Consortium for the Evidence-based practice of Obstetrics -- 
C.E.O. is dedicated to bringing science-based 
maternity care to all childbearing women

 Quotes and Excerpts from and 
 other respected sources  of professional information
on safety, complications & practice trends for obstetricians  

Bibliography, Recommended Reading and Scientific Citation from obstetrical sources for the: 

Medicalizing Normal Childbirth


Has the Medicalisation of Childbirth Gone Too Far?  BMJ 2002;324:892-895 (13 April)
Richard Johanson, professor of obstetrics a, Mary Newburn, head of policy research b, Alison Macfarlane, professor of perinatal health c.


Promoting Evidence-based practice in maternal care would keep the knife away; BMJ Vol 324 20 April 2002;


Childbirth, Pregnancy tied to PTSD, Experts say, Ob.Gyn.News; Mar 15 2003 Vol 38, No 6


Excerpts from “Adverse Perinatal Outcomes; Association of Women's Health, Obstetrical and Neonatal Nurses Journal (AWHONN) June| July 2003


Delayed consequences for baby of Narcotic Use in labor


Promoting Evidence-based practice in maternal care – would keep the knife away; Editorial -- BMJ  Vol 324 20 April 2002;  


In maternal health care, their is a recognized gap between evidence of effectiveness and clinical practice. Indeed, too often routine care is not evidence-based and there is a strong resistance to stopping harmful or useless procedures. Unnecessary caecarean section and episiotomy are good examples of the mismatch between evidence and practice and of the complexities that change entails as two articles in this issue illustrates.  


Unnecessary caecarean is known to increase health risks for both mother and newborn child and adds burdens to healthcare budgets. There has been a sustained growth in caesarean sections rates worldwide.... 


Contrary to anecdotal evidence that portrays Brazil as a place where women demand caesarean section, two recent articles show that providers, rather than patients, use women's alleged preference as an excuse to follow  their inclination. 


Informed choice is central to good quality care. Unfortunate, mother's decisions on obstetric procedures are too often anything but true exercises of free will: woman receive incomplete information, they voice their "preferences" while experiencing severe stress and pain, and (especially in developing countries) the social gap between patient and provider curbs their decision-making power. 


To achieve goals of providing women and families with the opportunity to become active players in their own healthy care, charges will have to occur. Firstly, technical quality and interaction between patients and professionals will have to improve; this includes explicitly offering women the chance to make informed health related decision using effective instruments which is itself is a challenge. 


.....while we continue to discuss unnecessary interventions, millions of women that require these procedures do not have access to them and risk their own and their children's lives



Childbirth, Pregnancy tied to PTSD, Experts say, Ob.Gyn.News; Mar 15 2003 Vol 38, No 6


Pregnancy and childbirth should added to the last of risk factors for posttraumatic stress disorder and diagnostic code for traumatic childbirth should be created...


"Every obstetrician .... has seen patients with posttraumatic stress disorder related to pregnancy and childbirth, but physician recognition of PTSD--- in all patients, including women who have had difficult births--is still low. 


Women who have traumatic births may not be able to fully articulate the event later on. 


The literature on PTSD and pregnancy and childbirth is scant and mostly from Europe.  "The Europeans are ahead of us and have been looking at what happens after birth in women," she said. 



 Adverse Perinatal Outcomes”; Excerpts // Kathleen Rice Simpson, PhD, RNC, FAAN & G. Eric Knox, MD
Association of Women's Health, Obstetrical and Neonatal Nurses Journal (AWHONN) June| July 2003


[This is an excerpt from a 9-page article in the AWHONN journal that drew on records of malpractice litigation as example of 'preventable' deaths or damage that are a result of systemic problems in medical care. What follows are simply the description of two such cases of "iatrogenic' (doctor-caused) or nosocomial (hospital employee cased) complications.]


Production Pressure: Haste Makes Waste


Elective Induction of Labor -- After the unit's daily limit of four elective labor induction was filled, a physician requested admission of another women for elective induction. The unit's three nurses were caring for the four women being inducted plus another women in spontaneous labor. 


The physician was informed that his patient would have to wait until there were enough nurses available to safely care for his patient. The physician called the nurse manager and demanded that his patient be admitted because of "decreased fetal movement" that had "developed" after the original request was refused. The nurse manager told the nurses to do what they could to accommodate the physician to begin the induction. 


The nurses argued for an immediate non-stress test and induction later that afternoon when staff were going to be available, but were overruled by the nurse-manager and the physician. ..... The admission process occurred over 35 minutes during which the other five patients were being cared for by two nurses. A patient of another physician had an fetal heart rate bradycardia lasting 25 minutes in the 60s secondary to uterine hysperstimulation and hypertonus [complication of induction in which the uterus dramatically over-reacts to the Pitocin]  Terbutaline .25 mg [a drug that counteracts the affects of Pitocin] was administered by subcutaneous injection and an emergent Cesarean birth was performed 27 minutes after the FHT bradycardia was noted. The baby was born depressed with Apgar scores of 3 at one minute and 4 at five minutes. Umbilical artery cord pH was 6.86 with a base excess of -17.  The baby developed cerebral palsy. 


A jury held the institution responsible for inadequte maternal-fetal assessment during oxytocin administration. 


Pressure, Speed and Impacted Shoulders -- A woman was completely dilated at 2:10pm. The physician was called for impending birth and arrived at 2:30 pm. On examination the fetal head was noted to be at +2 station. An office full of patients was waiting; the physician did not feel there was time to wait for spontaneous fetal decent. He asked the nurse for fundal pressure while he applied forceps. She reluctantly agreed and the fetal head was brought down to +4 station with forceps and fundal pressure. The head was delivered at 2:35 pm, but shoulder but shoulder dystocia occurred. Eight minutes later the fetal body was delivered


The baby was non-responsive at birth with Apgar scores of 0-1-3. The baby suffered neurologic damage and developed cerebral palsy. During the litigation process, it was discovered that fundal pressure was routinely used at this hospital to shorten the second stage of labor for convenience. Up to this time there had been only reports of minor injuries to several mother and babies but no significant adverse outcomes. The liability claim was settled prior to trial for 5.6 million with each paying half. 


Discussion: Production Pressure


The fundamental issue facing every organization is the constant tension between production and protection. Under most circumstances, an organization leans toward production at the expense of safety for two reasons (Reason, 1997). First, those who manage organization are trained in, develop and possess production rather than safety skills


Whether implicitly understood or not an important task of nurse and physicians is a continuous series of choices between production and safety.  .... Production pressure and miscommunication, as illustrated in the preceding two stories, are two of the most important factors that contribute to and are the cause of loss of situational awareness, an important cause of medical accidents and patient harm. 


Photographic Sampler of Medicalized Labor & Normal Childbirth as a “Surgical Procedure”