Belly Up

* bellies * birth * babies * breastfeeding *

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.