Anonymous wrote:

Anonymous wrote:More bluntly: which groups of women pay the health price for training new physicians in the art of delivery, since PP seems to think preservation of that knowledge is so critical? Exactly which babies and delivering mothers get to be the training grounds? I would like to know from the PPs lamenting the loss of training in forceps births.

Who is paying the price for the new surgeons now? Where are they training to operate? Are they born with that knowledge?

Anonymous wrote:More bluntly: which groups of women pay the health price for training new physicians in the art of delivery, since PP seems to think preservation of that knowledge is so critical? Exactly which babies and delivering mothers get to be the training grounds? I would like to know from the PPs lamenting the loss of training in forceps births.

Anonymous wrote:

Anonymous wrote:In other words PP, which would you choose.

A hospital where there was not a single avoidable c section but where 3 in 100 women died or had a significant injury during childbirth and lets say 1 in every 100 babies died.

Or a hospital where they quickly leaped to c sections and say 15 of the 100 had c sections that would have been able to be avoided but only one woman in 100 died and less than 1 in 100 babies died.

Because I think that is the choice you are making, helping those 15 women avoid c sections has a higher value quotient then preventing those 2 women's deaths. If I am wrong, please correct me.

Well it all depends on what numbers you plug in after "let's say", doesn't it? Because it's a theoretical exercise, you are able to pick the numbers that work for you.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:The article noted many things - you only picked the parts that you like. But thanks for telling me what I believe.

It seemed you missed a very simple message of the essay: the doctor's bag is getting lighter. It used to be full of all kinds of tricks and tools, including the scalpel. Now, it's just the scalpel. Not because they believe the other tools won't work; it's because they don't know how to use them. They simply never learned. And that's why women with any deviations from the "uncomplicated vaginal birth" pathway find themselves with fewer options. Not because physicians believe these options aren't suitable, but mostly because they don't know how to use them. It's a very simplified picture, for sure, with lots of gray and nuanced parts, but that's the direction of travel. We should be able to acknowledge this as reality.

DP. Sure, but what is the point.of this acknowledgement if countering this, or as PP so eloquently said, "preserving artisanship," comes at such a high price to laboring mother's? I don't see the point of any acknowledgement when it would be unethical to take steps to preserve that artisanship.

On the contrary. It would be highly ethical to take steps to preserve these skills because they do work, and educate physicians on how to practice them safely, and when to progress to a C-section. At its most reduced, this line of thinking says: unless a vaginal birth is progressing perfectly, do a C-section. Don't learn to manage complications in any other way. At the tiniest sign of any variation, get the operating room ready. Not because you think a C-section is the best way to manage these complications, but because, simply, you don't know any other way. Truly, when all you have is a hammer...

Anonymous wrote:In other words PP, which would you choose.

A hospital where there was not a single avoidable c section but where 3 in 100 women died or had a significant injury during childbirth and lets say 1 in every 100 babies died.

Or a hospital where they quickly leaped to c sections and say 15 of the 100 had c sections that would have been able to be avoided but only one woman in 100 died and less than 1 in 100 babies died.

Because I think that is the choice you are making, helping those 15 women avoid c sections has a higher value quotient then preventing those 2 women's deaths. If I am wrong, please correct me.

Anonymous wrote:

Anonymous wrote:The article noted many things - you only picked the parts that you like. But thanks for telling me what I believe.

It seemed you missed a very simple message of the essay: the doctor's bag is getting lighter. It used to be full of all kinds of tricks and tools, including the scalpel. Now, it's just the scalpel. Not because they believe the other tools won't work; it's because they don't know how to use them. They simply never learned. And that's why women with any deviations from the "uncomplicated vaginal birth" pathway find themselves with fewer options. Not because physicians believe these options aren't suitable, but mostly because they don't know how to use them. It's a very simplified picture, for sure, with lots of gray and nuanced parts, but that's the direction of travel. We should be able to acknowledge this as reality.

I did not simply take out one thing. I took issue with the very heart of the argument. That the lack of tools comes from the fact that they found a more reliable tool, and while perhaps certain tools like forceps are better then c sections in the hands of experts, they overall lead to worse outcomes when applied on a large scale.

So, because this is what I think the conundrum is here, what is the acceptable maternal and fetal injury rate to preserve the 'art' of doctoring?

If every doctor in the country uses forceps first, in order to ensure that many doctors know how to use forceps well, and ensuring that many doctors use forceps poorly despite training is that an ethical choice when we know that if the standard of care moved to c sections more women and babies survived? Even if that is at the expense of some mothers who would have been able to avoid a c section (but perhaps not avoid a traumatic vaginal delivery). These are really difficult questions, but this essay seems to say that losing the 'art' of medicine is a shame while only quietly alluding to the fact that the reward of that loss is less death and birth injury. Why would we want to preserve procedures that injured more humans? That is against the oath.

Anonymous wrote:It’s major abdominal surgery. It’s expensive and not necessary a lot of the time.

Anonymous wrote:The article noted many things - you only picked the parts that you like. But thanks for telling me what I believe.

It seemed you missed a very simple message of the essay: the doctor's bag is getting lighter. It used to be full of all kinds of tricks and tools, including the scalpel. Now, it's just the scalpel. Not because they believe the other tools won't work; it's because they don't know how to use them. They simply never learned. And that's why women with any deviations from the "uncomplicated vaginal birth" pathway find themselves with fewer options. Not because physicians believe these options aren't suitable, but mostly because they don't know how to use them. It's a very simplified picture, for sure, with lots of gray and nuanced parts, but that's the direction of travel. We should be able to acknowledge this as reality.

Anonymous wrote:

Anonymous wrote:The article noted many things - you only picked the parts that you like. But thanks for telling me what I believe.

It seemed you missed a very simple message of the essay: the doctor's bag is getting lighter. It used to be full of all kinds of tricks and tools, including the scalpel. Now, it's just the scalpel. Not because they believe the other tools won't work; it's because they don't know how to use them. They simply never learned. And that's why women with any deviations from the "uncomplicated vaginal birth" pathway find themselves with fewer options. Not because physicians believe these options aren't suitable, but mostly because they don't know how to use them. It's a very simplified picture, for sure, with lots of gray and nuanced parts, but that's the direction of travel. We should be able to acknowledge this as reality.

DP. Sure, but what is the point.of this acknowledgement if countering this, or as PP so eloquently said, "preserving artisanship," comes at such a high price to laboring mother's? I don't see the point of any acknowledgement when it would be unethical to take steps to preserve that artisanship.

Anonymous wrote:The article noted many things - you only picked the parts that you like. But thanks for telling me what I believe.

It seemed you missed a very simple message of the essay: the doctor's bag is getting lighter. It used to be full of all kinds of tricks and tools, including the scalpel. Now, it's just the scalpel. Not because they believe the other tools won't work; it's because they don't know how to use them. They simply never learned. And that's why women with any deviations from the "uncomplicated vaginal birth" pathway find themselves with fewer options. Not because physicians believe these options aren't suitable, but mostly because they don't know how to use them. It's a very simplified picture, for sure, with lots of gray and nuanced parts, but that's the direction of travel. We should be able to acknowledge this as reality.

Anonymous wrote:

Anonymous wrote:
Your argument seems to be that whatever birth happens more frequently, that is the birth doctors are skilled in. But despite the fact that c sections only account for 1 in 3 births now you don't seem concerned that doctors don't have adequate skills to perform them. Even if it became 50/50 (which I do not think it will be) that would mean doctors would see vaginal births just as frequently as c sections and would of course be skilled in managing them.

You have no idea if those options would have been available to you with a younger doctor, that is purely hypothetical. And you seem to be extracting logical conclusions based on no real evidence.

Every C-section is the same. It's a standardized procedure. Every vaginal birth is different, and there are dozens of maneuvers that exist to deliver the baby. Even if vaginal births may constitute two-thirds of an ob's workload, he or she may not encounter the same technique more than once or twice a month. In that same month, he or she would have performed dozens of C-sections that differ little from each other.

That forceps may not have been offered to me with a younger doctor who isn't skilled in using them is what my 50+ yr old ob said, and I have no reason to doubt her. But it's OK if you don't trust the opinion of the doctor you've never met. Let's look at an authority no one doubts.

https://www.newyorker.com/magazine/2006/10/09/the-score

".....Forceps have virtually disappeared from the delivery wards, even though several studies have compared forceps delivery to Cesarean section and found no advantage for Cesarean section. (A few found that mothers actually did better with forceps.)...

....The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills—the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands.

But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.

....This procedure, once a rarity, is now commonplace. Whereas before obstetricians learned one technique for a foot dangling out, another for a breech with its arms above its head, yet another for a baby with its head jammed inside the pelvis, all tricky in their own individual ways, now the solution is the same almost regardless of the problem: the C-section. Every obstetrician today is comfortable doing a C-section. The procedure is performed with impressive consistency.

....We have reached the point that, when there’s any question of delivery risk, the Cesarean is what clinicians turn to—it’s simply the most reliable option. If a mother is carrying a baby more than ten pounds in size, if she’s had a C-section before, if the baby is lying sideways or in a breech position, if she has twins, if any number of potentially difficult situations for delivery arise, the standard of care requires that a midwife or an obstetrician at least offer a Cesarean section. Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth.

I asked Dr. Bowes how he would have handled obstructed deliveries like Rourke’s back in the sixties. His first recourse, as you’d expect, would have included forceps. He had delivered more than a thousand babies with forceps, he said, with a rate of neonatal injury as good as or better than with Cesarean sections, and a far faster recovery for the mothers. Had Rourke been under his care, the odds are excellent that she could have delivered safely without surgery. But Bowes is a virtuoso of a difficult instrument. When the protocols of his profession changed, so did he. “As a professor, you have to be a role model. You don’t want to be the cowboy who goes in to do something that your residents are not going to be able to do,” he told me. “And there was always uncertainty.” Even he had to worry that, someday, his judgment and skill would fail him.

These were the rules of the factory floor. To discourage the inexpert from using forceps—along with all those eponymous maneuvers—obstetrics had to discourage everyone from using them. When Bowes finished his career, in 1999, he had a twenty-four-per-cent Cesarean rate, just like the rest of his colleagues. He has little doubt that he’d be approaching thirty per cent, like his colleagues today, if he were still practicing.

...And yet there’s something disquieting about the fact that childbirth is becoming so readily surgical. Some hospitals are already doing Cesarean sections in more than half of child deliveries. It is not mere nostalgia to find this disturbing. We are losing our connection to yet another natural process of life. And we are seeing the waning of the art of childbirth. The skill required to bring a child in trouble safely through a vaginal delivery, however unevenly distributed, has been nurtured over centuries. In the medical mainstream, it will soon be lost."

https://www.newyorker.com/magazine/2006/10/09/the-score

But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I feel like it’s important to differentiate unassisted vaginal delivery from forceps/vacuum delivery. Does anyone know how instance of prolapse differs there? I feel like this is similar to the scheduled c vs c section after labor difference in outcomes. FWIW my birth classes didn’t spend much time on pelvic floor injuries but it was clear about the pros and cons of lots of interventions and I came away thinking c sections were WAY less scary than forceps. And this was a “natural birth” class too!

Anecdotally: I'm the one who mentioned her friend group and the friends with prolapse, and as I recall none of them had forceps or vacuum deliveries. My own mom had unassisted and unmedicated vaginal births and she developed serious prolapse issues in her 70s.

My mom had four babies vaginally, all pretty easy. Needed total reconstruction of her pelvic area/bladder in her 40s.

PP who asked: great to know, thank you both for the info!

PP here with the friend group I referenced. FWIW, my anecdotal sense is that post-vaginal-birth prolapse is actually very common, but because the medical system and society in general does not care about the medical problems of older women, it is swept under the rug or just normalized. You see it here too: “oh, women who had c-section also get prolapse.” Well, yes, but not at the same rate, and there is also a question of severity. There is a strong desire to hide or minimize pelvic floor damage to women for deeply misogynist reasons IMO.

Natural birth advocates are as guilty of this as the gerontologists who discount the suffering of older women.