stand, squat, have your partner massage your sore back – but whatever you do, the worst position is lying there motionless. How come we all knew this 35 years ago, and yet doctors are now treating fetal monitors as routine requirements? The World Health Organization recommends that the best outcomes for mothers and babies appear to occur with cesarean section rates of 5-10%, yet in North America, one out of every three babies is delivered by C-section.

    It seems that these days, if you’re an obstetrician armed with high-tech hammers, every baby looks like a nail.

  • doctor

    The rate of cerebral palsy in term pregnancies has decreased substantially in the past 35 years. The overall rate has remained the same because of the increase in premature births. You have to read between the lines with all of these statistics.

  • http://myheartsisters.org Carolyn Thomas

    The United Nations has ranked the U.S. as 33rd in the world in its 2009 Infant Mortality Rates (6.3/1,000 live births – almost double the rates in other developed countries like Sweden and Norway). That embarrassing status is hardly an enviable endorsement of the way American babies are being delivered.

    And the U.S. is ranked #3 in the world in C-sections (coincidentally, Sweden and Norway are ranked well down that list at #14 and 15 respectively). As Dr. Dorn says, the 1974 predictions that fetal monitoring technology was the “new found cure for adverse neonatal outcomes” were tragically unrealistic.

  • ninguem

    It’s been pointed out, time and again, that countries vary widely in what they call an infant mortality.

    If it’s born in the USA, came out of a woman’s womb, has a pulse, cries, it’s a live birth. It may not have the slightest chance of survival. Nevertheless, when it dies, even if inevitable, it’s an infant mortality.

    Other countries may have certain cutoff dates. Born before a certain gestational age, it’s a stillbirth. They may well be perfectly justified in withholding care, it may be a guaranteed waste of resources with no hope of success.

    The fact remains, that baby is called an infant mortality, neonatal mortality, etc., and elsewhere it’s called a stillbirth.

    The statistic that interests me is, if I have a premature baby, where does it stand the best chance of survival. The baby becomes premature because of socioeconomic factors beyond the control of medicine.

  • ninguem

    Just one citation, I’ve got a bunch.

    http://www.sidsalliance.org/research/studies/Liveborn_and_stillborn_very_low_birthweight_infants_in_Switzerland.pdf

    Liveborn and stillborn very low birthweight infants in Switzerland: comparison between hospital based birth registers and the national birth register.

    Muller M, Drack G, Schindler C, Bucher HU.

    Swiss Med Wkly. 2005 Jul 23;135(29-30):433-9.

    Klinik fur Neonatologie, UniversitatsSpital Zurich, Switzerland.

    Background and Aim: Perinatal and infant mortality rates are considered key indicators of medical care. The aim of this investigation was to examine how representative and reliable the official national figures of Switzerland are by comparing them with the data in local birth registers.

    Methods: 124 of 156 maternity hospitals in Switzerland, catering for about 80% of all newborn infants, participated in the study. The hospital based birth registers were screened for the years 1996 and 2000 for live and stillborn infants weighing less than 1500 g. These data were matched with the data in the official register (federal office for statistics).

    Results: in 1996 a total of 753 newborn infants and in 2000 820 infants weighing between 300 and 1499 g were officially registered. In the hospital based registers in 1996 101 additional infants and in 2000 94 infants were identified that had not been officially registered; 31 of these were stillborn before 24 completed weeks. Infants registered only locally had lower birth weight and lower gestational age than those recorded in both registers.

    Conclusion: In Switzerland a significant number of very low birth weight infants who died soon after birth are not officially registered. If these infants are included, the national perinatal mortality rate would increase from 6.9 per thousand to 8.0 per thousand.

    Reasons for underreporting are unclear but may be due to varying definitions of stillbirth and different lower limits for reporting in various cantons. We suggest adopting the WHO-rules for reporting all births and to include gestational age, head circumference, Apgar scores and umbilical artery pH in the national birth register.

  • HJ

    Outcomes of planned home births with certified professional midwives: large prospective study in North America.
    Johnson KC, Daviss BA.

    RESULTS: 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.

    So the mortality rates betwwen delivering in a home setting vs. a hospital are similar, it seems to me that the technological interventions don’t have any real purpose. With the rising cost of health care, why do doctors continue to use such “tests” that raise the cost of health care without evidence of benefit?

    Women who had access to more technology also had more interventions that could affect their long term health and that of their child. Given that the mortality rates are similar, the technology produced inferior outcomes. Perhaps it’s about the money.

    • http://www.myheartsisters.org Carolyn Thomas

      My sentiments exactly, HJ. We have successfully ‘medicalized’ childbirth – even for low risk mothers.

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