Epidurals: Time to stop labouring over 'natural' childbirth
A new book says that women should routinely have epidurals in labour. Experts on both sides of the ‘pain is gain' divide give their view
Anyone who has had a baby knows that childbirth as a competitive sport puts
the Olympics in the shade. I'll never forget the “post-match analysis” at my
antenatal class, where intelligent, educated women offered grovelling apologies
to our childbirth instructor for their “second rate” (i.e, anaesthetised)
births. I couldn't help feeling that two thirds of the class had forked out
£150 to be made to feel like bad mothers before their babies had taken their
So it was a relief to come across the book, Enjoy your labor: A new approach to pain relief for childbirth, by Dr Gilbert Grant, director of obstetric anaesthesia at New York University Medical Center. He says that the biblical edict to women to “bring forth children in sorrow” is simply no longer applicable.
So which theory is right? I decided to ask experts on both sides to share their views on the “best” way to give birth.
Dr Grant believes that women should get an epidural, even before pain starts. According to him, much of the information that women receive is incomplete or inaccurate, and that the lucrative “natural childbirth industry” creates fear and guilt about epidurals. He believes that opposition to anaesthesia during childbirth is the result of a deep-seated misogyny: “There is no other situation in medicine in which pain relief is routinely withheld. No man would be asked to undergo an appendectomy, which lasts about 24 minutes, without pain relief, yet the pain of labour, which can last for more than 24 hours, is viewed as something women have to endure.
“Natural childbirth has become a multimillion-dollar industry. The fear of epidurals is promoted by those who discourage their use - and who have a vested interest in doing so.
“Childbirth instructors describe epidurals as unnecessary, or even harmful, interventions and make women feel that requesting one is a sign of weakness that may harm their baby. Labour is seen as an extreme sport - ‘no pain, no gain' - and yet this quasi-religious fervour is based on myth and misconception. The founders of natural childbirth movements NCT and Lamaze, both men, incidentally, claimed that women in primitive cultures experienced no pain in labour. Pain in childbirth, they claimed, is a product of Western civilised society - a learned phenomenon. The implication was that if women breathed ‘properly' or assumed the ‘correct' positions, the labour would be pain-free. Women were made to feel they had failed if they asked for pain relief. There is evidence that in all cultures giving birth has been a painful experience,” says Grant.
“Opponents of the epidural also claim that it may impact negatively on breast-feeding, but there is little data to prove this. On the other hand, there is evidence that unrelieved pain is one of the risk factors for post-natal depression.
“Modern low-dose ‘walking epidurals' allow women to remain active while retaining the muscle strength to push out the baby. Technological advances mean that women are able to administer their own dosage and this makes them feel more in control. Furthermore, studies show that babies born to women who have had epidurals come out in better shape than those from ‘natural' childbirth.
“Women should be allowed to choose if they want pain relief, but should have access to accurate information. It is barbaric that pain should still be viewed as an integral, even desirable, element of childbirth.”
We should let women have home births
Sheila Kitzinger, author of Birth Crisis, believes in home birth for women who are not at especially high risk.
“Birth can be ecstatic and empowering,” says Kitzinger. “However, too often
women report finding it torture. They feel that they had no control and
gratitude that they and their babies are alive is mixed with a sense that they
have been violated.
“This can happen even with a so-called normal birth. But it occurs most often with high-tech births: when there are obsetric interventions that may make a woman feel as if she is being treated like an object. A birth experience in which a woman feels, ‘I didn't give birth. I had an operation', that she was 'like meat on a table', or 'it was like a rape' can result in post-traumatic stress, involving nightmares and panic attacks that adversely affect relationships with her baby and partner. This unhappiness is a result of the aggressive management of birth, typical of a mechanistic approach to the human body and childbirth that is governed by the clock.
“Our medicalised culture is one reason why it is important that there is a home birth alternative. Home birth offers a model on which hospitals should base practice, and that enables midwives to learn how to keep birth normal. Yet for many women, getting a home birth is an obstacle race.
“We need to change the system so that it is simple and straightforward for women to have home births. Birth should be something a woman feels she has achieved, rather than something that has been done to her.”
Pizza boys deliver, women birth
Michel Odent has been instrumental in influencing childbirth practice for decades. He is best known as the obstetrician who introduced birthing pools and home-like birthing rooms, asserting that women feel inhibited in an unfamiliar environment. Controversially, he also believes that the father's presence in the delivery room is the main reason for long and difficult labours.
“Silence and privacy are keywords where childbirth is concerned and birthing pools are useless if these needs are not understood. Yet NICE guidelines encourage midwives to talk to women (discussing birth plans, providing information, asking permission to perform procedures) and the word ‘privacy' never appears,” says Odent.
“A labouring woman needs first to be protected against any stimulation of the thinking part of her brain - the neocortex. This part of the brain needs to take a back seat and allow the primal ‘unthinking' part of the brain connected to basic vital functions to take over. A woman needs to be in a world where she doesn't need to think or talk.
“We need to smash the limits of political correctness where fathers' presence at birth is concerned. In his desire to ‘share the experience' the man asks questions, offers reassuring words and denies his partner the privacy that is one of her most basic needs.
“Studies show that the male presence slows down the process of labour and makes intervention more likely and yet this has become the cultural norm. Theories that emerged in the 1950s with the natural childbirth movement have simply made birth more complicated: women are told how to push or how to breathe, they are conditioned to believe that they are unable to give birth by themselves. The key words in the NICE guidelines are associated with management: women need ‘support', babies need to be ‘delivered'.
“The Free Birth movement advocates a woman's right to a totally unassisted birth. I like both their message and their motto: 'Pizza boys deliver, women birth!'
“It is true that immersion in warm water can help to reduce adrenalin and facilitate the birth process, making contractions more effective. However, after two hours of immersion there is a feedback effect, reducing levels of oxytocin and causing contractions to tail off. Hence birthing pools should not be used until a woman is well advanced in her labour.
“We are at a turning point in the history of childbirth. For centuries different cultures have interfered with the process of birth, imposing cultural rituals which ignore the basic physiological needs of mother and newborn. Now we must get back to basics.”
Revealed: the Butcher of Bega
THE SUNDAY TELEGRAPH (Australia)
By Clair Weaver and Carmel Melouney
February 24, 2008 12:00am
THEY call him the Butcher of Bega: a NSW doctor who has committed such monstrous acts that hundreds of terrified victims have remained silent for more than five years. Dr Graeme Stephen Reeves is alleged to have routinely mutilated or sexually abused as many as 500 female patients while he was working as a gynaecologist and obstetrician at various hospitals across Sydney and the NSW south coast. Despite the NSW Medical Board ruling he had psychiatric problems which "detrimentally affect his mental capacity to practice medicine'' more than a decade ago, he managed to continue treating women without detection in a devastating trail of botched operations and negligence. Hundreds of former patients have come forward with harrowing - and graphic - evidence about Dr Reeves, who was struck off in 2004 for breaching practice restrictions. As many as 500 emails from women were received by the private watchdog, Medical Error Action Group, last week telling of their humiliation and pain after parts of their genitals were removed or sewn up without their consent. The outpouring came after a former patient of Dr Reeves, Carolyn Dewaegeneire, broke her five-year silence with two other women to give a public account of her ordeal on Channel Nine's Sunday program last weekend. Despite the shocking revelations on the program, Dr Reeves is still not being investigated by the police, the NSW Medical Board or the Health Care Complaints Commission, over the latest allegations. He is also free to re-apply to return to medical work at any time after serving a three-year ban. The hospitals where Dr Reeves has practiced include HornsbyKu-ring-gai, Sydney Adventistat Wahroonga, The Hills Privateat Baulkham Hills, Royal Hospital for Women and the Bega and Pambula hospitals. Mrs. Dewaegeneire was admitted to Pambula Hospital on August 2002 to have a minor lesion removed from her labia. Before she lost consciousness to a general anaesthetic, she said Dr Reeves leaned over and whispered in her ear: "I'm going to take your clitoris, too''. After the operation she discovered all her external genitalia had been cut off her body. It is alleged Dr Reeves later boasted of removing "all the fun bits'' - and said she wouldn't need them as her husband had died. Lorraine Long, of the Medical Error Action Group, said she was inundated with emails from women complaining about Dr Reeves in the past week. She plans to have the women submit their evidence to police and pursue a class action against Dr Reeves for compensation. "Women are coming forward in droves from Bega, Pambula, Westmead, Hornsby and The Hills Private hospitals,'' she said. "We will have more power by acting together. (Health Minister) Reba Meagher has got to get to grips with this. “How did he escape detection for so long?'' For years, women in Bega and Pambula have been too frightened and ashamed to talk about their injuries - or their partners did not want them to go public, Ms Long said. Dr Reeves was struck off for gross misconduct in 2004 for continuing to do obstetric work in breach of conditions imposed on him by the Medical Board in 1997 following the deaths of a woman and a baby under his care. Another patient's life had also been endangered, the board found. It is understood the woman, a mother of three with post-natal depression, died after being refused antibiotics by Dr Reeves, despite pleas from nursing staff. He successfully escaped detection for two years by moving from Sydney - where he had been the subject of complaints by fellow medical staff at Hornsby Hospital - to the NSW south coast. He lied his way into a job as a gynaecologist and obstetrician at Bega and Pambula, claiming he wanted a "lifestyle change''. Neither his employer, the Greater Area Health Service (GSAHS), nor the NSW Medical Board made checks on his activities, which were restricted because of his previous record. But, incredibly, Dr Reeves was given a red-carpet welcome and was regarded as a prestigious addition to the Bega Valley hospital services. Announcing his employment, the then CEO of GSAHS, Dr Denise Robinson, told a local newspaper: "We are delighted that Dr Reeves has come to the area and we are very happy to see local women with access to this (gynaecological and obstetric) service in the Bega Valley once again.'' But women who had placed their trust in the new doctor were soon being allegedly betrayed in the most intimate of ways. The litany of complaints included losing a kidney, having genitals sewn up or cut up, inappropriate examinations, fondling and lewd comments. Andrew Dix, registrar and chief executive officer of the NSW Medical Board, told The Sunday Telegraph the board had already handed out to Dr Reeves its most severe punishment: deregistration. The board did not report him to the Director of Public Prosecutions for criminal negligence before 2004 because it did not have sufficient evidence and "there were in fact people who said that he was a competent gynaecologist'', he said. But Mr. Dix admitted if the board had known about all the allegations against him that have now surfaced "we would have treated it differently''. He said Dr Reeves was not regarded as having a serious mental illness when he was disciplined by the board in 1997. "There was no hard evidence of a major psychiatric illness,'' he said. But NSW Medical Tribunal documents show the board ordered Dr Reeves to have psychiatric treatment for his "personality and relations problems and depression''. By 2004, the board had noticed his "bare-faced lies'' and "deceptive conduct'', and subsequently struck him off for "gross professional misconduct of the most serious kind''. NSW Police said they were not currently investigating any medical complaints against Dr Reeves. Mr. Dix pledged that the NSW Medical Board would oppose any attempts by Dr Reeves to re-register. "One would say that, on the basis of the material available to us, we would be doing that quite vigorously.'' Improved measures since 2004 - like Internet access to the medical registry - would improve monitoring and prevent such situations being repeated, Mr. Dix said. He encouraged women with complaints to contact the board. Dr Reeves refused to comment on the allegations when The Sunday Telegraph visited him last week.
Saturday March 15, 05:57 AM
More Butcher of Bega victims emerge
More cases against the so-called Butcher of Bega continue to emerge. In the latest horror story said to involve the rogue doctor, twin babies died and their mother came close to death. It is one of the most shocking accounts yet to emerge linked to rogue obstetrician Graeme Reeves, which reveals health authorities knew of his gross negligence almost 10 years before he was struck off, The Sydney Morning Herald reports. It says at least three babies died under the care of Mr Reeves. This follows an investigation of court files, which paint an alarming picture of his negligence, incompetence and brutality.
The NSW government was forced to compensate Iwona Taborek at a cost of hundreds of thousands of dollars after her treatment at the hands of Mr Reeves in 1995. Her twins died at Hornsby Hospital and she almost bled to death after Mr Reeves tried to pull her placenta from her uterus using the wrong type of forceps and without any medication, resulting in severe lacerations to her vagina and cervix and uncontrollable haemorrhaging.
The case raises further serious questions about what the Health Care Complaints Commission and the NSW Medical Board knew of Mr Reeves, and about the role of health authorities in reporting such cases.
The unkindest cut
Mar 17, 2007 04:30 AM
Patients about to undergo surgery with Toronto obstetrician and gynecologist Dr. Richard Austin have no way of knowing that more than a dozen women have claimed they suffered physical and emotional harm under his care.
They wouldn't be aware that some of Austin's complication rates and unintentional cuts to internal organs are beyond what are acceptable, according to medical experts.
A search of the website of the College of Physicians and Surgeons of Ontario – the doctors' self-regulatory body – shows an unblemished record. And The Scarborough Hospital where he has surgical privileges does not make data on doctors available to the public.
No Ontario law compels physicians or hospitals to reveal details of a surgeon's performance, such as the number of operations performed, complaints, malpractice suits, settlements or complication rates.
But after searching public records at the Toronto courthouse, the Star discovered 14 women have filed suit against Austin since 1991.
Only one of the allegations has been proven in court, and there's no way of evaluating whether the number of lawsuits is unusual for an obstetrician-gynecologist. The Canadian Medical Protective Association, a publicly funded defence fund that pays patient compensation on behalf of physicians, doesn't disclose figures on lawsuits by medical specialty.
We don't know whether the cases were more complicated than usual, or whether the conditions in the operating room were less than ideal.
The overall number of suits against Austin is considered by experts to be above average.
Paul Harte, one of Canada's leading medical malpractice lawyers, called Austin's 14 malpractice claims "significantly higher than average."
There is a wall of silence surrounding what are called adverse events in Ontario hospitals, and there is no public transparency or accountability built into the system. In this case, the hospital won't comment, the college won't say anything and Austin, 63, declined repeated requests for an interview.
In a written statement to the newspaper, the doctor said he would "respond fully to any allegation in the proper forum at the proper time. I will not comment on these issues in the context of a newspaper article. I hope that the Toronto Star will not initiate a controversy that destroys my reputation and career in such circumstances."
Four of the 14 lawsuits filed since 1991 are still before the courts. A judgment was reached in one case in which a judge ruled Austin was guilty of battery against a patient. Five of the suits were settled out of court. Four were dropped, including three in which the complainants cited high legal costs as part of the decision to abandon their cases.
At least four women who launched lawsuits also filed complaints about the same incidents to the college. The Star interviewed a fifth woman who complained to the college about Austin last year and reporters stumbled upon a sixth complaint dating back to 1999 in a college document obtained through a patient.
So far, all of those complaints to the college have been handled in secret.
This is what some patients allege:
· Two say their newborn infants suffered permanent injury due to medical negligence
· At least five say they suffer incontinence problems or had to wear colostomy bags after having internal organs inadvertently cut during surgeries
· Two claim they awoke from surgery to find ovaries had been removed without their knowledge.
Court documents state Karen Astaphan had her right ovary removed due to painful cysts in 1992, but when she woke up, she was told Austin had taken out both. Almost two weeks later, after experiencing back pain and nausea, another doctor discovered a tube to her kidney called the ureter was completely blocked. Another operation opened it up.
In 1996, she sued Austin. The Ontario Court of Justice found that while the evidence against Austin didn't prove he fell below the "standard of care required by law," he was guilty of battery – "the unjustified application of force to the person of another" for the "loss of her left ovary and damage to her ureter." She was awarded $20,000 in damages.
Joanna Rozbicka-Czlapinski claims that a day after corrective bladder surgery under Austin's care in 1997, a nurse told her both of her ovaries had been removed against her wishes.
"I had no (female) organs, I was shallow," she says.
Rozbicka-Czlapinski settled out of court with Austin for $22,500, she said in an interview.
In Manitoba, patients can look up any malpractice judgments, criminal convictions or disciplinary actions on the province's College of Physicians and Surgeons' website.
In many American states, transparency and accountability is greater. The Massachusetts board of medicine website, for example, provides detailed disciplinary and court actions on every doctor including malpractice payouts, criminal convictions, pleas and admissions, any discipline taken by the hospital such as revocation or suspension of privileges, and any disciplinary action taken by the state regulatory board.
In Ontario, other than current and past disciplinary actions listed by the college on its website, no such information is available. In fact, only one per cent of the approximately 2,300 annual complaints lodged with the college actually result in a public hearing.
Virgin Anthony didn't complain in 1995, after the 57-year-old nursing home housekeeper says Austin accidentally cut her bladder during an abdominal hysterectomy. "My whole life turned around," she says now, describing how she is incontinent and prone to bladder infections.
It was a chance conversation with a friend last year that changed her mind. A colleague at work told her about a woman she knew who had "serious medical problems" after a surgery with Austin. Anthony eventually contacted Toronto lawyer Amani Oakley, who is representing three other women who are suing Austin for medical negligence.
Anthony couldn't sue because too much time had passed. But she filed a complaint with the College of Physicians and Surgeons last November alleging Austin had been "incompetent" in his treatment and that he "failed to advise her that he had had other complications when he performed this type of surgery." The complaint is still under consideration and no public hearing has been scheduled to date.
Hospitals, which closely monitor surgical complications and patient outcomes for their own internal records, do not make their data on physicians available to patients about to undergo surgery.
When someone like Anthony complains to the College of Physicians of Surgeons of Ontario, there's no public record unless the college schedules a disciplinary hearing.
Another patient, civil servant Kathleen Vieneer, complained to the college after she was admitted to The Scarborough Hospital in September 2002 for a hysterectomy. During the operation, her bowel was accidentally cut and, three days later, she lost consciousness and went into shock with respiratory failure, court records show. Three months later, after emergency surgery, she was finally discharged, but will have to wear a colostomy bag to collect feces for the rest of her life.
Vieneer alleged Austin performed her operation in a "substandard" way, and that he failed to approach her or her family after the surgery.
The college agrees Austin had poor bedside manner, and recommended his case be referred to the quality assurance committee, which identifies "deficiencies in physicians' medical care and service" and provides "appropriate remediation." Any findings it reached are not public.
The college decision also references a "strikingly similar concern respecting inadequate assessment of an in-hospital patient (that) was raised about Dr. Austin in a complaint heard by this committee in 1999."
The complaints committee said it "could not conclude" Austin performed the surgery in a substandard manner, but it did note the investigation was "rendered extremely difficult" because there was "not a single chart note by Dr. Austin from the time of the surgery" and "Dr. Austin's response to the college appears to contain inaccuracies."
College officials won't say how many complaints they've received against Austin.
"I am only able to confirm information that is on the public register; namely, that Dr. Austin in not currently the subject of a discipline hearing, and there is no previous finding by the discipline committee in relation to this doctor," says spokeswoman Kathryn Clarke.
But court documents provide a glimpse of the data available to hospital supervisors, and in Austin's case, they provide the only public information to date about his track record in the operating room.
They were filed as part of a $500,000 negligence lawsuit Vieneer filed against the gynecologist, his colleagues and the hospital in 2003.
Vieneer's lawyers asked the hospital for Austin's complication rates between 2000 and 2003. The hospital documents show Austin had complication rates – or unexpected problems related to a procedure – for total abdominal hysterectomies (the surgical removal of the uterus by an incision in the abdominal wall rather than the vagina) of 30 per cent in 2000, 30 per cent in 2001, 9 per cent in 2002 and 10 per cent in 2003.Complication rates are based on hospital patient outcome records.
A comprehensive 1992 study of more than 160,000 hysterectomies in Ohio – cited by the Society of Obstetrics and Gynecology of Canada in its clinical practice guidelines – found a complication rate of 9.1 per cent was average for abdominal hysterectomies, which means that Austin did not have a higher- than-average complication rate in 2002, the year Vieneer had her hysterectomy.
In a statement of defence filed in January 2004, Austin and his surgical assistant during the operation deny any negligence and say the surgery was "undertaken and performed in a careful, competent and prudent manner." They also deny Vieneer suffered "any damages or injuries for which they are responsible and put the plaintiff to the strict proof thereof."
In a separate statement of defence filed in court, Scarborough Hospital denies "any breach of duty, want of care, or negligence" and also denies that Vieneer "sustained the damages as alleged."
Experts were hesitant to speak publicly about another doctor's complication rates, saying they know nothing about Austin's practice, the types of patients he sees or if the number includes things such as pneumonia that are considered a complication even though they have nothing to do with the surgery.
However, seven experts contacted by the Star agreed a 30 per cent complication rate for total abdominal hysterectomies was high.
And in the Vieneer case, which is still before the courts, Scarborough Hospital officials detail Austin's "perforation" rates – unintended cuts to organs and tissue – which range from 2 per cent to 7 per cent over a four-year period.
"Overall, these numbers are too high," said Dr. Farr Nazhat, a professor of obstetrics and gynecology at Mount Sinai Medical Center in New York, referring to both the 30 per cent complication rate and the perforation rates.
"A seven per cent perforation rate is high and somebody has to look into it," says Nazhat who has published more than 100 peer-reviewed research papers in the areas of gynecology and obstetrics.
"It's seven times (higher than typical rates.)"
In cases where a surgeon displays a pattern of high complication rates, hospitals have a responsibility to monitor the problem closely, he pointed out.
Province-wide data on accidental cuts, lacerations or punctures during abdominal hysterectomies between 2002 and 2006 ranged between .02 and .09 per cent, according to the Canadian Institute for Health Information.
Of the 14 lawsuits against Austin, all but two name Scarborough Hospital as a defendant, alleging, among other things, that hospital officials knew of problems with Austin's surgical abilities but failed to monitor him or inform his patients.
Every year, doctors in Ontario are asked about their medical record as part of the process of renewing privileges required to work within hospital walls. At The Scarborough Hospital, each doctor must complete a form that includes the question: "Were there any adverse judgments, settlements, findings or decisions entered or made in any professional misconduct proceeding, peer review proceeding, or malpractice action wherein you were a party?"
This form is reviewed by the department chief then presented to a full hospital advisory committee for approval, said Dr. Steven Jackson, chief of medical staff. It then goes to the hospital's board of directors for final approval and reappointment.
Jackson says he can't recall a physician ever being denied reappointment at Scarborough Hospital. Austin continues to practise there and officials will say little about his record, though Jackson did say the process for awarding privileges has been followed in Austin's case.
"I can't really comment on individuals because there are matters in the court right now dealing with these types of issues," Jackson said in an interview.
When asked if he considered Austin's complication rate high, Jackson said: "I'm not an expert in that particular area. I couldn't tell you what the standards would be." Under the Hospitals Act, the board of directors of a hospital is ultimately responsible for appointing doctors, determining privileges, revoking or suspending the appointment, or refusing to reappoint a member of medical staff.
Since the Ontario Hospital Association doesn't keep track of suspensions, the Star called eight hospital corporations to ask if they've ever revoked a doctor's privileges. Most didn't respond, but Hamilton Health Sciences Centre said they once suspended privileges and the doctor quit. The University Health Network has dismissed two doctors in the past 10 years.
"The last time (we) did it was six years ago now," said Dr. John Wright, vice-president of medical affairs of the network, which includes Toronto General, Toronto Western and Princess Margaret hospitals. "But if a similar situation came up again I'd do whatever it took to safeguard staff and patients."
The process can take years because outside experts are called in to investigate, Wright explained. Both doctor and hospital are represented by lawyers when they go before the medical advisory board and, in the end, the doctor can appeal. It costs several hundred thousand dollars, according to Wright.
Meanwhile, some of Austin's former patients say they will live with the effects of his medical mistakes for the rest of their lives.
"It's very, very painful physically, emotionally," says Anthony, a divorced mother of two. "I'm still living with it."
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