Optimal Care in Childbirth: The Case for a Physiologic Approach

Amy Romano Henci Goer


SKU: MI4028 Author: ,

Meticulously documented, Optimal Care in Childbirth: The Case for a Physiologic Approach pulls back the curtain on medical-model management of childbirth. Written for those who want to practice according to the best evidence, assist women in making informed decisions, or advocate for maternity care reforms, Optimal Care in Childbirth provides an in-depth analysis of the evidence basis for physiologic care as the standard of care. The book examines:

  • why the research shows so little benefit for physiologic care and so little harm from medical-model management
  • what’s behind the cesarean epidemic
  • what the research establishes as optimal care for initiating labor, facilitating labor progress, guarding maternal and fetal safety, birthing the baby, and promoting safety for mother and baby after the birth
  • the true, quantified risks of primary cesarean surgery, planned VBAC versus elective repeat cesarean, instrumental vaginal delivery, and regional analgesia
  • how the organization of the maternity care system adversely impacts care outcomes

About the Authors

Henci Goer, award-winning medical writer and internationally known speaker, has made it her life’s work to analyze and synthesize the maternity care research in order to determine what constitutes safe, effective, satisfying care in childbirth. An independent scholar, she has become an acknowledged expert on evidence-based maternity care. Her first book, Obstetric Myths Versus Research Realities, to which this book is the successor, was a valued resource for childbirth professionals. Wanting to give pregnant women and their families the same access to the research evidence and therefore the ability to make informed decisions about their care, she followed it with The Thinking Woman’s Guide to a Better Birth.

Amy Romano has worked in the maternity care field as a clinician, research analyst, educator, and consumer advocate since 2001. In 2010, she joined Childbirth Connection, where she directs the Transforming Maternity Care Partnership, a national effort to improve maternity care quality in the United States. Prior to joining Childbirth Connection, she practiced midwifery in the home, birth center, and hospital settings and taught in the nurse-midwifery program at the Yale School of Nursing. She also spent six years as a perinatal research and advocacy consultant to Lamaze International, where she analyzed, summarized, and critiqued research for the Lamaze community and launched the award-winning research blog, Science & Sensibility. Romano was also a member of the editorial team for the 9th edition of the landmark women’s health book, Our Bodies, Ourselves, released in 2011. She received her undergraduate degree from the University of Michigan and both a certificate and masters’ degree in nursing at the Yale School of Nursing. Romano was the 2012 recipient of the Kitty Ernst Award, one of the American College of Nurse-Midwives’ highest honors.

USA 2012

Table of Contents

Section I: Introduction

Chapter 1: Why This Book? The Failure of Obstetric Management

  • Two Contrasting Models: By Their Fruits Ye Shall Know Them
  • Obstetric Management: Broken Promises
  • Obstacles to Change: The Usual and Not-So-Usual Suspects

Chapter 2: Why This Book? The Failure of Obstetric Research

  • Evidence-Based Medicine: the New Dogma
  • The Limitations of Medical Model-Based Research

Chapter 3: About This Book: The Nuts and Bolts  Read the Chapter

  • Our Mini-Review Methods

Section II The Cesarean Epidemic

Chapter 4: The Chase to the Cut

  • A History of the Cesarean Epidemic
  • Rationales for the Cesarean Epidemic: “Round Up the Usual Suspects”
  • “If You Don’t Want to Get Cut, Don’t Go to a Surgeon”
  • What Is Really Driving the Cesarean Rate?
  • Elective Cesarean Surgery: Who Gets to Vote in This Election?
  • The Disinformation Campaign
  • ACOG Ethics: An Exercise in Sophistry

Chapter 5: The Case Against Liberal Use of Cesarean Surgery

  • Liberal Use of Cesarean: Bad for Mothers
  • Liberal Use of Cesarean: Bad for Babies
  • Liberal Use of Cesarean: The Gift That Keeps on Giving
  • Liberal Use of Cesarean: Anything Good about It?
  • Strategies for Optimal Care
  • Mini-Reviews

Chapter 6: The Case Against Elective Repeat Cesarean

  • What Are the Tradeoffs Between Planned VBAC and Elective Repeat Surgery?
  • Who Should Labor? . . . Any Woman Who Wants To
  • What Scar Rupture and VBAC Rates Should Be Achievable?
  • What Policies and Practices Produce the Best Outcomes in Women Planning VBAC?
  • Strategies for Optimal Care
  • Mini-Reviews

Section III: Optimal Care for Initiating Labor

Chapter 7: Inducing Labor: Patience Is a Virtue

  • Elective Induction
  • Prophylactic Induction
  • Antenatal Tests: The Emperor Has No Clothes
  • Induction and Cervical Ripening: The Method in the Madness
  • Strategies for Optimal Care
  • Mini-Reviews

Section IV: Optimal Care for Promoting Labor Progress

Chapter 8: Promoting Progress in First-Stage Labor: Yes We Can

  • The Four Preventive P’s
  • Obstacles to Practicing the Four P’s
  • The Root of the Problem: A Closer Look at Research Principles
  • An Ounce of Prevention is Worth a Pound of Cure
  • Strategies for Optimal Care
  • Mini-Reviews

Chapter 9: Augmentation: Forced Labor

  •  Active Management of Labor: Fiction Versus Fact
  •  The AMoL Toolbox: The Parts Are No Better Than the Whole
  •  Labor Dystocia as State of Mind
  •  Strategies for Optimal Care
  •  Mini-Reviews

Section V: Optimal Care for Guarding Safety and Wellbeing in Labor

Chapter 10: Electronic Fetal Monitoring (Cardiotocography): Minding the Baby

  • EFM, the Early Years: Self-Interest, 1; Science, 0
  • The Facts About EFM
  • Why Doesn’t EFM Work as Predicted?
  • EFM, the Later Years: Refusal to Face Facts
  • EFM and Conflicts of Interest
  • Why Does Use of Continuous EFM Persist?
  • Is the Routine Use of Continuous EFM Ethical?
  • Strategies for Optimal Care
  • Mini-Reviews

Chapter 11: Routine IVs Versus Oral Intake in Labor:  Read a Passage
“Water, Water Everywhere, Nor Any Drop to Drink”

  • How Risky Is Oral Intake in Labor?
  • Is There Any Value to Oral Intake?
  • Are IVs an Adequate Replacement for Oral Intake?
  • Why Doesn’t Evidence Change Practice?
  • Strategies for Optimal Care
  • Mini-Reviews

Chapter 12: Epidurals and Combined Spinal-Epidurals:  Read a Passage
The “Cadillacs” of Analgesia

  • Under the Hood
  • The Great Debates: Do Epidurals Affect Cesarean Delivery? Do They Affect Newborn Behavior?
  • Qui Bono? (Who Benefits?)
  • What Do Women Want?
  • Strategies for Optimal Care
  • Mini-Reviews

Section VI: Optimal Care for Birthing the Baby

Chapter 13: Second-Stage Labor: Lead, Follow, or Get out of the Way?

  • Giving Birth Versus Being Delivered
  • Critiquing Managed Second Stage: Shortcomings in the Research
  • Glimpses in the Fog: What Can Be Gathered from the Research?
  • Is Physiologic Second Stage Harmful?
  • Clearing the Slate: Optimal Care for Women in Second Stage
  • Strategies for Optimal Care
  • Mini-Reviews

Chapter 14: Instrumental Vaginal Delivery and Fundal Pressure:
When Push Comes to Pull—or Shove

A Short History of Instrumental Vaginal Delivery and Fundal Pressure
Underlying Unities of the Bipolar Viewpoint
The Truth, the Whole Truth, and Nothing But the Truth About Instrumental Delivery and Fundal Pressure
Strategies for Optimal Care

Chapter 15: Episiotomy: The Unkindest Cut  Read a Passage

The Case Against Episiotomy
What Do Obstetricians Know and When Did They Know It?
Why Hasn’t Episiotomy Withered Away?
The “Cut Above”: Déjà Vu All Over Again?
Strategies for Optimal Care

Section VII: Optimal Care for After the Birth

Chapter 16: Third-Stage Labor Active Management: The Wrong Answer to the Right Question

  •  Would Universal Application of Active Management of Third Stage Improve Outcomes?
  •  Did Expectant Management Get a Fair Trial?
  •  What About Harms?
  •  Medical Model Bias and the Triumph of Cognitive Dissonance
  •  The Case for a New Approach
  •  Strategies for Optimal Care
  •  Mini-Reviews

Chapter 17: Newborn Practices: Don’t Just Do Something; Sit There!

  • Active Management of Newborn Transition: How We Got Here
  • When Intervening Becomes the Norm
  • First, Do No Harm
  • Strategies for Optimal Care
  • Mini-Reviews

Section VIII: Optimal Practice for a Maternity Care System

Chapter 18: Supportive Care in Labor: Mothering the Mother Versus Serving the Doctor

  • Missing in Action: Why Isn’t Supportive Care Part of the Package?
  • Why Isn’t Supportive Care Part of the Package? Effects of the Medical Model
  • Why Isn’t Supportive Care Part of the Package? Effects of the Institutional Social Structure
  • Why Isn’t Supportive Care Part of the Package? The Doula Paradox
  • Harms of the System: “Power Corrupts; Absolute Power Corrupts Absolutely”
  • What Perpetuates This Dysfunctional System?
  • Mini-Reviews

Chapter 19: Midwife-Led Care: Organizing an Optimal Maternity Care System

  • What Constitutes an Optimal Maternity Care System?
  • Midwives: The Optimal Primary Care Providers
  • Is Midwife-Led Care Only for Low-Risk Women?
  • Obstacles to Change
  • Beacons of Hope?
  • Mini-Reviews

Chapter 20: The Place of Birth: Birth Homes

  • What to Expect in a Birth Center
  • But What About Safety?
  • Better Safe Than Sorry?
  • Are We Asking the Wrong Question?
  • Integrating Birth Centers into a System of Maternity Care
  • Mini-Reviews

Chapter 21: The Place of Birth: Home Births

  • Beliefs About Safety Among Women Choosing Home Birth
  • Do Women Consider Risks of Home Birth?
  • VBACs and Breeches and Twins, Oh Why?
  • Do We Know if Home Birth is Safe?
  • Mini-Reviews


  • Optimal Care for Protecting Maternal Mental Health: “If Mama Ain’t Happy, Ain’t Nobody Happy”
  • Optimal Care for Not-So-Optimal Babies: The Plus-Sized Baby: What’s the Big Deal?, The Malpositioned Baby: Rotation, Rotation, Rotation!, The Baby with Meconium Staining: Meconium Happens

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