Transcript
Speaker: Welcome! I'm Michelle Manzing. A mother? an actress. and a board -certified OBGYN. who spent the last 40 years delivering babies.
Speaker: The national C -section rate. is 32 .5 % and climbing. Mine is 9. percent.
Speaker: The difference is no accident. I studied it. And I practice what I call informed patients. Too many C -sections are done in the name of safety.
Speaker: with very little attention. paid to asking why. So in this show. through stories and science. I explore why so many unnecessary C -sections happen in the United States and what we can do about it.
Speaker: because the best way to stay off the cutting edge. May... be as simple as asking why.
Speaker: I am... a person who questions a lot. And it got me into trouble. As an OBGYN resident.
Speaker: Because during my second year. I was fortunate enough to be able to take an elective. that most people in Obstetrics and Gynecology. don't get to take.
Speaker: It was supposed to be an elective. in human sexuality, which you'd think obstetricians and gynecologists. are to be experts in But honestly.
Speaker: Another aside. We don't have any training in that.
Speaker: But I had some extra time and my department chair agreed. So I... was assigned to follow. a PhD sex therapist.
Speaker: named Sally Schumacher. No. Sally's. Patients weren't. particularly thrilled to have somebody hanging out. while they're doing their sex therapy things so quite quickly we discovered that we were going to have to do something else.
Speaker: And it was a wonderful experience for me because... Sally spent... hours with me before I even began my rotation with her. Just... consciousness -raising making me think about why it was.
Speaker: that I wanted to go into obstetrics and gynecology. It was a quite wonderful experience, especially like when you're a resident, you are so busy.
Speaker: You're working. Back then we worked. 90 hours a week or more. So having a place to just reflect on why you're doing. Your specialty is like unheard of.
Speaker: But did it? I did it. And I enjoyed it. And so in the process of discovering why I wanted to go into women's health, I wanted to...
Speaker: See what a birthing center was all about. I wanted to learn what midwives did because the only midwife that we had in my residency program was a very nice woman, but she just took...
Speaker: Histories. In the... Attendance clinics. And that's it. She never delivered any babies. That was quite different than what happened when I was in medical school at the University of Miami. the midwives had quite thriving over busy practice.
Speaker: So they were wonderful to work with. If you wanted to do a delivery and actually have it be. a fulfilling experience. You try to get along with a midwife back then.
Speaker: Nothing like that was happening at my residency program. in Winston -Salem, North Carolina. So we... decided together, Libby. ah sally and i that we would go to a birth center in high point north carolina And the midwife, the certified nurse midwife that was in charge of that clinic.
Speaker: was named Libby Dixon. Oh. I went in. With Sally, she accompanied me, and it's a little bit of a drive from Winston -Salem to High Point.
Speaker: I went in and. I got it. Meet Libby. And. interview her or interview me to decide if it's going to work out if I spent some time.
Speaker: shadowing her. at the ah birth center that she had. It was a freestanding birth center. Just across the parking lot. from the High Point Hospital. So it was a safe transfer if people were having problems.
Speaker: What a change that was from what was happening. but My residency program. The first six months of my residency program. I must have done 200 C -sections.
Speaker: That's all I got to do. My hands got... a rash. all the way up my arms because I washed them so many times a day. We barely got to do any vaginal deliveries. They wanted us to be like really good at doing C -sections before we could do anything else. Now, these weren't patients that we took care of. These were patients of the attendings because we work with a lot of private attendings or they were patients of the service.
Speaker: who were run by the residents, but also under the auspices of a um faculty attending So that's where I spent my life on obstetrics. And it wasn't exciting to me.
Speaker: It was somewhat intimidating. It's not that I didn't love doing surgery, but I really wanted to. do some deliveries. I actually got... Jawas. of the Family medicine docs.
Speaker: Who got. to do all the deliveries. So I went. To the high point. talk with Libby and one of the most embarrassing things that happened was I'm sitting in this really homey environment in her office.
Speaker: And Sally's sitting next to me on a... ah Love, Steve. And I started feeling kind of like uncomfortable. And it was like, if I don't just go ahead and say it.
Speaker: i'm not being true to the purpose of being here so i blurted out How does the doctor let you deliver babies? and She just kind of looked at me and... had a little
Speaker: She wasn't. upset with me. She just kind of... smiled. And I realized what a stupid thing I just said because... She's independently practiced.
Speaker: are licensed to practice. I couldn't understand how that doctor could let her do that. So she just said, well, you know, you're a second year resident now. and You...
Speaker: Work with interns, right? And they go, yeah. She goes, are you just going to let an intern? do a delivery the first time you see them? And I'm going, no. She goes, well. How do you... Let them finally do a delivery.
Speaker: And I go, well, I work with them and I... watch them, and I make sure that they're doing it correctly, and then I back off. She said exactly.
Speaker: That's how it works. Probably doesn't have to be quite. as close looking as that for a midwife because they've been trained where a family A medicine intern coming onto an obstetric service has no reason to. have had any experience delivering babies.
Speaker: But that was... I think the moment that our friendship began because we got past it. I dared to ask? And she, in her kind way.
Speaker: took this audaciously stupid question and just made something of it. So I did. work. With Libby. during that two -month block. I didn't go there every day. I did a lot of other things, but I did a fair amount of observing how they managed things as a midwifery practice.
Speaker: And. What I noticed was that all the interventions that we were doing At. The Mecca? Winston -Salem, North Carolina Baptist, actually Forsyth Memorial Hospital.
Speaker: were not being done there. They didn't do electronic fetal monitoring. I don't think I ever saw him intentionally rupture someone's membranes, break the amniotic sac.
Speaker: I... Never saw him cut an episiotomy. I rarely saw patients with IVs. I certainly never saw.
Speaker: something that's called the intrauterine pressure catheter. And the patients just didn't get C -sections.
Speaker: They'd have to go to the hospital if they did. They were low -risk patients. And they got their care for cheaper because they didn't have to go to the hospital. So there were a lot of people that were self -pay.
Speaker: They have the strangest library of books for people to read. I was so taken by one. I don't think I'll ever forget. It was a...
Speaker: book on how to cook your placenta. I was like, cook your placenta? Don't they just go down to the lab to get... incinerated.
Speaker: But no, they're people that... I found out. bury their placentas next to trees that they plant when their child's born. And some people believe that eating pieces of the placenta is good for regenerating what you lose. um During. a pregnancy.
Speaker: So that was an odd experience. There was a video. It was a Bradley video. And I remember that too. No anesthesia. All of our patients, unless they came in really late, were pretty much getting epidurals. It was about 85%.
Speaker: This one, they're on a table. They do their delivery. This is shown in the video. And then they get up and walk from the delivery table to wherever they're going postpartum. And I just sat there with my mouth open like.
Speaker: They could have the baby and get up and walk. So that clearly was not happening at the hospital. So there were a lot of differences in the way things were practiced and the people. the women and their partners were so engaged in their care, they were actually Asking questions and challenging a little bit and bringing other weird books to add to the library.
Speaker: Oh. I was. Stunned with how much diversity. of choices there could possibly be when what I was practicing, what I'd seen in medical school, what I was seeing in residency, was very confined.
Speaker: Very confined and very intervention. centered.
Speaker: When I realized that... And that time I was watching her. There weren't any patients that went to get a C -section. It turns out their C -section rate was like 5 % or 6 % of people that would get transferred to the hospital or maybe needed to have a C -section because their baby was breached and they didn't do breach deliveries. So it was very different because our C -section rate was over 25%.
Speaker: to 23%. So... I had a question. My question was... Why do midwives have lower C -section rates? than obstetricians. And I found out that family medicine docs have a C -section rate somewhere in between the two.
Speaker: For low -risk patients, because if you talk to an OB, b they'll go, oh no, you know, it's... it's It's different. It's apples and oranges.
Speaker: We have different low -risk patients. That's nonsense. A low -risk patient is a low -risk patient. You can make a low -risk patient a high -risk patient by doing things to them. But in general, if they're designated as low -risk, it doesn't matter if they belong to a midwife or a family doc or an obstetrician. So I figured something is going on, and I think the interventions have something to do with it.
Speaker: And. I was looking up the the simplest intervention. Well. let's Let's go back a step. Sally. said to me,
Speaker: I'd like for you to do a research paper. and propose a study that we can... Have you do? on labor and delivery and i was like back putting no no no no no i do not have time i do not want to do research she goes oh just just just humor me just come up with a study and let's see what happens So my question was, why did...
Speaker: Why do midwives have... Such lower C -section rate. And. I thought well, They... Don't do interventions, and we do. So let's look at an intervention. The most common intervention. that we did was something called AROM, A, capital A.
Speaker: capital R, capital O. capital M, which stands for artificial rupture of membranes, snagging the bag. breaking the water. Now there's a belief amongst obstetricians A lot of other people.
Speaker: But when you do that, it speeds up labor. But... The menopause patients were doing just fine and they weren't on any clock. They just labored like they labored and then they delivered.
Speaker: So I wondered, you know, like, is it possible that... By doing something as simple as snagging that bag. you You begin to think.
Speaker: that if... A body does not speed up labor. that there's something wrong with it. And that maybe if you think there's something wrong with it, you'll do something else.
Speaker: to try to so you know make it be right again. And so that was my premise. Does artificial rupture of membranes actually speed up labor? And I had a nice little study that I figured out for it. It was kind of fun to figure out the forms of the study and everything. And then she said, okay, well, that looks great. Now I want you to present it to the department. And I was like, no, no, no, no, no, no. I wrote this for you, but I don't want to.
Speaker: turn you know Turn it into the department. I really don't want to do a study. I don't have time. she just just do me a favor and go to the research meeting and present it.
Speaker: So I loved her so much. I was like, okay. So I went to the research meeting and I presented the justification. for why I wanted to do the research, which was basically there wasn't any good documentation that artificial rupture of membranes.
Speaker: sped up labor. And there was a question that was justifiable about why obstetricians had more C -sections than ah certified nurse midwives. And I'd found this little study from Germany that showed that the more interventions that were done,
Speaker: the more likely the patient was to have a C -section. So that was the... weigh in. And... So I presented it. And the perinatal.
Speaker: Section head. Basically... sneered at me. and said, Who do you think you are? To question. the knowledge of our forefathers.
Speaker: All right. was like. I'm in front of a group of about 10 attendings. Humiliated at this point. Because I just... I thought I was presenting something.
Speaker: That was asking a research question. But suddenly I was being raked over the coals. Because I dared to ask a question. And. The whole idea of... you know of of Ugh.
Speaker: of blaspheming our forefathers was an interesting twist on it. But. I'm in front of them. They're not saying anything. And he's just like...
Speaker: quizzing me of course i could justify everything about what i wanted to do but I could barely talk because I just wanted to cry. I, my eyes were filling with tears. I was so humiliated. I just wanted to get out of that room that I never wanted to go in in the first place. So he dismissed me. I got out of there. And I just.
Speaker: Outside the room, i I just burst into tears. and And... the biostatistician. followed me out. And he said,
Speaker: Dr. Manting, are you okay? And I'm like, the tears are pouring out of my eyes and I'm talking to him and I'm saying, yes, I'm fine. He goes, well. I just want to let you know that that was an elegant little study that you...
Speaker: designed. Who helped you? And I said, I just figured it out on my own. He goes, well, that was really clever of you. That's the same type of study design that.
Speaker: The doctor that... Just... Yelled at you is going to be presenting. But it's going to have... A potential of about a 1%.
Speaker: Death rate. in the fetuses that would be affected. And I was like, Gosh, my rupturing membranes didn't have any death rates associated with it. It was...
Speaker: It was just seeing if it sped up labor. So mine seemed really benign compared to maybe sticking a needle in an umbilical cord when the baby's still in the mom's belly. and puncturing and causing bleeding that seemed pretty aggressive to me. And that was okay for him to do, but it wasn't okay for me to look at something that's our most basic intervention.
Speaker: So... I was happy he talked to me and I think I stopped crying by the time I left there. And then I went to Sally's office and I said, I'm done. That's it. I don't have to do this research project. And then I told her what happened. And she said, oh, I'm so sorry. I didn't mean for you to get caught up in something like that. Well, of course she didn't.
Speaker: know how aggressive surgical specialties are when they're kind of all together in a room you know and and you know i was the little person on the totem pole so i was like really available to be um
Speaker: harassed because residents in my program didn't really do that type of presentation very often. But I was curious. That's the thing. I was curious. I knew I wasn't going to do that study. There was going to be no hope of that. But I was curious about his anger.
Speaker: It's like... Why? You know, why are we talking about forefathers when I'm just asking, does this doing that? rupturing membranes actually speed up labor. And so I just started asking. We work with private attendings. There was so much energy around this idea. I realized you don't question that. There's something going on.
Speaker: that it's inside people. And. And I i've I've been working on that to this day. I mean, I think I figured it out. And the stories that I'm going to tell on the podcast are related to this process of figuring it out. Because at this point, I've been in practice for 40 years and taking the lessons that I learned in that second year of residency when I worked with Libby.
Speaker: ah Dixon and I went to visit Ina May Gaskin at the farm in Tennessee and started trying to Dude.
Speaker: a little less intervention, to be more thoughtful about the idea that maybe Normal labor doesn't need me to do all my little intervention dances and play with that.
Speaker: And I think the result is 40 years of practice with a 9 % C -section rate. when the 2025, C -section rate for the United States is over 32 % and climbing.
Speaker: So I invite you to come to my podcast. Message me, send me an email, michelle__manting at yahoo .com. Comment here. If you have other questions or topics that you want me to address, I'll try to incorporate them in the podcast. Thanks for being here today.
Speaker: I have a sub stack off the cutting edge. I welcome you to come and read what I'm writing about. these issues.
Speaker: That's all for today. Thanks for listening. Check out the website. Check us out on Substack for all the science, the stories. and the statistics are in a really nice way.
Speaker: And don't forget. and keep on asking those questions.