Belly Up

* bellies * birth * babies * breastfeeding *

Wednesday, November 9, 2011

Stripping, Stretching, Sweeping-You Want to do What?

Ready to be swept?
Sweeping, stretching and stripping all sound a bit scary, after all one's lower uterus is not used to getting much action. So what is all this stretching stuff?  Sweeping of the membranes, also called stripping or stretching the membranes, is a procedure performed during a vaginal exam.  A finger is placed into the cervix,  then in technical terms, "the inferior pole of the membranes is detached from the lower uterine segment by a circular movement of the examining finger".* In lay terms that means that a finger is placed through the cervix and separates the membranes of the amniotic sac from the bottom part of the uterus, lifts it up a bit and a finger is run around the exposed diameter.  The agitation of this area and manipulation of the membranes may cause the body to increase production of  prostaglandins, ie the hormones that are thought to ripen the cervix in preparation for labor.

It is this prospect that the stripping will lead to spontaneous labor either in the short or long term that makes this procedure attractive.  Studies do show that having the membranes swept can create clinically significant results.  If done at each appointment from 38 weeks on, membrane sweeping was shown to slightly reduce the number of pregnancies that go past 41 and 42 weeks.  However as most pregnancies will not go past 42 weeks anyway this information has limited significance for the average expectant woman but is useful for a woman with a history of post dates pregnancies (postdates meaning past 42 weeks, not past EDD).  The studies also showed that membrane sweeping did somewhat reduce the need for other means of induction such as the use of prostaglandins or oxytocin/pitocin.  What the studies don't say is why those inductions were needed.  If they were needed because the pregnancy had a medical need to end and this procedure helped end those pregnancies safely with less intervention- then this is great news.  However if it means we have found yet another way to end a thriving pregnancy- that really isn't great news at all.
This kind of sweeping might
help you get ready
for labor too
Membrane sweeping may not seem like a big deal as many providers do routine vaginal exams the last weeks of pregnancy anyway (see my post on routine vaginal exams) so a more vigorous exam doesn't seem like a big step to take, but it is invasive and it is an intervention.  The sweeping is usually uncomfortable for mom as it is basically a vaginal exam on steroids and often produces light bleeding or spotting afterwards.  Membrane sweeping can lead to irregular, uncomfortable but ultimately unproductive contractions that are only capable of disrupting mom's prospects of a good night's sleep...but not actual labor.  At worst the procedure can cause the baby's amniotic sac to rupture which can mean a premature baby if the stripping was done shy of term or lead to an unnecessary induction and/or c-section. The risk is also higher that GBS will be passed on to the baby when membrane stripping is done on women who are GBS positive.

Not wanting to dwell on the negative, membrane sweeping is one of the evidenced based methods that can sometimes stimulate labor without the use of other more invasive or higher risk means such as cytotec or pitocin and sometimes inductions really are indicated or desired.  The membrane sweeping can create a situation where the body is tricked, so to speak, into producing more of its own hormones in hopes of avoiding the use of other synthetic hormones.  Another huge bonus is that it can be done out side of the hospital so that mom can be at liberty until she reaches a point where she is having contractions, be it that night or in 4 weeks, that deem it time to go elsewhere.  It needs to be kept in mind though that membrane sweeping is not a sure thing. It seems to be one of those things that works when one's body is ready and doesn't if it is not.

Both midwives and OBs use this procedure, though obviously some more than others and often under different circumstances.  Some careproviders do routine membrane stripping starting at 37 weeks, some suggest it only when a mom has a prior history of a post dates pregnancy or if there is concern over the baby's size (though fetal measurement is hardly an accurate science) and some will only use it when there is a need to encourage the pregnancy to end for either the health of mom or baby.  However it is very uncool for a careprovider to strip a woman's membranes without obtaining consent.  If you are pregnant and membrane stripping comes up, it is wise to find out why your provider is recommending this procedure.  A healthy pregnancy will end when baby and mom are ready so if a careprovider routinely does membrane stripping he may have a more medical or highly managed philosophy of birth and this intervention is then likely to be the first of many.  Membrane sweeping may also inadvertently undermine a woman's trust that her body will know when to birth.  On the other hand, if the pregnancy needs to end, membrane stripping is a great option to try before advancing to other more invasive and higher risk methods. 


Tuesday, October 4, 2011

PROM-Not About Big Hair and Fancy Dresses

Not that kind of prom!
It seems on TV that every pregnant character has a scene when out of the blue her water breaks and intense contractions immediately follow.  However, while a big gush of water makes for good television, labor starting in this fashion is the exception and not the rule.  Left to its own devices, most of the time the bag of waters (BOW) will  rupture during transition, that crazy intense time at the end of labor and not at the beginning of the process.  When labor starts with the water breaking,  that is called PROM, or premature/prolonged rupture of membranes. 

Here are the cliff notes for PROM as it pertains to full-term labors:
  • PROM is defined as the BOW breaking 1 hour prior to the start of contractions
  •  PROM is thought to affect 8-10% of all pregnancies
  •  75% of women will spontaneously start labor within 24 hours after PROM
  •  95% of of women with PROM will deliver within 28 hours
While PROM may be a normal variation of labor, the small (but normal) percentage of moms that experience PROM do face special challenges, especially if they are hoping for a low intervention birth.  The standard of care that most OBs practice is that when a mom's water breaks she is directed to come into the hospital post haste regardless if she is having contractions or not.  If she is not having contractions, she may be given a bit of time to walk around to see if labor starts, but most likely she will be encouraged to start a chemical induction and told that choosing to delay this induction will increase the risk of infection to herself and her child.

As noted, statistics do show that labor will likely start one way or the other within 24 hours, which means some women will start having regular contractions immediately while others will start at hour 23.  The problem is no one knows which women will be the fast starters and who will be just getting going in the 23rd hour.  In light of that range of variation, the differences in the managed care model of chemical induction and the watchful waiting model of the expectant care can be discussed. 
There is a lot of research on PROM and as usual it is not a black and white issue.  It is clear in the studies that most moms will shortly start labor on their own (within 24 hours) and various studies have compared the risk of infection between the watchful waiting approach vs the do something now approach.  Most research states that there is little statistical difference in neonatal  infection rates between the two groups, though there may be a slight increase in the risk of maternal infection in the expectant group.  Infection rates in either group though are both low, under 1%.  (Ironically one study states that despite infection rates being equal, more babies are actually sent to the NICU for observation after the expectant approach which probably indicates a bias assuming expectant care will lead to problems despite there being proof to the contrary)*  C-section rates have also been compared and rates are found to be comparable in both groups of women.

Amniosure, a test to
 confirm rupture of membranes
 However, muddying the waters (love a good pun!) is that while most studies do indicate that the risk of maternal infection rises slightly around 24 hours post water breaking, there is evidence that suggests the risk may actually rise 24 hours after the first vaginal exam not just from the time of the rupture.  To put that in perspective, what happens when mom goes into the hospital (as directed) right after her water breaks?  Mom gets a vaginal exam to determine if her water really broke and to asses what is happening with her labor. Since the time of her water breaking and the time of her first exam will then correspond fairly closely, it is hard to definitively say if the infection risk goes up due to the water being broken or if it is increased due to the vaginal exams...or perhaps some combo of the two.

What does this mean for expecting couples?  If your water breaks what should you do?  These are great questions and expectant parents should preferably decide how they want to answer them before finding themselves leaking amniotic fluid.  The answer will depend on the careprovider, the couple's attitude toward the research, the type of birth they are planning and even the ever present concern about rush hour traffic.  If one experiences PROM and the decision is made to hang out at home, mom should eat/drink and try to get some rest.  She can pay attention to her baby's movements, be aware if she starts to run a fever and follow her intuition.  If it is chosen to go into the hospital mom should limit vaginal exams and discuss with her careproviders the risks of using pitocin to start labor vs the risks of waiting for labor to start.  She can also consider low tech ways of bringing on labor such as nipple stimulation with a breast pump or walking.

*Abstract of this particular study:

Tuesday, September 13, 2011

Group B Strep - Its Not About Your Throat

Not that kind of Strep!
We can probably all remember at some point having the sore throat and fever of strep throat.  However Group B Strep is not a sore throat in one's vagina (and thank goodness for that).  Group B Strep, otherwise known as GBS, is a generally harmless bacteria that makes its home in the intestinal track of our bodies.  It is generally intermittent and it is thought that roughly 1/3 of the population has this bacteria hanging out deep in their intestines at any given time.

While GBS is not a big deal for most adults, during their little trip through the birth canal some babies pick up GBS and a small number of those babies will become sick.  Babies that are born prior to 37 weeks of pregnancy, those whose membranes were broken for an extended period or whose mothers ran a fever during labor are at greater risk of infection.  Typically in the US a women is not told much about GBS and may not even know what they are being tested for when they are given a routine vaginal swab late in their pregnancy.  However, there is math behind GBS and here is how it breaks down:*

- An expecting woman has a 1 in 3 chance of carrying GBS
- If she has it and does nothing, there is a 1 in 200 (0.5%) chance that her baby will get GBS
- If the baby gets GBS, there is a 6% chance that he will develop severe complications/die
- 3 out of 10,000 (0.03%) of babies born to GBS positive mothers NOT treated will die
- 1 out of 10,000 (0.01%) of babies born to GBS positive mothers who ARE treated will die

Obviously without or without treatment, the odds are highly favorable that a baby born to a GBS mom will be healthy, but anytime you start talking about dead babies that is downright scary.  In order to mitigate the small but real risk, maternity providers seek to push the risk closer to the 0.01%  level rather than the 0.03% level.   The current standard of care is that a woman who tests positive by vaginal swab in her 3rd trimester (or anytime in her urine) will receive IV antibiotics during labor.  However there are a number of options out there and antibiotics carry their own risks, so in the spirit of informed consent lets look at the issue.

Antibiotic use is prevalent in our country and currently 1/3 of laboring moms can expect to receive antibiotics for GBS during labor  However studies done by the CDC show that antibiotics fail to prevent up to 1/3 of GBS deaths each year.  While it is clear that use of antibiotics does reduce the GBS infection rates,  there is now mounting evidence that reduction in GBS must be weighted against the increase in death and illness from the subsequent infections created by drug resistant "super bugs" that have arisen from the overuse of antibiotics.  In fact ampicillin and amoxicillian are no longer useful in treating GBS due to their overuse and much stronger drugs are currently used.  Another risk of antibiotics includes the risk of yeast infection in moms and babies, but even more troubling is that statistically as many infants may have allergies to the antibiotics given during labor as the number of babies who will be infected by GBS and these allergic reactions can also be life threatening.

Another factor to consider is that while maternity providers have sought to reduce deaths from GBS infection, they also can create the situations where the risk factors of GBS exist.  One risk is prolonged rupture of membranes.  The membranes may naturally rupture at any point during labor, but care providers often artificially rupture membranes when a woman is still in early labor thus putting her at risk for having prolonged rupture of membranes. Inductions (and scheduled surgical births) have increased the number of late preterm babies, ie babies that due to miscalculation in the due dates are born just before 37 weeks of pregnancy which is another known risk factor for GBS infection.  As the artificial rupture of membranes tends to go hand and hand with induction, a reduction in inductions will also reduce the incidents of increased risk due to prolonged rupture of membranes.

Women do have choices about how they want to handle the GBS issue.  First of all any testing in a health care setting is optional.  A woman can choose to not get tested and many make this choice.  Others choose to be tested but do their own vaginal swab, usually when they provide a urine sample so as to avoid the uncomfortable process of having someone else do it.  Women can take measures to reduce their risk of even having GBS using a variety of regimens that can boost the immune system and clear any GBS hanging out in intestines.(taking garlic and echinechia is a common route).  There are also other ways to treat besides taking antibiotics.  In Europe where IVs (and thus IV antibiotics) are not standard during labor, a vaginal wash called chlorhexadine is commonly used and has documented high effectiveness.  Chlorhexadine is easily bought here in the US so it certainly represents a choice that is readily available.

Basically these are the choices:
1. Choose to follow dietary, herbal or homeopathic methods to decrease the risk of carrying GBS
2. Choose testing and treat with antibiotics
3. Choose testing and treat with chlorhexadine during labor
4. Choose not be be tested, educate yourself about the early symptoms of GBS infection in infants

I want to close by saying that if a GBS positive mom decides the best option is to treat with antibiotics this does not mean that she must be hooked up to an IV her whole labor.  It takes 20-40 mins for the IV bag to empty and mom will receive a bag only once every 4 hours.  After the bag is empty, the IV may be made into a heplock leaving mom free to move as desired.  The IV can be timed to be given during a period when the careprovider also monitors the baby, that way both are done concurrently and mom can then be left alone for a while.  Choosing to be treated with IV antibiotics also doesn't take away the option of an out of hospital birth as most midwives are able to give moms an IV at home or in a birth center.  If getting antibiotics, mom should also purchase some good probiotics and watch for yeast in herself and baby.

*A big huge thank you to Ann Crowell, CPM, LM at Gentle Beginnings for having a handout with this math already done.  I am so thankful I didn't have to mess with a calculator myself.  Ann is a fabulous MW in the DFW area if  you are looking!

Tuesday, July 12, 2011

Is It Time? (To Go To The Hospital)

Your baby's birth place? 
It is a common concern to worry about delivering
on the way to the hospital
I think it crosses the mind of most expectant parents, particularly dads, that the baby may arrive before everyone is comfortably (so to speak) situated at their chosen place of birth.  TV has certainly not done anything to alleviate this fear.  It also crosses the mind of most expectant parents, particularly moms, that she may arrive at the hospital only to be told to go home because what she is experiencing isn't really labor.  Both scenarios leave expectant couples with the looming question of when is the right time to make a like a baby and head out* (to the hospital).  The answer will of course depend on a lot of things, traffic included, however the odds are much better that a couple will arrive at the hospital way too early than too late. 

The rule of thumb most childbirth educators teach first time parents is the 5-1-1 rule.  In other words, don't even think about going to the hospital until contractions are every 5 minutes, lasting a minute and all that fun has been happening for an hour.  Usually this pattern signifies that labor has progressed through most of the latent, or early, phase and perhaps even into the beginning of active labor, ie 3 to 4 centimeters dilation.  I don't suggest disregarding the 5-1-1 rule, but I would suggest some ways to personalize and improve upon it, especially if your goal is natural childbirth or holding off on an epidural until the risks of it use are somewhat reduced.   Keep in mind that if an average 1st time mom arrives at the hospital based on 5-1-1 alone she probably has 7 to 12 hours before baby's think of 5-1-1 as the minimum suggestion of when to leave your house, not a mandatory requirement of when to show up at the hospital.

So why not go in?  This is a fair question with a good answer.  A woman is usually more comfortable (and generally safer) at home and her body will give recognizable signs as labor progresses-or at least before the aforementioned backseat delivery.  The protocols at many hospitals can make labor less efficient, more painful and, for low risk mothers and babies, these protocols often carry more inherent risk than benefit.  The longer a woman labors at the hospital the greater the odds are that she will receive one or more of these interventions and their sequela.  (the most common of these interventions are restrictions on mom's mobility and her food and drink intake and labor augmentation with pitocin).  Obviously some hospitals are better than others and at the more mother-friendly facilities the question of when to go the hospital may be more of a practical matter as opposed to the difference between a vaginal birth or major abdominal surgery.

In addition to the 5-1-1 guideline, there are other signs to look for before heading out the door.  A laboring woman will go through emotional changes, often referred to as emotional signposts.  During the early phases of labor mom is happy.  She keenly feels the contractions but is excited that labor has started.  Other than complaints about the contractions, mom is her normal self and this is not the time to go to the hospital even if contractions are at 5 minutes apart.  As labor progresses mom interacts less with those around her.  She will usually not want to deal with issues that do not pertain to her labor. This change will be noticeable during and between contractions.   As the end of labor approaches, she will be consumed with her contractions and may only speak comments that involve few words.  When mom is no longer engaged with the world around her, that is an emotional signpost stating that it is time to get her in the car.

Mom will also have physical changes.  During the later stages of labor most women get shaky and may feel like they will vomit.  They will feel hot, they will feel cold and mom may appear flushed around 6 or 7 cm.   As labor progresses moms may moan through contractions and contractions will consistently last over a minute.   Many women will have bloody show during early labor and it will get progressively heavier.  Mom may mention that she feels pressure in her bottom during contractions. This usually means the baby is descending through the pelvis during the active stage of labor and unless there is also involuntary pushing it is probably not the pushing stage quite yet (though if mom is experiencing back pain as well it may indicate a posterior baby).  Certainly theses changes should not be seen as a checklist with each one having to be observed.  However, if none of these signs have occurred, you can feel confident in your choice to stay home a bit longer if everyone is comfortable otherwise.

Of course there are other factors to keep in mind. I suggest that couples labor where they feel most comfortable, both mentally and physically.  In some situations this is going to be at the hospital, but for most it will involve laboring for a time in their own home.  For those who don't live close to their place of delivery, a park, a friend's house or hotel close to the hospital might be a happy medium.  If a couple does arrive at the hospital only to find they are not as far along as hoped, the nurses won't laugh at them and the couple can even choose to not be admitted and perhaps go walk someplace close until some of the physical or emotional signs I mentioned do start to show up. 

And if you do happen to be that person who is a friend of a friend that we all hear about who had a baby on the side of the road in the backseat of a least it makes a great story!

*I deeply apologize for the lame joke.  I just couldn't help myself.

Friday, June 17, 2011

Eat, Drink and Be Merry

For years women have been told not to drink or eat while they are in labor.  The main reason for this forced fasting was to lower mom's risk of aspirating the contents of her stomach if general anesthesia was required during the delivery.  While the food and drink restriction may then seem logical, the restriction didn't necessarily actually avoid the problem.  When the stomach is empty, the contents actually increase in acidity which then may increase the risk of aspiration and furthermore, withholding food specifically during labor does not insure that the stomach is empty as the hormones of labor slow digestion.  As soon as the body recognizes labor, it slows the digestive process to ensure that there is a reserve of energy in mom's stomach.  Unless a woman routinely avoids eating during the last weeks of pregnancy (as if!), an empty stomach cannot be assured.  It can however be assured that withholding food can result in dehydration and ketosis...both unpleasant for mom and baby during labor and both are much more common than the use of general anesthesia during labor, which is rare. 

This may not be the best choice!
Luckily the American College of Obstetricians and Gynecologists, fondly known as ACOG, recently (circa 2009) decided to reverse its policy on withholding beverages for laboring women.  This is good news except the new recommendations have not made their way into common practice in many hospitals around this country.  Women are still being routinely denied the opportunity to drink even water during labor, never mind something crazy like a cup of tea or juice and the reason still being given is the risk of aspiration.  Other moms are simply told that eating or drinking will make them throw up.

Vomiting does happen to some laboring women, usually regardless if she has eaten or not. As previously mentioned, when a woman eats as desired in the early hours of labor, that food will barely start to digest and instead it will stay in her stomach and will provide the energy needed by both mom and baby throughout labor.  Then during transition, those fun last 3 centimeters of dilation, glucose levels will decrease to protect the baby's brain from excessive lactic acid while the baby's head is compressed during its journey through the pelvis.  High levels of lactic acid in the uterus may also cause contractions to be less effective over time. So the reason some moms vomit in the late stages of labor may just be that her body seems to determine how much nutrition it needs and then effectively gets rid of the extra.  That's where the vomit comes in...or out so to speak.

So where do IV fluids fit into the equation?  IV fluids are helpful if mom is suffering from dehydration or if she needs other medication during labor (ie pitocin or an epidural).  Of course if mom is unable to drink due to hospital policy then mom is indeed at risk of dealing with dehydration and may then need IV fluids, but IV fluids are not the same as food and drink.  For one they don't taste good or quench a dry mouth, but more importantly the use of IVs carry risk.  Having an IV decreases mobility and can be uncomfortable.  The biggest problem with IV fluids is the increased risk of fluid overload for both mom and baby and if the fluids used also contain glucose the baby's blood chemistry changes with increased insulin production which can cause problems immediately after birth.  Another concern is the risk of infection that is present anytime something is placed under the skin.  Bottom line, IV fluids do not provide a source of energy for a laboring mother and do not do a better job of hydrating during normal labor than allowing mom to just drink when she is thirsty.

I think the Cochrane Report from 2010 sums it up best,
Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women. 
So I say eat, drink and be merry during your labor!

Friday, June 10, 2011

Your Pelvis is Cooler than Elvis

Elvis's pelvis looks pretty wide here!
Today we are going to show the pelvis a little love.  Afterall, our pelvis is what we sit on, it holds our bodies in a upright position and also allows a woman to hold and grow a baby in her womb and then, when the time is right, it opens to allow that baby down and out.

I think many of us picture our pelvis as a fixed and immobile structure but that is not the case.  It is true that in non-pregnant women (and men) the pelvis is locked, but every pelvis is made up of 4 distinct bones that are held together by connective tissue, cartilage and ligaments.  The cool thing is that in a pregnant woman, as the pregnancy progresses and especially during the end of pregnancy and labor, the hormone relaxin is released and works to turn those connections into stretchy soft rubber bands (the midwife Gloria Lemay describes them as being like bubble gum) that allow the pelvis to loosen and to expand so a baby can pass through.

You may have come across a few medical terms for a pelvis: adequate, inadequate (or contracted) or even proven.  The term "adequate pelvis" is hardly a ringing endorsement for the powerful pelvis, but contracted is obviously worse and proven seems to hold the pelvis's ability in an attitude of guilty of inadequacy until proven innocent.  However, judging the size and ability of a pelvis prior to spontaneous labor is about as helpful as deciding the turtle neck part of a turtle neck shirt is too small to fit over your head before you try to put it on.  If a careprovider tells a mom that her pelvis is small, this is a huge red flag that he is setting her up for failure.  Probably not on purpose, but it means he may not appreciate the way the pelvis works during labor.  He certainly has not taken into account the bubble gum features of the pelvis.
 Relaxin is not the only thing that opens the pelvis.  The position one's body is in makes a difference as well. Squatting is said to increase pelvic dimensions by 30%.  That's a lot!   You can experience this simply by standing, placing your hands on the area just below your hips then move into a squat.  You can feel that your hands are now further apart than they when you were simply standing.  This same thing happens when walking, lunging, walking up stairs etc.  A baby's head also opens the pelvis, just as the example of the turtle neck demonstrates something that is pliable will make way for something being pushed through it.

Don't disrespect the pelvis...this position makes it smaller!
Conversely, as the pelvis is not fixed and is movable, there are also some things that can make it smaller too...which is of course the opposite of what one wants in labor.  Things like laying on one's back or in a supine position blocks the tailbone and sacrum from moving backwards and out of the way of the baby's descention and also decreases pelvic capacity.  Since the supine or semi-sit position is popular for hospital birth based on the convenience it extends to the careprovider, often the very way moms give birth lessens their ability to...give birth.  That's pretty disrespectful to the pelvis (and laboring women).

Induction also interferes with the pelvis's amazing ability to open.  Relaxin, that hormone that helps cartilage turn to bubble gum, is released in large quantities in the last days of pregnancy and during spontaneous labor.  When labor is induced, the body has not had a chance to finish its production of relaxin.  During an induced labor, depending on the circumstances, the body may not get the chemical signals that generally get it to start pumping out this and other labor hormones and therefore the pelvis is not able to reach its full potential.  Add in the other limitations, including the aforementioned pelvic closing positioning, that come with an induction and you can see why many times baby simply seems stuck in the pelvis.  The pelvis just didn't have the tools to do what it was designed to do.

Allowing the pelvis and the baby to work together in birth produces the best outcomes.  So when it comes time to have a baby, think bubble gum thoughts and make like Elvis....swing and tilt that baby out!


Tuesday, May 17, 2011

Uninformed Consent

A laboring mom walks into the hospital.  After some speculation, she is declared to be in labor and is ready to be admitted as an L&D patient.  As part of her admittance, mom will be handed three consents to sign.  One for vaginal delivery, one for surgical delivery and one for anesthesia.  Mom, who is probably quite uncomfortable, is given all three, and told she must sign them in order be treated...and that is what counts as informed consent in most births.  The nurse does not go over these forms, an OB does not come in and explain each bullet point, mom is just expected to sign all of them, even if she is not planning anesthesia or a surgical birth.  If labor is advanced (and even when it is not) it is very likely that mom is not reading the fine print on these consent forms, instead she is merely scribbling her name on a piece of paper as quickly as she can between contractions.

Of course with labor, mom does usually know for around 9 months that it is coming and she can become informed during that time so that when she signs these particular consents it can truly be informed consent.  But what about the rest of labor, and what about the choices couples make throughout their prenatal experience?  Are women receiving informed consent, or are they even asked for their consent in most case, informed or not? 

Informed consent is based on two separate but parallel aspects.  One is the obligation in a non-emergency situation of a health care provider to disclose all information concerning a person's care.  The second is then the autonomy of that person to agree, or refuse, the suggestions or procedures offered.  At the same time, a person should have the expectation that if she chooses to exercise her right of refusal she will still be treated with dignity and her right to autonomy respected by her health care providers.  However, if a person is told she must comply to certain rules, or that certain procedures are routine and no discussion of their various risks/benefits takes place, that person has not had the option to exercise her informed consent. (It is also not informed consent if a health care provider does not provide factual or unbiased information but I am going to save that discussion for another day.)

Let me just list a few examples of what informed consent is NOT.

1) Mom has been laboring a while, she is thirsty and has a dry mouth so she asks for water,  However her nurse tells her that it is against hospital policy for her to drink anything.  This example can be applied to numerous routine procedures and policies during labor including fetal monitoring, rules about IVs, being out of bed etc.

2) Back at the nurses station, mom's nurse and OB have been communicating via phone and the OB has decided to give mom some pitocin to speed up her labor.  The nurse walks in mom's room and hangs a bag of pitocin with the comment, "your OB wants you to have some medication to increase your contractions." 

Mom has not exercised informed consent in either of these cases.  Instead, in the first example  she was told what hospital policy was with no discussion.  Hospital policy is usually based primarily on efficiency, costs, and risk management of the institution, not the health or well being on any individual person or group.  It is not necessarily designed to produce a better outcome for your labor, rather it is to save money or prevent lawsuits for the hospital.  However, hospital policy is also always inclusive of informed consent so a patient can ask why this policy exists, how it benefits her labor and then decline and accept responsibility if she feels it is not in her or her child's best interest to comply.  In the example where mom is hooked up to pitocin, mom has every right to talk to her actual careprovider if she has questions or concerns.  In most cases the OB is not on location but a couple may have their nurse have him call their room or they can ask that he come in to discuss care options.  The couple may decide to accept the recommendations, but accepting medical care without informed consent can be dangerous to mom and to baby.  It also can lead to a lot of second guessing and blame if things don't go as planned.

There is a difference between a health care provider (or hospital) who pays lip service to informed consent by meeting the legal requirements put in place to help protect agaisnt lawsuits and a careprovider that actually informs a couple about what may or may not be in the best interests of mom and baby and encourages them to educate themselves.  A care provider and a couple should be working together towards the best care and labor experience for mom and baby.

Tuesday, May 3, 2011

Your Cervix is Not a Crystal Ball

When is baby coming???
 It is around mom's 38th week of pregnancy, she's just had a vaginal exam and the OB declares,"you are 2cm dilated, baby will be here soon!".  The week passes and the next week and perhaps even the next week.  Still, mom is pregnant and still 2cm...perhaps even more.


It is around mom's 40th week of pregnancy and she just had yet another vaginal exam where the OB has declared,"you are not dilated at all". 

Let me let you in on a little secret, your cervix is not a crystal ball.  It cannot predict when you will start labor.  It cannot predict if you will deliver before, after or even on your due date.  The cervix can do many wonderful things, but let's not give the cervix more credit than it is due.  A cervix cannot read the future. 

Having the cervix examined can satisfy mom's curiosity and when something is happening that can be exciting.  Obviously each bit of dilation that occurs before labor is less that must happen during labor.  However if cervical change is found, and especially if the careprovider adds the comment that labor will be soon, it can make the last weeks of pregnancy the longest of her life.  Everyday she is on high alert for impending labor and each day that it doesn't happen will be a disappointment.  Mom may now feel each discomfort of late pregnancy more acutely and her family might even travel to be in town for the big day.  However, instead of holding a baby they are all just staring at mom waiting for her to pop.  These women are often encouraged to electively induce by their due date and they agree because they are mentally exhausted from being told the baby would be here any second.

On the other hand when mom has an exam and nothing is happening, mom may start to loose confidence in her body and feel that she will be pregnant forever, or at least longer than she was hoping.  Even though it is completely normal for dilation not to occur until actual labor, these women are often made to feel that their bodies are not and will not work correctly and are pushed toward elective induction. Mom is discouraged and when the OB starts looking at induction dates, mom agrees because obviously she will not go into labor on her own any time soon and in the back of her mind she thinks her body may not even be capable of spontaneous labor.

The cervix is a a unique creature.  Some will naturally dilate prior to labor, some will not.  Some will dilate and efface slowly over time; many will only do so with the advent of contractions and a cervix that has birthed before is different than one that has not.  The bottom line is that a cervical check only tells the story of what is going on at the time of that exam.  It tells nothing about what will happen...even later that day.  A cervix does not need to reach a certain point for contractions to start, just the opposite.  Contractions will open a cervix when the time is right no matter what that cervix has been up to prior to that time.  So a mom who is closed up tight as drum is as likely to go into labor that night as the mom who is 2cm dilated and has been for a week or more.  The lucky labor winner will be the one that starts having effective contractions and that honor could go to either mom.

So why do many providers do routine vaginal exams at every appointment those last weeks of pregnancy?  I have never found a justification besides it just being a routine part of managed care. A body part cannot be "managed" if it is not assessed, measured and commented upon.  However, there is no evidenced based medical reason for routinely doing these late pregnancy exams.  In individual circumstances a vaginal exam can be helpful, but for the vast majority of women a cervix check can provide no useful or predictive clinical information and it is an uncomfortable and invasive procedure that actually carries some amount of risk. 

The good news?  You can say no thank you if you happen to be using a careprovider who does these routine vaginal exams.  If you are really curious and want to know what is happening in there, go for it, but just don't give your cervix more credit than it deserves....whatever is found means nothing about what will happen. 

Tuesday, April 19, 2011

Birth Planning

Have you heard this comment or one similar from a nurse or other careprovider?  "When a mom walks in with a birth plan, we just go ahead and set up the OR. Those moms always end up with c-sections."  This line has been said to some of my clients and I myself have heard it said by my friends who are nurses and OBs.  So is it true, do birth plans cause c-sections or at least increase a mom's likelihood of having one?  Should couples try to plan their birth?

First of all, let me just be blunt, these "birth plan" c-sections usually happen at hospitals where statistically a high proportion of women will deliver surgically because that is the birth culture of that hospital.  Basically the odds are stacked against a vaginal birth regardless if a couple walks in and hands the nurse a copy of a birth plan or a copy of a Tolstoy novel.  Furthermore, if this is a widely held view at any given hospital, it is probably not a place that is providing mother friendly care,  I mean it isn't nice to be dismissive of your patients requests and then to blame them for the need to perform a surgical procedure.  

However, where birth plans legitimately get a bad reputation is when a couple's birth plan is a poor match between the care provider they have chosen and the plan they have created.  This represents poor prenatal communication and will usually lead to tension between the various parties present at the birth, not to mention disappointment on the part of the parents.  A well developed birth plan should serve as a tool for communication prior to labor so this doesn't happen, in fact, when a birth plan is supported by everyone going in, it really is not even vital on the big day. 

So first things first, mom and dad have to figure out what they want.  This of course can be challenging as it is hard to know what your options are....when you don't know what your options are.  It is a bit like being at a restaurant and not being given a menu.   However, this is exactly why taking the time to think through your goals important.  Once you have researched and written out your concerns and desires for childbirth, it is time take this loose birth plan and go chat up your careprovider.  (Ideally this should be done when you are not half naked because nothing makes you feel less empowered than asking questions while you are nude and the other person is fully dressed.)  Then examine how you feel about your careprovider's reaction to your ideas.  Was he encouraging, did his answers make you feel supported and confident?  Did your priorities and vision of labor match in most areas?  If yes, congrats, pass go and collect your baby. 

If not, this is where the road is rougher, but make no mistake *you* are still in charge and the choices are straightforward.  You have three options: 1) decide that you will accept the way your careprovider does things 2) try to compromise with your careprovide to find some areas of give and take or 3) start looking for a new care provider  What you can't do is hope and pray and wish upon a star that somehow when you go into labor or reach your EDD that things will magically happen the way you are hoping.

Obviously choosing the first option means doing nothing (except maybe tearing up your birth plan), basically it is the default choice.  At this point mom is often late in her pregnancy, perhaps money has exchanged hands or it may seem overwhelming to start all over again with someone new.  The second option, trying to find areas of compromise, may or may not be easy depending on your comfort level negotiating with someone who will likely counter your attempts with sincere (albeit often biased) concerns about how your requests will jeopardize your baby's health.  However you may be able to get a bit closer to your goals and that is good.  Finally there is the option of switching to a new careprovider.  Most moms think this is the most daunting option, though those that have done it are usually surprised how easy it actually is and the benefits are huge.

Which brings us back to the birth plan.  Research consistently shows that couples that express the deepest satisfaction with their birth experience, no matter the type of birth or the outcome, are those that felt supported by those who served them and that the experience met their expectations whatever those expectations were.  Therefore the birthplan at its best is not a list of instructions for your careproviders but rather a tool to gain information and communicate beforehand so that you can have realistic expectations for your birth.  If the plans you have in mind are different than those of your careprovider it is better to know this beforehand.  Knowing your options and having realistic expectations can increase both your confidence and your chances of having the birth experience you want and a positive birth experience will have a positive effect on the family that can last a lifetime.

Tuesday, April 5, 2011

Does This Gown Make Me Look Fat?

functional or frustrating?
 Ah, the lowly hospital gown.  It isn't much to look at and for moms planning to breastfeed, it isn't all that functional once the baby arrives.  However, donning the gown is one of the very first rituals of giving birth in a hospital.  Most women don't even think twice about shedding whatever maternity clothes they arrived in and dressing for the occasion of their birth,  But can the gown represent something more?

Basically, maybe yes and maybe no.  For some the hospital gown represents the perfect accessory in which to handle the various bodily fluids that are often present during labor and birth.  You take it off when done, it disappears and you never have to deal with any laundry issues that might occur.  Just like Las Vegas, whatever happens to the gown in the hospital, stays in the hospital.

For others though. the hospital gown represents something less about simplicity and more about the idea that once in the gown, a laboring mom becomes a patient with special clothes that separate her from the "civilian" population of the unsick and unhospitalized.    She may even feel that in the gown she is treated like a passive partipant rather than a woman actively engaged in the process of birthing her child. Thus for this mom, the gown represents the lose of power and perhaps the lose of her autonomy over her labor choices.

So is the hospital gown a must for giving birth?  Absolutely not.  If you are the mom that loves the gown, embrace it in all its backless glory.  If you find the gown to be unfashionable, uncomfortable, immodest or otherwise annoying don't wear it.  If wearing the gown makes you feel less able to advocate for yourself and your child, by all means don't put the thing on.  Making the choice to put on the gown or not is the first of many choices you will make in your labor and as far as those choices may go, this one is pretty non controversial; simply tell the nurse you have brought your own clothes or that you prefer to wear what you currently have on.

That still leaves us with the aforementioned laundry question (get some hydrogen peroxide!)  and, well, you will probably want to wear something at least during some of your labor!  There is actually a company that sells labor clothes. I have shown a lovely pic of a model in Binsi skirt that is designed and sold for labor and birth (and as I am linking the site I hope I am not going to be sued for copyright infringement).  However, lots of other options exist.  Some moms make or buy their own hospital gown so that they feel cute during labor and others just wear something that is comfortable.  Obviously at some point your careprovider may have to access certain areas generally found under one's clothing, but these items can be removed easily when the time comes and a skirt is just as easily pushed up as the gown.

laboring in a black sundress
 Bottom line, when you are in labor, wear what makes you feel like the strong, competent and beautiful mom you are.  Wear clothes that enhance your experience of labor. Yes, it is just a gown or just a black tank top, but the choice of what to wear is yours to make and actually starting your hospital experience proactively making a choice can make it easier to make other choices that come your way during labor.  It may turn out to be the most frivolous of the choices you make that day and if things get complicated one that was relatively less important, but you may find laboring in your clothes to be the first step toward a more mother friendly labor. 

Tuesday, March 29, 2011

Birth, It's as Safe as Life Gets

   Approximately 34,000 people die in car accidents in the US each year
   Approximately 400 women die in childbirth in the US each year (1 out of every 13,000 births)

Makes you wonder if the most dangerous part of labor might be the drive to the hospital!  Obviously there is nothing funny about maternal mortality and the fact that around 400 women die in the US during childbirth is both troubling and tragic, but even with our poor showing as only the 39th safest country in which to give birth, bringing a child into the world is still pretty darn safe.  In my work with expecting couples I spend a lot of time addressing the fears they have surrounding birth as well as the constant pressure to consent to various testing and interventions simply out of fear or concern for the "just in case" situation.  Many people are going into their childbirth experience worried.  Of course most parents will always carry some inherent fear about their children's health and well being, but how did childbirth itself become something that is so feared in our society, especially when the statistics overwhelming show otherwise?

Are laboring moms ticking time bombs?

In the US birth is primarily an event that takes places in hospitals.  This is not a judgement call on my part, just a fact.  Associating the normal process of birth with the hospital may help create a dichotomy where on the one hand hospitals are the place where those who are very sick go and on the other hand where healthy new moms and babies are susposed to go.  Since doctors, specialized surgeons at that, attend most births this also adds to the element that birth is not a normal event and that a laboring mom is a ticking time bomb.  In fact I have seen it quoted in various medical literature that a normal birth is a retrospective diagnosis, meaning that until the baby is out and everyone deemed healthy, it must be assumed that things will go wrong.  This is of course is the backbone of the managed care model that dominates maternity care in this country.  It also explains the widespread use of routine interventions even in the most low risk of labors.  (I will discuss expectant care vs. managed care in a coming post...)

Television does not help the situation.  There birth is depicted in dramatic, sensationalized, and of course, short scenes that fit properly between commercial breaks.  On film, labor is most often shown with a mom out in public where her water breaks in dramatic fashion and she is immediately whisked off to the hospital huffing and puffing apparently having it made it through all 10 cm of dilation in just a few moments.  If only!  Of course occasionally labor happens this way, but it is definitely the exception and not the rule.  Since we do not live in a society where we watch each other birth, this scene becomes what we think of when we think of labor...the urgency, the rush to get the hospital, the rush for someone to do something before something can go wrong. 

I know as a parent I am all for reasonable precautions as I try to keep my children safe.  We use carseats and and seatbelts; I use my windshield wipers when it rains.  However I do not fear driving even knowing how many car accidents occur nor have I equipped my mini van with NASCAR technology and helments for us to all wear when we go out for a drive.  It is important to put risk and fear into persepctive or we would fear the mundanest of life's tasks.  Childbirth is no different and it is important to put both the risks and one's personal fears into perspective.   I do believe and support the idea that people can make different choices based on their situation about what precautions and choices are reasonable and I belive that educating yourself on birth, your options and your care is the best way to decrease fear.  (I also suggest not watching TV shows on childbirth!)

Not every baby's arrival will be perfectly smooth, but when it comes to life, birth is about as safe as it gets.

Tuesday, March 22, 2011

Seeing Is Believing

So while you keep hearing that c-section rates are ever increasing, there is nothing like a good chart to demonstrate what that increase "looks" like.  In one of my favorite blogs ( I found this graph  for the c-section rates here in Texas.
In the last 10 years you can see that every year the rates have increased and the overall rate since 1990 is much higher.  Bummer right? Or maybe not...let's look closer.  Have Texan women changed in the last ten years and are they now less capable of birth?  Perhaps infant or maternal  mortality rates have improved dramatically in the last ten years thus all the surgical births were necessary to save lives?  Obviously Texas women have not become disabled in any way, nor has immigration brought this state a large influx of ladies who are less capable of birth than those that resided here in the early 90's.  Fetal and maternal death rates have also not improved, in fact tragically, statistics show a small increase in maternal and fetal death in the last decade, so not only is all this rush to the OR apparently not saving lives, it may be putting them in jeopardy.

The ability to facilitate vaginal birth seems to be becoming a lost "art" for more and more careproviders.  The blame cannot simply be laid at the feet of OBs.  Certainly insurance costs drive up the number of women each OB needs to care for to be able to maintain his practice and therefore he has less time to spend providing continuous care and more incentive (assuming he wants sleep and have some semblance of a life) to schedule (week)day inductions...and inductions often lead to c-sections.  With each surgical birth, the c-section becomes more and more entrenched as the standard of maternity care.  Thus an OB is rarely ever going to be sued for a c-section, unnecessary or not.  Given the risk of being sued and losing one's livelihood vs performing a surgery that is considered standard, it is only logical that an OB may be inclined towards doing surgery, not to mention that is leads to more compensation and a better schedule along with the reduced exposure to liability.

Couples also need to look at themselves for the role they may play in the still increasing c-section rate.  I am not talking about the small percentage of moms that request elective c-sections or even moms that may not have access to education or options.  These moms do exist but are a small part of the picture.  Instead I am talking about couples that for whatever reason don't educate themselves about their options.  When moms continue to give their business to careproviders that do not provide good care they perpetrate the problem.  A pregnant mom is many things, but when it comes to her maternity care she is a consumer and she votes with  her feet, her wallet and her belly.   Taking more responsibility for pregnancy and birth is certainly personally empowering for moms, but it is also powerful in that if enough moms demand better care and purposely seek it out, more careproviders will start to offer that care for which these moms seek.  In fact parents simply using their clout as consumers could change how that c-section graph looks a few years from now - wth bars getting smaller not bigger.

Tuesday, March 8, 2011

I Want My Epidural! (but not fetal distress please...)

So you want an problem!  Actually I can't promise no problems as epidurals do carry inherent risks.  However, I want to make some suggestions for the mom who feels that in her labor an epidural is the way to go, but all things being equal, she would prefer to minimize these risks as much as possible.

Let me briefly discuss a few of the risks.  Epidurals are known to lower mom's blood pressure which can mean less oxygen for baby and this may result in fetal distress (and fetal distress often leads to surgical birth....).  Another concern involving the baby's oxygen is the supine position that mom is encouraged to assume after an epidural is placed.  The reason mom is told to lay down is because an epidural uses gravity to circulate its drugs, thus sitting up will produce a numb tush but not a numb cervix or uterus...which kinda defeats the whole point.  However, laying down can constrict the vena cava which is the blood flow to mom's lower body and to her baby so its constriction can lead to less oxygen for baby and possible fetal distress.  Epidurals often necessitate (or facilitate) the use of pitocin which, surprise!, also can cause fetal distress. Getting max O2 to baby is definitely one of the risks to try to overcome when choosing an epidural.

The 2nd group of risks surrounds the progress of labor.  Epidurals produce slightly longer labors, but many moms consider an extra few hours of pain free labor a fair trade.  However, an epidural given early in labor can slow contractions down significantly.  Obviously in this case pitocin is given to compensate which brings us back to the previous paragraph.  Often pitocin is used after mom gets an epidural not because labor is slow, but why not move things along as mom is comfortable.  Unfortunately this does not take the baby's concerns into account.  Epidurals also can encourage poor fetal positioning as the pelvic tone becomes flaccid and baby can no longer use it to aid in his rotation or to straighten an asynclitic head. Mom also loses much of her ability to partner with her baby to bring about rotation and descent.

Finally, an epidural can interfere with descetion in the 2nd stage in a few ways - mom may have trouble pushing effectively, she must remain in a position that reduces the size of her pelvic outlet and mom may push too hard and too fast.  Sounds like I just contradicted myself right?  When mom can't feel her muscles it can be hard for her to know which muscles to use and which ones are actually being used when pushing is happening.  Mom also doesn't get the bio feed back that is provided when a baby is stretching her perineum.  So some moms find it hard to move baby down and will need the assistance of forceps/vacuum and then, at the very end when the normal (and often uncomfortable) sensation of crowning would tell mom to slow down to allow her to stretch, an epidural mom can just push right through her perineum causing more tearing than may have occurred otherwise.

So what's a girl to do?  Here a few ways that might help to avoid fetal distress, surgical birth, extended tears and provide for a better overall epidural experience.

1.  Stay home until labor is well established and then some.  Get in the tub, eat, facebook each contraction if you want, but if all goes well you will arrive at the hospital close to the time that it is best to get an epidural.
2.  Wait to get an epidural until you are 5 cm or beyond.  This makes it less likely that cervical dilation will be significantly slowed and also makes it less likely labor augmentation drugs (pit) will be used.
3.  Ask if the nurse (or your doula) can tell the position of your baby.  If your baby is not anterior, do not get an epidural until he rotates. 
4.  After the epidural is in, do not lay on your back.  Lay on your side and flip to the other side every 15 mins.  This will aid in the baby's rotation and help the baby get oxygen. 
5.  Do not consent to pit augmentation unless your contractions significantly slow down.  Try nipple stim first.
6.  When you reach 10cm dilation, ask to labor down and have your epidural cut back.  As it wears off you may feel more of an urge to push and hopefully laboring down will have brought baby down a bit.
7.  Ask your careprovider to provide perineum support in the form of hot compresses and ask him to guide you in pushing your baby out slowly.  If a vacuum assist is used above the pubic bone, ask that after the vacuum has brought baby past that area if you may push again.

Tuesday, March 1, 2011

It's All Greek To Me- Iatrogenic Issues

A Greek docor (Iatros) blood letting
In the ancient Greek language, the term "iatrogenesis" means "brought forth by a healer". At its most basic iatrogenic means that the care one receives is actually harmful. Since at least the time of Hippocrates and his Hippocratic oath to do no harm, people have recognized the potentially damaging effects of a healer's actions. A good example of iatrogenic harm is seen in the now abandoned custom of blood letting. Today it is hard to imagine that anyone ever thought using leeches (can I just add an ewwww here?) on sick people was a good plan, but I think the case can made that what happens to many women in labor makes about as much sense.

Many problems that occur in childbirth are iatrogenic in nature. Here are just a few...
* Concern of infection after a labor of 24 hours with ruptured membranes...that were artificially broken by a careprovider in early labor.
* Fetal distress...caused by the pitocin given to induce or augment her labor.
* Slow or ineffective pushing stage...hindered by mom being limited on the bed to a position that narrows her pelvic outlet, works against gravity and possibly aggravated by an epidural that mutes the urge to push.
* Hermorhage during third stage...careprovider pulled on the cord and caused partial/uneven placental separation.

Often iatrogenic consequences are expected, like chemotherapy causing hair loss. Harm is done, but the overall hope is that the good done by the treatment will outweigh the bad. This is a fair risk benefit analysis when done with informed consent. But would you choose chemo if the research showed that you would lose your hair and throw up, however the treatment would do nothing to stop your cancer and might even cause you to need a series of other invasive treatments?

A lot that occurs in a typical birth is fixing problems the routines and procedures create and the informed consent component is often skipped altogether. Think whack-a-mole, except less fun.  Let's look at one common rule of hospital childbirth, telling mom not to eat or drink during labor (see note). Obviously mom and baby both still need hydration so mom is given a routine IV to offset the denial of nourishment.  However, being tethered to an IV restricts movement which will certainly make coping with labor more difficult.  Thus the routine IV increases the chance that mom will request pain medication further restricting her movement and also increasing the potential need for labor augmentation and/or an assisted or even surgical delivery.  Another big bummer...IV fluids don't even make mom's tummy growl any less.

Of course hunger and discomfort would all be totally worth it if they made mom more likely to have a healthy labor and baby. Unfortunately just the opposite occurs in studies of low risk labors. Drinking and eating do not raise mom's risks, but *not* having them will almost guarantee that she will be more uncomfortable and in a longish labor it means she may not have the energy to labor effectively or push her baby out. This is an iatrogenic problem, to equate it with the chemotheropy example, this means mom has lost her hair, still has cancer and now needs radiation too.  .

I occasionally hear the phrase "a c-section saved my baby" or some variation of that comment.  To be sure, this is often true with no caveats attached as c-sections do save lives.  However, all too often this statement is only true in the context that as mom is being wheeled into the OR to save the baby's life, it may have been the very careprovider's management of labor that put it at risk in the first place.

*Requesting a hep-lock is a way to have both worlds...easy access to a vein in case of need and no loss of movement.  Most hospitals won't offer this option but will happily do it if mom asks.

Tuesday, February 15, 2011

Naming Names

Wouldn't it be nice if hospitals just posted this info at the entrance!
Below I have listed the primary c-section rates for a number of local (to me anyway) area hospitals for 2008, the latest year compiled and published.  These numbers are self reported to the state health department by each hospital and are risk adjusted, meaning the numbers do not include repeat c-sections, c-sections done on moms carrying multiples, breech positioning, previas, or other higher risk situations.  Basically, the percentage shown is just the rates for low risk moms.   A good estimate of the total  percentage of c-sections being performed at any given hospital can be gotten simply by doubling the number.  Not perfect, but that will get you a ball park.

Hospital                                                                         City                                   % 
Baylor Med Ctr-IrvingIrving22.74
Baylor Med Ctr at CarrolltonCarrollton20.3
Las Colinas Med CtrIrving28.22
Med Ctr-LewisvilleLewisville21.96
Med Ctr-ArlingtonArlington26.35
Baylor Med Ctr-FriscoFrisco20.63
Baylor Regional Med Ctr-GrapevineGrapevine24.23
Baylor University Med CtrDallas24
Centennial Med CtrFrisco22.08
Med City Dallas HospitalDallas25.98
Methodist Dallas Med CtrDallas13.12
Methodist Richardson Med CtrRichardson14.81
Parkland Memorial HospitalDallas12.35
Texas Health Presbyterian Hospital DallasDallas27.67
Texas Health Presbyterian Hospital-PlanoPlano31.53
Baylor All Saints Med Ctr-Fort WorthFort Worth21.1

Here is the link to full data for the state of Texas:

The two hospitals with the lowest c-section rates are Parkland and Methodist, both of which are county hospitals where mostly uninsured and those not eligible for Medicaid deliver.  Overall this is a higher risk population.  Many moms in this group, be it due to income or issues of legal residence, may not receive much or any prenatal care and may have other issues in their lives that could potentially adversely affect their pregnancy.  However, the c-section rates at these hospitals are low despite this higher risk population of clients.  Conversely, the hospitals with the highest rates of surgical birth are in the more wealthy suburban areas.  Without going too far on the basis of one statistic, there does seem to exist some correlation between c-sections rates and the ability of an OB to get paid for doing them.  This would be horrible if moms delivering at county hospitals were getting inferior care evidenced by higher maternal and fetal death rates, but I have seen no research showing that to be the case.  Instead it seems these hospitals get the job done safely for all parties but more often in the cheaper (and by that I mean vaginally) way.  Unfortunately this then also suggests that profit motive (perhaps on the part of the hospitals, the OBs, or even the OBs' liability insurance) may lead to a large percentage of the surgeries that are performed on insured women.  At minimum it helps demonstrate that a lot of women are having major surgery performed unnecessarily.

Oh course I am not running out to drop my health insurance coverage, but something to think about.

Tuesday, February 8, 2011

Questions for Choosing A Hospital

(Mom, ask some good questions!)
If you have been involved in a serious car accident, it is pretty likely you will be happy to have the ambulance chauffeur you to whatever hospital is closest as you will probably have neither the time nor inclination to be doing interviews.  However, childbirth is different in that you have at minimum 9 months to look around and you can even start looking before the test shows two lines.  Here are just a few suggestions of things you can ask to gauge if a hospital is a good fit for you. 

Are there any restrictions on who is allowed in the room? If you want the baby's siblings, relatives, doula or a photographer in the room, make sure you ask the hospital what its policies are. Some hospital limit visitors to 2, others allow a frat party to be held in the room while mom labors.  Also check to see who is allowed in the operating room in case of a surgical birth. Some hospitals allow (and encourage) doulas and birth photographers in while others do not. As a side note, hospitals can also be very helpful if you are trying to keep a certain someone out of the room as well.

Can I eat and drink during labor? Many US hospitals restrict women to sips of fluid or ice chips during childbirth, but studies find that drinking and eating during labor had no adverse effects on mothers or babies; in fact, it actually improves hydration and relates to more positive experiences. So unless your idea of a complete and nutritious meal is ice chips, this is an important question.

Can I walk and move around during labor?
The medical community agrees that moving around makes labor less painful and more efficient, so ask how the hospital supports mom to incorporate movement into her labor and if they encourage intermittent fetal monitoring. Intermittent monitoring, where the baby's heartbeat is checked at regular intervals and is based on what is happening in labor rather than protocol, promotes movement and position change.  Conversely routine continuous monitoring makes it difficult for laboring moms to change positions and cope with contractions as they are tethered to machines and movement causes the flat disks to slide off mom's round belly. Continuous monitoring also creates a fair number of false alarms. Studies have shown that continuous monitoring of low-risk labors does not improve fetal or maternal outcomes but does tend to increase cesarean rates. Boo.

What are the rooms like?
Ideally, you want a large private room with soft lighting, a comfortable chair, a CD player, access to the Internet, a mini refrigerator, and a deep tub, preferably with Jacuzzi jets. In reality, outside of your home or a birth center, this room does not exist for laboring moms. However a few local hospitals do allow moms to bring in a tub for both labor and birth and a few others have a tub that is available to moms under some circumstances. Find out if birthing balls are available, and if not, if you can bring your own. If tubs are not available, ask if you can bring your own tub.

Are there rules about what I can wear and what I can bring? Can you labor in a T-shirt, or even your leopard strip string bikini, or do you have to wear a hospital gown? Many women are more comfortable in regular clothes and there is no medical reason that a mom cannot do so. If you want to record the birth, ask about any rules regarding still and video cameras. Lawsuits have prompted some hospitals to ban recording devices during some parts of labor and delivery while others allow full access. One of my favorite quotes from an OB was when he was asked about filming mom’s impending surgical birth. He simply answered, “ It’s your body and your baby so film anything you want.” Cool.

Do I have to deliver lying flat on my back? Squatting during delivery increases the pelvic opening by approximately 28 percent, reduces the need for forceps and speeds up the birthing process, however it is still common for hospitals and doctors to have mom on her back with her legs up in stirrups for the birth. Does the hospital have squat bars or other tools to help a mother who wants to squat during delivery? Will they be supportive if this is your choice?  Will they be able to find the squat bar when and if you want it?

Can I nurse my baby immediately? Studies show that infants who nurse soon after birth have a longer duration of breastfeeding than infants who are first put to breast 3 to 6 hours after birth. Yet many hospitals still take the baby after birth to be washed, weighed, and then rewarmed under a warmer in the nursery rather than in mom's arms. Ask whether you can nurse your baby immediately, perhaps even while he is still attached via your umbilical cord. Find out if the nurses are willing to do the baby's routine checks bedside or in the room with you and for what reasons your baby may be removed from your room at any point of your stay. Most hospitals (in my area anyway) are moving to the rooming in model of care but it is good to find this out beforehand as some hospitals have still not made the transition.  Those that have not transitioned generally take the baby away from the parents right at the 1 hour mark, even if you finally just got the little guy to latch on.

How does the hospital support breastfeeding? Do the nurses support rooming-in and breastfeeding-on-demand or scheduled feeding? The answer will be greatly effected by the answer to the previous question about often often the baby will be in the nursery vs in mom's room.  Also ask if there is a lactation consultant on staff and how often she is available. Some hospitals have great LCs but they only work Monday-Friday. Great if you deliver on Wednesday, not so great if you deliver on a Friday night.