Letters To The Editor

An either/or choice is not a good strategy for pain

I found Dr. Barbieri’s editorial on postpartum opioid use and breastfeeding interesting, but one key issue was not addressed: Following this guidance means that new mothers have to choose between breastfeeding and pain control. You may explain to a patient with 2-day cesarean delivery pain, “If you take pain medicine while breastfeeding, it can adversely affect the baby. So we will give you acetaminophen.” While some moms will deal with it, others will stop breastfeeding. With the increasing pressure to advocate for breastfeeding, this strategy is likely not realistic.

R. Lee Toler, DO
Bolivia, North Carolina

My pain management protocol

While presently in an office-based setting, back in my inpatient practice days I would order oxycodone plus acetaminophen for 1 to 2 days postoperative cesarean delivery, and only 1 day after normal spontaneous delivery if the patient had a large perineal repair or multiparous involution pain. Otherwise, it was ibuprofen 800 mg, then 400 to 600 mg on discharge home.

Gabrielle Long, CNM
Mohegan Lake, New York

Respect women’s postsurgical pain management needs

There is a real disrespect for pain control for women, such as after a cesarean delivery. I would like to see any male have major surgery through a large muscle like the uterus and not need significant pain control options!

Anne V. Hale, MD
El Paso, Texas

Dr. Barbieri responds

I agree with Ms. Long that most postpartum patients, including many who have had a cesarean delivery, can achieve adequate pain control with the use of parenteral and oral nonsteroidal anti-inflammatory drugs (NSAIDs) and oral acetaminophen. Drs. Toler and Hale are concerned that postpartum pain control might be suboptimal if opioids are underprescribed. However, in many developed countries obstetricians do not use opioid pain medicine for postpartum pain management, relying on NSAIDs and acetaminophen. Given the success of this approach, I think we can significantly reduce the use of opioids by postpartum women in the United States by optimizing our use of nonopioid medications.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

An either/or choice is not a good strategy for pain

I found Dr. Barbieri’s editorial on postpartum opioid use and breastfeeding interesting, but one key issue was not addressed: Following this guidance means that new mothers have to choose between breastfeeding and pain control. You may explain to a patient with 2-day cesarean delivery pain, “If you take pain medicine while breastfeeding, it can adversely affect the baby. So we will give you acetaminophen.” While some moms will deal with it, others will stop breastfeeding. With the increasing pressure to advocate for breastfeeding, this strategy is likely not realistic.

R. Lee Toler, DO
Bolivia, North Carolina

My pain management protocol

While presently in an office-based setting, back in my inpatient practice days I would order oxycodone plus acetaminophen for 1 to 2 days postoperative cesarean delivery, and only 1 day after normal spontaneous delivery if the patient had a large perineal repair or multiparous involution pain. Otherwise, it was ibuprofen 800 mg, then 400 to 600 mg on discharge home.

Gabrielle Long, CNM
Mohegan Lake, New York

Respect women’s postsurgical pain management needs

There is a real disrespect for pain control for women, such as after a cesarean delivery. I would like to see any male have major surgery through a large muscle like the uterus and not need significant pain control options!

Anne V. Hale, MD
El Paso, Texas

Dr. Barbieri responds

I agree with Ms. Long that most postpartum patients, including many who have had a cesarean delivery, can achieve adequate pain control with the use of parenteral and oral nonsteroidal anti-inflammatory drugs (NSAIDs) and oral acetaminophen. Drs. Toler and Hale are concerned that postpartum pain control might be suboptimal if opioids are underprescribed. However, in many developed countries obstetricians do not use opioid pain medicine for postpartum pain management, relying on NSAIDs and acetaminophen. Given the success of this approach, I think we can significantly reduce the use of opioids by postpartum women in the United States by optimizing our use of nonopioid medications.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

An either/or choice is not a good strategy for pain

I found Dr. Barbieri’s editorial on postpartum opioid use and breastfeeding interesting, but one key issue was not addressed: Following this guidance means that new mothers have to choose between breastfeeding and pain control. You may explain to a patient with 2-day cesarean delivery pain, “If you take pain medicine while breastfeeding, it can adversely affect the baby. So we will give you acetaminophen.” While some moms will deal with it, others will stop breastfeeding. With the increasing pressure to advocate for breastfeeding, this strategy is likely not realistic.

R. Lee Toler, DO
Bolivia, North Carolina

My pain management protocol

While presently in an office-based setting, back in my inpatient practice days I would order oxycodone plus acetaminophen for 1 to 2 days postoperative cesarean delivery, and only 1 day after normal spontaneous delivery if the patient had a large perineal repair or multiparous involution pain. Otherwise, it was ibuprofen 800 mg, then 400 to 600 mg on discharge home.

Gabrielle Long, CNM
Mohegan Lake, New York

Respect women’s postsurgical pain management needs

There is a real disrespect for pain control for women, such as after a cesarean delivery. I would like to see any male have major surgery through a large muscle like the uterus and not need significant pain control options!

Anne V. Hale, MD
El Paso, Texas

Dr. Barbieri responds

I agree with Ms. Long that most postpartum patients, including many who have had a cesarean delivery, can achieve adequate pain control with the use of parenteral and oral nonsteroidal anti-inflammatory drugs (NSAIDs) and oral acetaminophen. Drs. Toler and Hale are concerned that postpartum pain control might be suboptimal if opioids are underprescribed. However, in many developed countries obstetricians do not use opioid pain medicine for postpartum pain management, relying on NSAIDs and acetaminophen. Given the success of this approach, I think we can significantly reduce the use of opioids by postpartum women in the United States by optimizing our use of nonopioid medications.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Consider thalassemia traits in patients with iron deficiency

The editorial is an excellent review of iron deficiency as an associated finding with adverse health and pregnancy outcomes. However, one genetic issue appears to have escaped comment. In Florida, our African American patients have a commonly found association with microcytic anemia at least as often as iron deficiency: a variety of α- and ß-thalassemia traits that may occur individually or together. Other racial groups, including Mediterranean and Asian patients, also may carry both the α- and ß-thalassemia traits.

Your recommendation to routinely screen for ferritin deficit is laudable as a general health care practice. If the screening result is normal, however, consider thalassemia carrier states as a secondary explanation as well as a genetic issue requiring partner testing. Aggressive iron loading of a nondeficient anemic patient can risk excess absorption, storage, and ultimate organ compromise in later life if continued indefinitely.

Richard P. Perkins, MD
Fort Myers, Florida
 

Patient education is key to managing iron deficiency

Forty years ago, my professors expounded on how some people could not absorb iron and that the answer was intravenous iron infusion. After writing a few prescriptions, however, I found that I no longer had patients with absorptive problems once I learned to carefully, and with visual aids, explain the iron story and meticulously monitor compliance. I have been through the “slow Fe” and the “prenatal vitamins have iron” nonsense. Ferrous sulfate is about as good as anything. I have explained the theory of vitamin C−assist and found that telling people to avoid taking iron with meals is folly.

I suggest that the iron story is complete. Rather than wasting money on further research, we should spend funds on teaching young physicians to educate patients and monitor compliance. In recent years, I have found that a daily text message to the patient frequently is very helpful.

Robert W. Jackson, MD
Washougal, Washington

Dr. Barbieri responds

I thank Drs. Perkins and Jackson for their helpful recommendations for the management of iron deficiency anemia. I agree with Dr. Perkins that screening for thalassemia is an important part of preconception and prenatal care. In the editorial’s table on page 10 discussing the differential diagnosis of anemia, we mentioned the importance of hemoglobin electrophoresis and measurement of vitamin B12 and folate levels to identify cases of anemia caused by thalassemia or vitamin deficiency. I agree with Dr. Jackson that oral iron supplementation along with patient education can resolve most cases of iron deficiency in early and mid-pregnancy. However, in the last few weeks of pregnancy there may not be sufficient time for oral iron supplementation to be effective in resolving iron deficiency anemia. In this situation and in patients at high risk for malabsorption, including women with prior gastric bypass, intravenous iron might be the best approach to resolving the anemia.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Consider thalassemia traits in patients with iron deficiency

The editorial is an excellent review of iron deficiency as an associated finding with adverse health and pregnancy outcomes. However, one genetic issue appears to have escaped comment. In Florida, our African American patients have a commonly found association with microcytic anemia at least as often as iron deficiency: a variety of α- and ß-thalassemia traits that may occur individually or together. Other racial groups, including Mediterranean and Asian patients, also may carry both the α- and ß-thalassemia traits.

Your recommendation to routinely screen for ferritin deficit is laudable as a general health care practice. If the screening result is normal, however, consider thalassemia carrier states as a secondary explanation as well as a genetic issue requiring partner testing. Aggressive iron loading of a nondeficient anemic patient can risk excess absorption, storage, and ultimate organ compromise in later life if continued indefinitely.

Richard P. Perkins, MD
Fort Myers, Florida
 

Patient education is key to managing iron deficiency

Forty years ago, my professors expounded on how some people could not absorb iron and that the answer was intravenous iron infusion. After writing a few prescriptions, however, I found that I no longer had patients with absorptive problems once I learned to carefully, and with visual aids, explain the iron story and meticulously monitor compliance. I have been through the “slow Fe” and the “prenatal vitamins have iron” nonsense. Ferrous sulfate is about as good as anything. I have explained the theory of vitamin C−assist and found that telling people to avoid taking iron with meals is folly.

I suggest that the iron story is complete. Rather than wasting money on further research, we should spend funds on teaching young physicians to educate patients and monitor compliance. In recent years, I have found that a daily text message to the patient frequently is very helpful.

Robert W. Jackson, MD
Washougal, Washington

Dr. Barbieri responds

I thank Drs. Perkins and Jackson for their helpful recommendations for the management of iron deficiency anemia. I agree with Dr. Perkins that screening for thalassemia is an important part of preconception and prenatal care. In the editorial’s table on page 10 discussing the differential diagnosis of anemia, we mentioned the importance of hemoglobin electrophoresis and measurement of vitamin B12 and folate levels to identify cases of anemia caused by thalassemia or vitamin deficiency. I agree with Dr. Jackson that oral iron supplementation along with patient education can resolve most cases of iron deficiency in early and mid-pregnancy. However, in the last few weeks of pregnancy there may not be sufficient time for oral iron supplementation to be effective in resolving iron deficiency anemia. In this situation and in patients at high risk for malabsorption, including women with prior gastric bypass, intravenous iron might be the best approach to resolving the anemia.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Consider thalassemia traits in patients with iron deficiency

The editorial is an excellent review of iron deficiency as an associated finding with adverse health and pregnancy outcomes. However, one genetic issue appears to have escaped comment. In Florida, our African American patients have a commonly found association with microcytic anemia at least as often as iron deficiency: a variety of α- and ß-thalassemia traits that may occur individually or together. Other racial groups, including Mediterranean and Asian patients, also may carry both the α- and ß-thalassemia traits.

Your recommendation to routinely screen for ferritin deficit is laudable as a general health care practice. If the screening result is normal, however, consider thalassemia carrier states as a secondary explanation as well as a genetic issue requiring partner testing. Aggressive iron loading of a nondeficient anemic patient can risk excess absorption, storage, and ultimate organ compromise in later life if continued indefinitely.

Richard P. Perkins, MD
Fort Myers, Florida
 

Patient education is key to managing iron deficiency

Forty years ago, my professors expounded on how some people could not absorb iron and that the answer was intravenous iron infusion. After writing a few prescriptions, however, I found that I no longer had patients with absorptive problems once I learned to carefully, and with visual aids, explain the iron story and meticulously monitor compliance. I have been through the “slow Fe” and the “prenatal vitamins have iron” nonsense. Ferrous sulfate is about as good as anything. I have explained the theory of vitamin C−assist and found that telling people to avoid taking iron with meals is folly.

I suggest that the iron story is complete. Rather than wasting money on further research, we should spend funds on teaching young physicians to educate patients and monitor compliance. In recent years, I have found that a daily text message to the patient frequently is very helpful.

Robert W. Jackson, MD
Washougal, Washington

Dr. Barbieri responds

I thank Drs. Perkins and Jackson for their helpful recommendations for the management of iron deficiency anemia. I agree with Dr. Perkins that screening for thalassemia is an important part of preconception and prenatal care. In the editorial’s table on page 10 discussing the differential diagnosis of anemia, we mentioned the importance of hemoglobin electrophoresis and measurement of vitamin B12 and folate levels to identify cases of anemia caused by thalassemia or vitamin deficiency. I agree with Dr. Jackson that oral iron supplementation along with patient education can resolve most cases of iron deficiency in early and mid-pregnancy. However, in the last few weeks of pregnancy there may not be sufficient time for oral iron supplementation to be effective in resolving iron deficiency anemia. In this situation and in patients at high risk for malabsorption, including women with prior gastric bypass, intravenous iron might be the best approach to resolving the anemia.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The prevalent reason offered for increased mortality rates during weekend hours are shortages in staffing and services. The “weekend effect,” elucidated by Pauls et al.¹ in their recent meta-analysis, and the accompanying editorial by Quinn and Bell,² highlight these and other potential causes for this anomaly.

Pauls et al.¹ also cite patient selection bias as a possible explanation for the uptick in deaths during this span (off-hour admissions may be sicker). It is due to the latter that we wish to highlight additional studies published after mid-2013 when the authors concluded their search.

Recent disputes within the UK’s National Health Service³ concerning health system funding spurred timely papers in BMJ⁴ and Lancet⁵ on the uncertainty. They both discovered a stronger signal from patient characteristics admitted during this time rather than on-hand resources and workforce. These new investigations strengthen the support for patient acuity as a determinant in explaining worse outcomes.

We highlight these manuscripts so investigators will continue their attempts to understand the weekend phenomena as suggested by both Pauls et al.¹ and the editorialists.² To allow for the delivery of correct interventions, we must understand its root causes. In this case, it may be the unique features of patients presenting on Saturdays and Sundays and, hence, would require a different set of process changes.

Disclosure: The authors declare no conflict of interest.

The prevalent reason offered for increased mortality rates during weekend hours are shortages in staffing and services. The “weekend effect,” elucidated by Pauls et al.¹ in their recent meta-analysis, and the accompanying editorial by Quinn and Bell,² highlight these and other potential causes for this anomaly.

Pauls et al.¹ also cite patient selection bias as a possible explanation for the uptick in deaths during this span (off-hour admissions may be sicker). It is due to the latter that we wish to highlight additional studies published after mid-2013 when the authors concluded their search.

Recent disputes within the UK’s National Health Service³ concerning health system funding spurred timely papers in BMJ⁴ and Lancet⁵ on the uncertainty. They both discovered a stronger signal from patient characteristics admitted during this time rather than on-hand resources and workforce. These new investigations strengthen the support for patient acuity as a determinant in explaining worse outcomes.

We highlight these manuscripts so investigators will continue their attempts to understand the weekend phenomena as suggested by both Pauls et al.¹ and the editorialists.² To allow for the delivery of correct interventions, we must understand its root causes. In this case, it may be the unique features of patients presenting on Saturdays and Sundays and, hence, would require a different set of process changes.

Disclosure: The authors declare no conflict of interest.

The prevalent reason offered for increased mortality rates during weekend hours are shortages in staffing and services. The “weekend effect,” elucidated by Pauls et al.¹ in their recent meta-analysis, and the accompanying editorial by Quinn and Bell,² highlight these and other potential causes for this anomaly.

Pauls et al.¹ also cite patient selection bias as a possible explanation for the uptick in deaths during this span (off-hour admissions may be sicker). It is due to the latter that we wish to highlight additional studies published after mid-2013 when the authors concluded their search.

Recent disputes within the UK’s National Health Service³ concerning health system funding spurred timely papers in BMJ⁴ and Lancet⁵ on the uncertainty. They both discovered a stronger signal from patient characteristics admitted during this time rather than on-hand resources and workforce. These new investigations strengthen the support for patient acuity as a determinant in explaining worse outcomes.

We highlight these manuscripts so investigators will continue their attempts to understand the weekend phenomena as suggested by both Pauls et al.¹ and the editorialists.² To allow for the delivery of correct interventions, we must understand its root causes. In this case, it may be the unique features of patients presenting on Saturdays and Sundays and, hence, would require a different set of process changes.

Disclosure: The authors declare no conflict of interest.

We would like to thank Drs. Flansbaum and Sheehy for their interest in our article.¹ We appreciate their mentioning the highly publicized disputes and additional manuscripts^2,3 that were published after our literature review, which was conducted in 2013.

As discussed by Drs. Flansbaum and Sheehy and the editorial accompanying our article,⁴ the precise contributions, if any, of various potential factors (eg, patient characteristics, resources, workforce) to the development of the weekend effect is uncertain at this time; although, as mentioned by Drs. Flansbaum and Sheehy, more recent work^2,3 suggests that patient characteristics may be a more important determinant on outcomes.

Despite the uncertainty surrounding the exact composition and contributions of various elements to the weekend effect, it does appear to be a real phenomenon, as noted by the editorialists.⁴ We hope that our manuscript encourages future investigators to help elucidate the nature of the input contributing to the weekend effect.

We would like to thank Drs. Flansbaum and Sheehy for their interest in our article.¹ We appreciate their mentioning the highly publicized disputes and additional manuscripts^2,3 that were published after our literature review, which was conducted in 2013.

As discussed by Drs. Flansbaum and Sheehy and the editorial accompanying our article,⁴ the precise contributions, if any, of various potential factors (eg, patient characteristics, resources, workforce) to the development of the weekend effect is uncertain at this time; although, as mentioned by Drs. Flansbaum and Sheehy, more recent work^2,3 suggests that patient characteristics may be a more important determinant on outcomes.

Despite the uncertainty surrounding the exact composition and contributions of various elements to the weekend effect, it does appear to be a real phenomenon, as noted by the editorialists.⁴ We hope that our manuscript encourages future investigators to help elucidate the nature of the input contributing to the weekend effect.

We would like to thank Drs. Flansbaum and Sheehy for their interest in our article.¹ We appreciate their mentioning the highly publicized disputes and additional manuscripts^2,3 that were published after our literature review, which was conducted in 2013.

As discussed by Drs. Flansbaum and Sheehy and the editorial accompanying our article,⁴ the precise contributions, if any, of various potential factors (eg, patient characteristics, resources, workforce) to the development of the weekend effect is uncertain at this time; although, as mentioned by Drs. Flansbaum and Sheehy, more recent work^2,3 suggests that patient characteristics may be a more important determinant on outcomes.

Despite the uncertainty surrounding the exact composition and contributions of various elements to the weekend effect, it does appear to be a real phenomenon, as noted by the editorialists.⁴ We hope that our manuscript encourages future investigators to help elucidate the nature of the input contributing to the weekend effect.

FOR THE MANAGEMENT OF LABOR, PATIENCE IS A VIRTUE
ROBERT L. BARBIERI, MD (EDITORIAL; AUGUST 2017)

Questions value of ACOG/SMFM guidelines

The labor management guidelines recommended by the American College of Obstetricians and Gynecologists (ACOG) and the Society of Maternal-Fetal Medicine (SMFM) are terrible. Now retired, I trained in 1959–1963. In my career as an obstetrician, my primary cesarean delivery rate was 10% or less, and part of that was external pressure from people who did not know how to deliver a baby. Persistent occiput posterior position is a problem of inadequate flexion of the head, often due to ineffective contractions earlier. In such a situation, “pit” early! Rotate the head if you must, and teach residents how, please. The guidelines do not discuss the exhausted mother who goes home after a long labor or hours of pushing. I have interviewed new obstetricians in my community as early as 1980 who did not know what deep transverse arrest was. There, I am done voicing my disgust with obstetrics as it is practiced today.

James Honig, MD
Merritt Island, Florida

Managing difficult labor scenarios

I concur with Dr. Barbieri’s views on labor management that watchful waiting and giving the patient adequate time to progress naturally is the key to increase the chances of vaginal delivery. After all, labor is a physiologic process and should progress naturally. Having said that, I would like to know Dr. Barbieri’s views on handling certain circumstances in which patients these days land in the labor room, including 1) postdatedpregnancy with reduced fetal movements and not in labor; 2) full-term/postterm pregnancy with free-floating head and poor Bishop score; 3) full-term pregnancy with niggling pains for more than 1 week; and many such conditions that place you in the dilemma of whether to induce, knowing that chances of failure are high.

Manju Hotchandani, MD
New Delhi, India

Midwives always use patience to guide labor

As a Certified Nurse-Midwife since 1985 (now retired), “patience” in managing labor has always been my guide, as it has been for my midwifery colleagues. This is another example of ACOG finally acknowledging the truths we women have always known, without crediting the wisdom of midwives over the centuries. Lamaze International’s 6 Healthy Birth Practices also must have been their guide. “Evolving concepts of normal labor progress,” as though this was new information, would be humorous if it were not so frustrating!

Marsha Kelly, CNM
Charlotte, North Carolina

Dr. Barbieri responds

The readers of OBG Management have vast clinical experience, and we can all learn from their insights and guidance. On behalf of all our readers, I thank Drs. Honig and Hotchandani and Ms. Kelly for taking the time to share their expert advice.

Every clinician involved in the birth process is deeply committed to a safe delivery for both mother and baby. Clinicians guide the birth process based on the unique characteristics and needs of each woman. Dr. Honig advocates for the active management of the labor process, while Ms. Kelly advocates for less intervention. Both approaches to labor management may be optimal depending on the unique clinical needs of each woman. Dr. Hotchandani inquires about managing common obstetric presentations. In my practice, induction is recommended for all women postterm who report consistently reduced fetal movement with the goal of reducing the risk of sudden intrauterine fetal demise. For healthy women at term with painful contractions and reassuring fetal status, but no cervical change, we support and counsel the patient and offer therapeutic rest with morphine. For women at term with a floating head and poor Bishop score, we would not intervene, until 41 weeks’ gestation when we would initiate gentle cervical ripening with mechanical or pharmacologic treatment.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

FOR THE MANAGEMENT OF LABOR, PATIENCE IS A VIRTUE
ROBERT L. BARBIERI, MD (EDITORIAL; AUGUST 2017)

Questions value of ACOG/SMFM guidelines

The labor management guidelines recommended by the American College of Obstetricians and Gynecologists (ACOG) and the Society of Maternal-Fetal Medicine (SMFM) are terrible. Now retired, I trained in 1959–1963. In my career as an obstetrician, my primary cesarean delivery rate was 10% or less, and part of that was external pressure from people who did not know how to deliver a baby. Persistent occiput posterior position is a problem of inadequate flexion of the head, often due to ineffective contractions earlier. In such a situation, “pit” early! Rotate the head if you must, and teach residents how, please. The guidelines do not discuss the exhausted mother who goes home after a long labor or hours of pushing. I have interviewed new obstetricians in my community as early as 1980 who did not know what deep transverse arrest was. There, I am done voicing my disgust with obstetrics as it is practiced today.

James Honig, MD
Merritt Island, Florida

Managing difficult labor scenarios

I concur with Dr. Barbieri’s views on labor management that watchful waiting and giving the patient adequate time to progress naturally is the key to increase the chances of vaginal delivery. After all, labor is a physiologic process and should progress naturally. Having said that, I would like to know Dr. Barbieri’s views on handling certain circumstances in which patients these days land in the labor room, including 1) postdatedpregnancy with reduced fetal movements and not in labor; 2) full-term/postterm pregnancy with free-floating head and poor Bishop score; 3) full-term pregnancy with niggling pains for more than 1 week; and many such conditions that place you in the dilemma of whether to induce, knowing that chances of failure are high.

Manju Hotchandani, MD
New Delhi, India

Midwives always use patience to guide labor

As a Certified Nurse-Midwife since 1985 (now retired), “patience” in managing labor has always been my guide, as it has been for my midwifery colleagues. This is another example of ACOG finally acknowledging the truths we women have always known, without crediting the wisdom of midwives over the centuries. Lamaze International’s 6 Healthy Birth Practices also must have been their guide. “Evolving concepts of normal labor progress,” as though this was new information, would be humorous if it were not so frustrating!

Marsha Kelly, CNM
Charlotte, North Carolina

Dr. Barbieri responds

The readers of OBG Management have vast clinical experience, and we can all learn from their insights and guidance. On behalf of all our readers, I thank Drs. Honig and Hotchandani and Ms. Kelly for taking the time to share their expert advice.

Every clinician involved in the birth process is deeply committed to a safe delivery for both mother and baby. Clinicians guide the birth process based on the unique characteristics and needs of each woman. Dr. Honig advocates for the active management of the labor process, while Ms. Kelly advocates for less intervention. Both approaches to labor management may be optimal depending on the unique clinical needs of each woman. Dr. Hotchandani inquires about managing common obstetric presentations. In my practice, induction is recommended for all women postterm who report consistently reduced fetal movement with the goal of reducing the risk of sudden intrauterine fetal demise. For healthy women at term with painful contractions and reassuring fetal status, but no cervical change, we support and counsel the patient and offer therapeutic rest with morphine. For women at term with a floating head and poor Bishop score, we would not intervene, until 41 weeks’ gestation when we would initiate gentle cervical ripening with mechanical or pharmacologic treatment.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

FOR THE MANAGEMENT OF LABOR, PATIENCE IS A VIRTUE
ROBERT L. BARBIERI, MD (EDITORIAL; AUGUST 2017)

Questions value of ACOG/SMFM guidelines

The labor management guidelines recommended by the American College of Obstetricians and Gynecologists (ACOG) and the Society of Maternal-Fetal Medicine (SMFM) are terrible. Now retired, I trained in 1959–1963. In my career as an obstetrician, my primary cesarean delivery rate was 10% or less, and part of that was external pressure from people who did not know how to deliver a baby. Persistent occiput posterior position is a problem of inadequate flexion of the head, often due to ineffective contractions earlier. In such a situation, “pit” early! Rotate the head if you must, and teach residents how, please. The guidelines do not discuss the exhausted mother who goes home after a long labor or hours of pushing. I have interviewed new obstetricians in my community as early as 1980 who did not know what deep transverse arrest was. There, I am done voicing my disgust with obstetrics as it is practiced today.

James Honig, MD
Merritt Island, Florida

Managing difficult labor scenarios

I concur with Dr. Barbieri’s views on labor management that watchful waiting and giving the patient adequate time to progress naturally is the key to increase the chances of vaginal delivery. After all, labor is a physiologic process and should progress naturally. Having said that, I would like to know Dr. Barbieri’s views on handling certain circumstances in which patients these days land in the labor room, including 1) postdatedpregnancy with reduced fetal movements and not in labor; 2) full-term/postterm pregnancy with free-floating head and poor Bishop score; 3) full-term pregnancy with niggling pains for more than 1 week; and many such conditions that place you in the dilemma of whether to induce, knowing that chances of failure are high.

Manju Hotchandani, MD
New Delhi, India

Midwives always use patience to guide labor

As a Certified Nurse-Midwife since 1985 (now retired), “patience” in managing labor has always been my guide, as it has been for my midwifery colleagues. This is another example of ACOG finally acknowledging the truths we women have always known, without crediting the wisdom of midwives over the centuries. Lamaze International’s 6 Healthy Birth Practices also must have been their guide. “Evolving concepts of normal labor progress,” as though this was new information, would be humorous if it were not so frustrating!

Marsha Kelly, CNM
Charlotte, North Carolina

Dr. Barbieri responds

The readers of OBG Management have vast clinical experience, and we can all learn from their insights and guidance. On behalf of all our readers, I thank Drs. Honig and Hotchandani and Ms. Kelly for taking the time to share their expert advice.

Every clinician involved in the birth process is deeply committed to a safe delivery for both mother and baby. Clinicians guide the birth process based on the unique characteristics and needs of each woman. Dr. Honig advocates for the active management of the labor process, while Ms. Kelly advocates for less intervention. Both approaches to labor management may be optimal depending on the unique clinical needs of each woman. Dr. Hotchandani inquires about managing common obstetric presentations. In my practice, induction is recommended for all women postterm who report consistently reduced fetal movement with the goal of reducing the risk of sudden intrauterine fetal demise. For healthy women at term with painful contractions and reassuring fetal status, but no cervical change, we support and counsel the patient and offer therapeutic rest with morphine. For women at term with a floating head and poor Bishop score, we would not intervene, until 41 weeks’ gestation when we would initiate gentle cervical ripening with mechanical or pharmacologic treatment.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“FOR THE MANAGEMENT OF LABOR, PATIENCE IS A VIRTUE”
ROBERT L. BARBIERI, MD (EDITORIAL; AUGUST 2017)

Questions value of ACOG/SMFM guidelines

The labor management guidelines recommended by the American College of Obstetricians and Gynecologists (ACOG) and the Society of Maternal-Fetal Medicine (SMFM) are terrible. Now retired, I trained in 1959–1963. In my career as an obstetrician, my primary cesarean delivery rate was 10% or less, and part of that was external pressure from people who did not know how to deliver a baby. Persistent occiput posterior position is a problem of inadequate flexion of the head, often due to ineffective contractions earlier. In such a situation, “pit” early! Rotate the head if you must, and teach residents how, please. The guidelines do not discuss the exhausted mother who goes home after a long labor or hours of pushing. I have interviewed new obstetricians in my community as early as 1980 who did not know what deep transverse arrest was. There, I am done voicing my disgust with obstetrics as it is practiced today.

James Honig, MD
Merritt Island, Florida

Managing difficult labor scenarios

I concur with Dr. Barbieri’s views on labor management that watchful waiting and giving the patient adequate time to progress naturally is the key to increase the chances of vaginal delivery. After all, labor is a physiologic process and should progress naturally. Having said that, I would like to know Dr. Barbieri’s views on handling certain circumstances in which patients these days land in the labor room, including 1) postdated pregnancy with reduced fetal movements and not in labor; 2) full-term/post-term pregnancy with free-floating head and poor Bishop score; 3) full-term pregnancy with niggling pains for more than 1 week; and many such conditions that place you in the dilemma of whether to induce, knowing that chances of failure are high.

Manju Hotchandani, MD
New Delhi, India

Midwives always use patience to guide labor

As a Certified Nurse-Midwife since 1985 (now retired), “patience” in managing labor has always been my guide, as it has been for my midwifery colleagues. This is another example of ACOG finally acknowledging the truths we women have always known, without crediting the wisdom of midwives over the centuries. Lamaze International’s 6 Healthy Birth Practices also must have been their guide. “Evolving concepts of normal labor progress,” as though this was new information, would be humorous if it were not so frustrating!

Marsha Kelly, CNM
Charlotte, North Carolina

Dr. Barbieri responds

The readers of OBG Management have vast clinical experience, and we can all learn from their insights and guidance. On behalf of all our readers, I thank Drs. Honig and Hotchandani and Ms. Kelly for taking the time to share their expert advice.

Every clinician involved in the birth process is deeply committed to a safe delivery for both mother and baby. Clinicians guide the birth process based on the unique characteristics and needs of each woman. Dr. Honig advocates for the active management of the labor process, while Ms. Kelly advocates for less intervention. Both approaches to labor management may be optimal depending on the unique clinical needs of each woman. Dr. Hotchandani inquires about managing common obstetrical presentations. In my practice, induction is recommended for all women post-term who report consistently reduced fetal movement with the goal of reducing the risk of sudden intrauterine fetal demise. For healthy women at term with painful contractions and reassuring fetal status, but no cervical change, we support and counsel the patient and offer therapeutic rest with morphine. For women at term with a floating head and poor Bishop score, we would not intervene, until 41 weeks’ gestation when we would initiate gentle cervical ripening with mechanical or pharmacologic treatment.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“FOR THE MANAGEMENT OF LABOR, PATIENCE IS A VIRTUE”
ROBERT L. BARBIERI, MD (EDITORIAL; AUGUST 2017)

Questions value of ACOG/SMFM guidelines

The labor management guidelines recommended by the American College of Obstetricians and Gynecologists (ACOG) and the Society of Maternal-Fetal Medicine (SMFM) are terrible. Now retired, I trained in 1959–1963. In my career as an obstetrician, my primary cesarean delivery rate was 10% or less, and part of that was external pressure from people who did not know how to deliver a baby. Persistent occiput posterior position is a problem of inadequate flexion of the head, often due to ineffective contractions earlier. In such a situation, “pit” early! Rotate the head if you must, and teach residents how, please. The guidelines do not discuss the exhausted mother who goes home after a long labor or hours of pushing. I have interviewed new obstetricians in my community as early as 1980 who did not know what deep transverse arrest was. There, I am done voicing my disgust with obstetrics as it is practiced today.

James Honig, MD
Merritt Island, Florida

Managing difficult labor scenarios

I concur with Dr. Barbieri’s views on labor management that watchful waiting and giving the patient adequate time to progress naturally is the key to increase the chances of vaginal delivery. After all, labor is a physiologic process and should progress naturally. Having said that, I would like to know Dr. Barbieri’s views on handling certain circumstances in which patients these days land in the labor room, including 1) postdated pregnancy with reduced fetal movements and not in labor; 2) full-term/post-term pregnancy with free-floating head and poor Bishop score; 3) full-term pregnancy with niggling pains for more than 1 week; and many such conditions that place you in the dilemma of whether to induce, knowing that chances of failure are high.

Manju Hotchandani, MD
New Delhi, India

Midwives always use patience to guide labor

As a Certified Nurse-Midwife since 1985 (now retired), “patience” in managing labor has always been my guide, as it has been for my midwifery colleagues. This is another example of ACOG finally acknowledging the truths we women have always known, without crediting the wisdom of midwives over the centuries. Lamaze International’s 6 Healthy Birth Practices also must have been their guide. “Evolving concepts of normal labor progress,” as though this was new information, would be humorous if it were not so frustrating!

Marsha Kelly, CNM
Charlotte, North Carolina

Dr. Barbieri responds

The readers of OBG Management have vast clinical experience, and we can all learn from their insights and guidance. On behalf of all our readers, I thank Drs. Honig and Hotchandani and Ms. Kelly for taking the time to share their expert advice.

Every clinician involved in the birth process is deeply committed to a safe delivery for both mother and baby. Clinicians guide the birth process based on the unique characteristics and needs of each woman. Dr. Honig advocates for the active management of the labor process, while Ms. Kelly advocates for less intervention. Both approaches to labor management may be optimal depending on the unique clinical needs of each woman. Dr. Hotchandani inquires about managing common obstetrical presentations. In my practice, induction is recommended for all women post-term who report consistently reduced fetal movement with the goal of reducing the risk of sudden intrauterine fetal demise. For healthy women at term with painful contractions and reassuring fetal status, but no cervical change, we support and counsel the patient and offer therapeutic rest with morphine. For women at term with a floating head and poor Bishop score, we would not intervene, until 41 weeks’ gestation when we would initiate gentle cervical ripening with mechanical or pharmacologic treatment.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“FOR THE MANAGEMENT OF LABOR, PATIENCE IS A VIRTUE”
ROBERT L. BARBIERI, MD (EDITORIAL; AUGUST 2017)

Questions value of ACOG/SMFM guidelines

The labor management guidelines recommended by the American College of Obstetricians and Gynecologists (ACOG) and the Society of Maternal-Fetal Medicine (SMFM) are terrible. Now retired, I trained in 1959–1963. In my career as an obstetrician, my primary cesarean delivery rate was 10% or less, and part of that was external pressure from people who did not know how to deliver a baby. Persistent occiput posterior position is a problem of inadequate flexion of the head, often due to ineffective contractions earlier. In such a situation, “pit” early! Rotate the head if you must, and teach residents how, please. The guidelines do not discuss the exhausted mother who goes home after a long labor or hours of pushing. I have interviewed new obstetricians in my community as early as 1980 who did not know what deep transverse arrest was. There, I am done voicing my disgust with obstetrics as it is practiced today.

James Honig, MD
Merritt Island, Florida

Managing difficult labor scenarios

I concur with Dr. Barbieri’s views on labor management that watchful waiting and giving the patient adequate time to progress naturally is the key to increase the chances of vaginal delivery. After all, labor is a physiologic process and should progress naturally. Having said that, I would like to know Dr. Barbieri’s views on handling certain circumstances in which patients these days land in the labor room, including 1) postdated pregnancy with reduced fetal movements and not in labor; 2) full-term/post-term pregnancy with free-floating head and poor Bishop score; 3) full-term pregnancy with niggling pains for more than 1 week; and many such conditions that place you in the dilemma of whether to induce, knowing that chances of failure are high.

Manju Hotchandani, MD
New Delhi, India

Midwives always use patience to guide labor

As a Certified Nurse-Midwife since 1985 (now retired), “patience” in managing labor has always been my guide, as it has been for my midwifery colleagues. This is another example of ACOG finally acknowledging the truths we women have always known, without crediting the wisdom of midwives over the centuries. Lamaze International’s 6 Healthy Birth Practices also must have been their guide. “Evolving concepts of normal labor progress,” as though this was new information, would be humorous if it were not so frustrating!

Marsha Kelly, CNM
Charlotte, North Carolina

Dr. Barbieri responds

The readers of OBG Management have vast clinical experience, and we can all learn from their insights and guidance. On behalf of all our readers, I thank Drs. Honig and Hotchandani and Ms. Kelly for taking the time to share their expert advice.

Every clinician involved in the birth process is deeply committed to a safe delivery for both mother and baby. Clinicians guide the birth process based on the unique characteristics and needs of each woman. Dr. Honig advocates for the active management of the labor process, while Ms. Kelly advocates for less intervention. Both approaches to labor management may be optimal depending on the unique clinical needs of each woman. Dr. Hotchandani inquires about managing common obstetrical presentations. In my practice, induction is recommended for all women post-term who report consistently reduced fetal movement with the goal of reducing the risk of sudden intrauterine fetal demise. For healthy women at term with painful contractions and reassuring fetal status, but no cervical change, we support and counsel the patient and offer therapeutic rest with morphine. For women at term with a floating head and poor Bishop score, we would not intervene, until 41 weeks’ gestation when we would initiate gentle cervical ripening with mechanical or pharmacologic treatment.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.