Induction Increases the Risk of C-Section

Well, the journal of duh strikes again – it’s being reported that induction increases the c-section rates for first time moms.  This is nothing new to those of us who have been around the birth world for awhile, but the medical acknowledgment of this is still rewarding.  The issue really relates to what do we do now?

If we take this study and put it on the shelf, not changing the practices that have led to the high induction rates – does it really matter?  And just what can the birth activist do to help lower induction rates, particularly the elective, “I’m tired of being pregnant.” inductions?

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Wedding Analogy

I woke up the other morning thinking about an experience I had last summer.  I was following a mommy blogger who was preparing to have her first baby.  She was talking about her 36-37 week prenatal visit.  She was hoping that the baby would stay breech so that she could schedule a c-section and be done with it.  Her whole post mad me feel sad.

She had started blogging, as many women do, around her wedding.  She had countless posts with paragraph after paragraph about the intricate details of which flower for which bridal party member and why.  She talked for hours about the flavors of the cakes.  And let’s not forget the wedding dress – that needed the be exactly what she wanted.  It had to be perfect.

To be fair this mom was an event planner.  This was what she did for a living.  She took one day and turned it into something really special for her clients.  She said that a marriage should start out on a perfect note, that it set the stage for the marriage.

So when I heard her talking about how birth was only a day and that it didn’t really matter, I knew she was wrong.  And more than that, her own statements about marriage, when applied to her thoughts about birth were incongruent.  How could she say that how you gave birth didn’t matter?  That it didn’t deserve the same amount of planning that her wedding did.  All she wanted to do was to get it over with…

My heart broke for her.  She is certainly entitled to her opinion and I said nothing to her.  But what I wanted to say was that you could get an amazing sense of empowerment through birth.  That giving birth to your baby was every bit as important and empowering as stepping into the limelight in a beautiful dress as you walked down the aisle towards your husband-to-be. And please note, I’m not saying that you can only achieve this through one type of birth, because that’s not what I believe.

So, if in her world, a marriage that was not carefully planned could start your marriage out on the wrong foot – why couldn’t a birth that wasn’t prepared for also cause similar issues?

In the end her baby turned, much to her dismay.  She decided to “try” a vaginal birth via scheduled induction.  She had an early epidural and what sounds like (via Twitter) a violent instrumental delivery.  She had a really rough recovery and gave up breastfeeding early so that she could rest and heal.  She intends to breastfeed her next baby after her scheduled c-section with baby number two.  I can’t help but thinking if a bit of planning for her birth, like a childbirth class might have helped her a bit.  I think it would have helped her achieve her breastfeeding goals at the least. Her birth certainly impacted her beginning into parenting.

So what I had wanted to say to her before her baby was born, but never posted, was that just because you elope and don’t plan for your wedding, doesn’t mean that your marriage is doomed.  It means you missed out on a beautiful experience, the support, the thrill of planning and the joy of walking down the aisle…

It can wait for tomorrow…

I had one of those days where I had a list of things to do while out on the town, had my 10 month old in tote, and because of forces out of my control, got none of them done. I planned my outing to go something like this: get the oil changed in my car, go to the bank, and pick up dog food. NONE of this happened. I was waiting around way too long at the oil change shop when they said I was next in line (they lied). During this time the baby got cranky and by the time we were out there (without the oil change), it was nap-time so we did not proceed to the bank or the dog food store. What a HUGE waste of my day. When I got home I was really worked up and frustrated and then yelled at my husband who unfortunately works from a home office and is available to yell at whenever the mood strikes me, poor guy. On top of this, the baby would not go down for her nap when we got home so she was still cranky. Great.

When daddy stopped work for the day and was able to lend a hand in childcare, I was able to breathe and reflect a bit. My anger subsided and this feeling of  ”it’s okay, it can wait for tomorrow” took over me.

This got me thinking about all those mommas that are being persuaded into labor induction and this made me sad. In my first pregnancy my OB asked me if I’d like to schedule a cesarean when I was about 17 weeks along. There was no medical reason for this, it was for convenience! This is when a light bulb went off for me and I got the momma sixth sense that something was very, very wrong here. I immediately proceeded to change providers and practically ran to a natural birthing center where ended up having a non-complicated, peaceful, water birth.

What about the mommas who do not know that there are birthing choices? Do women think that it is normal to schedule a date to induce labor? To schedule cesareans?

It seems that many young, healthy women that I’ve had conversations with recently do not believe it is possible to have a natural birth. They were told for one reason or another that they aren’t “allowed” to. That they “have to” schedule inductions to not pose any “risk” to the labor process. These women pack their bags, do their hair and makeup before they leave for their scheduled date at the hospital, get induced and often receive an epidural when they get there, and with one or two pushes the baby is out.

Is this what birth has become? Do we have our babies like we shop online? For convenience? If there is no MAJOR medical reason why you need to have your labor induced, please stop to to think of the risk you are really putting your baby in by inducing.

Why would labor be induced?

There are several possible reasons. Those nearer the top of this list are cases where the benefits may outweigh the risks. Those nearer the bottom of this list,  the risks are more likely to outweigh the benefits.

1. If the baby or mother has a SEVERE health condition which makes it riskier to continue the pregnancy than to induce;  severe pre-eclampsia, diabetes with complications (it is estimated that this rationale for induction only applies to 3% of pregnancies)
2. Water breaking. If mom is more than 35 weeks pregnant, and it’s been more than 24-48 hours since membranes ruptured, most caregivers recommend induction to reduce risk of infection.
3. A baby that’s “overdue” – pregnancy lasting over 42 weeks.
4. If baby or mother has a MILDER health condition.
5. A pregnancy lasting over 41 weeks.
6. The baby is “too large.” (Although this is a common reason for physicians to recommend induction, research seems to indicate that there are not significant benefits to inducing labor)
7. Convenience or preference. Of the mother, or the caregiver. The risks outweigh the benefits.

Summary of induction risks.

All of the forms of induction can lead to stronger, more painful, and more frequent contractions, which may lead the mother to use pain medications she might otherwise not require. These powerful contractions may also limit oxygen supply to the baby, so increase the risk of fetal distress. Also, due to the uncertainty of due dates, and the variation in the amount of time any given baby requires to reach maturity, early induction carries a risk of causing premature birth. There is a significant increase in the chance of cesarean.

Questions to ask your provider if induction is recommended:

1. Why? What are the reasons why it would be better to deliver the baby sooner?

2.  How? Could we start with one of the non-medical options and see if that works?

2.  When? Is this something that needs to happen today? What would happen if we waited a few more days? Another week? Is it possible that it can wait for tomorrow….

Think about it, challenge providers, do your research. Only you know what’s best for yourself and your baby. 

Much love,

Amy

Loyally Devoted to Doctor

I recently read the book The Highly Sensitive Person by Elaine N Aron, Ph.D. In the chapter called Medics, Medication, and Highly Sensitive People, the author states:

“Keep in mind, too, that it is common to feel an attachment to anyone you have been with during an arousing experience, especially if it was a truly painful or emotionally significant ordeal. In the medical realm you hear these sorts of extra feelings when people describe their surgeon or women talk about the person who delivered their child, which is perfectly normal. The solution is simply to know why it happens and compensate for it appropriately.”

In the chapter about relationships, she talks about studies that were done that showed people are far more likely to fall in love under stressful circumstances. She applied this phenomenon to attachment in all relationships, not just romantic relationships. Later when I read the above statement in the medical chapter, so many things started to make sense to me.

Why do women love their maternity care provider, even when they may have done unnecessary procedures on them and not allowed them to make their own choices? Why do many providers use scare tactics? Why do women hold so adamantly to the belief that their provider “saved their life” or “saved their baby” or “was a great doctor” or “really took good care of me”, even when evidence to the contrary is right in front of them? Why do they fail to make important connections, such as that their c-section may have been one of the many unnecessary ones, or that there may not have been a true evidence based need for their induction? Why is childbirth treated like a major emergency with so much fear and anxiety around it? Why aren’t all women who give birth in this system severely traumatized from it, and instead defend and adore their doctors? The answer is simple: the culture of fear that surrounds childbirth actually endears women to their doctors. It cements the relationship between women, their doctors, and the hospitals their doctors practice at. It ensures that the women will keep coming back, and will recommend their providers to all their friends as they speak about them in glowing heroic terms. It is quite brilliant really, providers and hospitals have found the key to running a very successful business, and it has nothing to do with allowing women to make their own choices. They simply have to give the illusion prenatally that the woman can make her own choices for her birth, and then make sure that the actual experience of birth is one filled with fear, anxiety, and of course a healthy baby, and then the narcissistic provider will come out looking like roses to the woman who must endure the “horrors of childbirth”.

Of course, I am not really giving the doctors the benefit of the doubt here. They likely don’t know on a conscious level what they are really doing. They have been trained to act this way, by people who were also trained to act this way, and it is reinforced for them every time a woman profusely thanks her doctor for a job well done, and every time a woman tells her birth horror story where the good doctor makes an appearance as the hero who delivers her baby to her despite all the dangers that presented at the last minute. Both the woman and the doctor seem ignorant of the psychological effects that framing every average birth as a medical emergency creates.

In the statement above, the author states: “it is common to feel an attachment to anyone you have been with during an arousing experience, especially if it was a truly painful or emotionally significant ordeal.” This describes childbirth perfectly. The word “arousing” here is referring to sensory levels. That can mean physically, emotionally, sexually, or any other assault to the senses, good or bad, that can be had. We know childbirth can be described as “arousing” in many ways. It is also inherently “painful” and “emotionally significant”. Even when women use drugs, there is still some level of pain before she took them, and depending on what type of drugs she took, she may still experience pain while she is taking them. So really, all births fit this criteria. Births in a hospital, or at home, or in a birth center all have these same basic elements. It seems women are wired to form an attachment to the people who were with her and helped her through the event. This could be her partner, her doula, her midwife, her doctor, her nurse, or her friend or relative. I think this type of attachment likely had an evolutionary purpose at one time. It would be ideal to attach to an older, wiser woman who assisted with the delivery of babies who would have been there to care for the mom postpartum, and to slowly help her to bond and form an attachment to the baby. This wise woman would then help the mother learn to breastfeed and care for her new infant, while slowly pulling back her own attentions from the situation. This is what we have in homebirth midwives today. How would our ancestors have fared if a man had shown up in the tribe to deliver a baby, and then disappeared immediately afterward? The woman would be left adoring him, yet not having help from him to form an attachment to her infant. Never learning how to breastfeed or other infant care skills. What would have become of humanity? What is becoming of humanity?

Midwives and doulas seem to understand this phenomenon. Doulas usually visit a woman once or twice postpartum and are available if she needs to talk or has questions about the baby, breastfeeding, or the birth. Midwives start seeing a woman more and more as the birth approaches, and then once the baby is born, they start to taper off again, seeing her less and less until she is no longer needed at all. This is a much more natural and appropriate response to caring for a woman during such a pivotal transition in her life. What happens when women see doctors or CNM’s in hospitals though? They are likely seeing a practice, not a specific provider. They will likely not give birth with the same doctor or CNM they saw prenatally. They may never see the same doctor or CNM again after they give birth, or perhaps just once at the six week checkup. How does this affect women emotionally, or in her relationship with her baby, when instead of having a slow winding away from her provider, there is just an abrupt ending to the relationship? Does this interfere with breastfeeding, or affect feelings of trauma related to the birth, or feelings of depression related to her new role as mother? It is ingrained in our psyche to attach to these people who help us through such a major event in our life. How will the people we choose handle this responsibility? Are we choosing someone who will corrupt our experience and force an unnatural attachment to them by creating more anxiety around the experience? Are we choosing someone who will be there for us days, weeks, and months later to answer our questions about the baby or to offer us emotional support? Will the person we choose even be available for the birth, and will we ever see them again afterward?

Now I realize why other women feel the way they do about their provider. I did not attach to my provider, I was instead extremely traumatized by her actions. I still wonder why some women are traumatized, and others fall in love with their providers, given the same set of circumstances. I wonder if it is actually more natural, and thus common, to attach to a provider even when (or perhaps especially when) that provider creates an atmosphere of fear. It makes sense then why so few of us are speaking up about the system and the way women are treated. It makes sense that women are extremely loyal to their providers, even when many aspects of their births were disappointing or upsetting to them. It makes sense that many women are reluctant to accept that there is anything wrong with maternity care. It makes sense why the maternity care system is so hard to change and is met with so much resistance from every side.

What can birth activists do to help women form healthy attachments during this transitional time in her life? It may be tempting to try to convince all women to have a homebirth with a midwife since we know that they are probably the best option for healthy attachments and a healthy weaning away as well, however, if a woman has already formed a strong attachment to a certain provider, it may be more realistic to recommend having a doula. A doula will be there prenatally, for the birth, and postpartum, and therefore can provide much of the physical and emotional support that new moms need and deserve. Some moms may hire a doula, yet keep her same provider that she has formed an attachment to, and others may find that a doula is a stepping stone to having a homebirth the next time. One day I hope that maternity care shifts to being centered around the mother again, and not around the provider and his schedule or routine.

The Infamous Cascade Chart

As someone strongly involved in the birth community, this is probably one of my favorite pictures floating around the internet that I run across every once and a while.? One day when I find out the person who actually put these thoughts and cascade of interventions into a physical chart to view, I am going to kiss them!

I have always loved how it starts with induction, because lets face it, so many women today are starting their labors with some kind of artificial labor stimulant. Whether it be pitocin, or the oh so dangerous cytotec. I can personally say I have been the victim of the cascade myself with my first child. Had I seen this before my pregnancy with him, I would have never opted for the induction. Many do not realize that induction in many cases will fail, almost half of the time according to the most recent figures, and when I quote that, I am quoting Robbie Davis Floyd in a 2008 interview, I believe it was in Pregnant in America but my birth/pregnancy movies and interviews all start to blur together when you watch so many of them. These babies are not ready to be born in many cases, especially when we are seeing these inductions before the “due date” or the 40 week gestation mark. Although we know that “due dates” aren’t much to put stock into, many women and providers use them as some type of eviction date, which history has shown to be a pretty bad idea. No one is going to be pregnant forever and many women left alone will go into labor on their own. Now granted, there are cases that induction is medically necessary and for these special cases, I am completely thankful. Without induction these women would be subjected to cesarean sections instead of labor inductions which could in turn be even more hard on their body, and experience over all.
What we do not understand with the induction of labor is, we are creating unnaturally strong contractions in attempt to simulate something similar to natural labor. As someone who has experienced pitocin labor, and natural labor, I would take a million natural contractions over being on the receiving end of pitocin again. The comparison in my opinion is not even in the same ball park. Another issue with these contractions as most know, is the fact that they are more likely to cause fetal distress on the baby because they are not natural contractions or what normal contractions are supposed to be. So in turn we are putting our children under unnecessary stress. Especially if they are not ready to come and join us in “our world” yet. Again something I learned with my first.
Then we have the provider who comes in and looks at the fetal heart monitoring and says, “Oh No! Your baby is in danger!!” So off to the operating room we go for an “emergency” cesarean which in reality was caused by the pitocin to begin with. You would think by this point there would be a bit of common sense in the Obstetric community to say, ya know, I think we are causing these actions instead of blaming the increasing cesarean rate on “patient choice cesareans” which only make up 3% at most of the incredibly high cesarean rate in our country.

But a cesarean is only one path that this induction cascade can lead to. There are still women out there that will have a vaginal delivery when subjected to a labor induction, but in turn these women have greater risks for other procedures including episiotomies which have all in all been proven to really have little to no benefit to women in the long run. While episiotomy rates are starting to decrease, they are still over used in many communities. For example, here in my state of Connecticut, some hospitals have an over 25% episiotomy rate, when science tells us there really shouldn’t be over 10%. Trying to obtain these numbers are like pulling teeth too FYI!

We also have vaccum extraction. I had never really discussed this or spoken with someone who experienced this until I met my Chiropractor in the summer of 2008. He was discussing with me why Chiropractic care in infants is important, and then he described his own daughters birth, they had applied the vaccum to the top of her head, and while “assisting” her out, they pulled so hard the vaccum literally flew right off of her head. My Chiropractor described it so vividly… “I thought her HEAD popped RIGHT OFF! I was horrified to even look!”? My heart broke for him because no parent should have to go through that kind of fright during the birth of their child!

These all often lead to epidurals, which especially if you are going to have a cesarean section, you will either have this or a spinal block. All types of anesthesia that will have a direct impact on the baby. Although I have experienced women told there will be no effects on their baby at all.
I am sure most know about the “breast crawl” and I can say after watching a baby who’s mother did have an epidural, as opposed to a mom who had a natural birth, there is no comparing the instincts of the baby. While I had epidurals with both of my children, I didn’t have the opportunity to breastfeed then until they were a little over an hour old. My first was almost 2 hours. For more information on epidural effects on babies, click this link!

The last thing I want to touch on is the separation of mother and baby after a cesarean section which is very common. It is pretty uncommon for an newborn to be allowed to stay in the OR with mom, although it does happen sometimes. I can really related to the lack of bonding, breastfeeding problems, and reduced bonding because of this because I deeply experienced this with the births of both of my children. While I bonded, it was not that “instant motherly love” I am sure most feel. It hurts me to this day to know that my bonding was an almost learned bonding because I knew as a mother it was something I needed to do in order to protect my babies.? While most women who have had cesarean sections are not quick to admit this, I think by discussing this and acknowledging that this is a true problem it will only help to improve it for others in the long run. I also noticed that mothers who do experience this may be ashamed or fearful to admit this because it make portray them in a less than perfect light, or maybe others may look down on them because of this, but they should not be ashamed. It happens and there is nothing we can do about it but help other women to not go through what we did!

Be empowered by your birth, no matter how you birth!
If it is a bad experience, help to educate others so they do not go through what you did, so they can avoid the pain or heartache you have dealt with!

Labor Begins On Its Own

The first healthy birth practice is simple enough – let labor start on its own.? This means no meddling around.? You don’t need to tinker with a process that’s ultimately perfect for the vast majority of women.? Your baby’s brain grows so much in the last few weeks of pregnancy – why lose that?? Why risk induction?? Here are some ways to avoid induction:

• Don’t whine about being uncomfortable to your doctor or midwife.? That’s what you do to strangers, your family and your girlfriends.? Your practitioner might just put you out of your misery (and theirs).
• Just say no to late pregnancy vaginal exams.? Sure it might tell you how far your are dilated (or not), but you also risk breaking your water, infection and the like – not to mention who enjoys vaginal exams?
• Don’t answer your phone or except pressure from email.
• Do not be swayed by false promises of fast labors or easy starts like stripping the membranes.

What would you add to this list?

Be sure to check out the advice from Lamaze on the Healthy Birth Practice #1: Let Labor Begin on its Own.? You should also see the materials provided at Mothers Advocate, including a really great, but short video.

Reducing Infant Mortality

Please watch this video and then spread the word about how to reduce infant mortality. Click here to visit the website and get help with writing to your legislator, or sending them this video.

Reducing Infant Mortality from Debby Takikawas on Vimeo.

ACOG Revises Induction Protocol

The American College of Obstetricians and Gynecologists (ACOG) has issues a press release saying that there is a revision to it’s labor induction guidelines. The basics from the press release do not look very different from what I had heard from ACOG before, so I’ll have to wait to have the paper in my hands. Here are some basics from the press release:

• Wait until 39 weeks or do fetal lung maturity testing
• Use cervical ripening before full blown labor induction
• Do not use Cytotek on someone with one prior cesarean
• Induction reasons may be for physical reasons with mom or baby or other reasons that are reasonable, like distance from hospital in a rural area
• There are risks to induction
• There are some reasons induction is not an option (placental, fetal position, etc.)

What are your thoughts on labor induction? One thing that jumped to my mind was that they said labor induction had doubled since 1990 and that now 1 in 5 women were induced. That number sounded really low to me.

More Healthcare is Not Better Healthcare – well, duh…

I had to snicker when I saw the headlines that proclaimed that more healthcare was not better healthcare. I mean seriously, birth has been proving that time and time again. ?The more medicalized we’ve made birth the higher the cesarean rate has risen, and the higher the infections, NICU admissions, breathing problems in babies, etc. have risen. ?The more we induce labor, particularly before babies are really ready, the more we see a rise in NICU admissions, cesarean section rates rise, etc. ?Do you see the circle we are going in? ?We’re like a silly puppy dog chasing our own tails. ?

I’d like to suggest that we all just back away from the prenatal care. ?Prenatal care that means invasive tests and inductions of labor when not medically indicated, that is… ?Let’s use the interventions that we have as we really need them – sporadically. ?Just because a new fancy procedure is really cool and works really well to help sick mothers and babies, doesn’t mean it’s good for all mothers and babies.

New Study On Scheduled Cesareans

There is a new comprehensive study about the safety of cesareans before 39 weeks gestation.? From the article, Early Repeat C-sections Increase Risks, Study Finds, published in the Washington Post, there is this quote about the study:

The study of more than 24,000 full-term infants found that those delivered at 37 weeks to mothers who had elective repeat C-sections were about twice as likely as newborns delivered at the recommended 39 weeks to experience breathing problems, bloodstream infections and other complications. Babies born at 38 weeks were 50 percent more likely to have problems; the risk was about 20 percent higher just a few days early.

The article states that the rate of cesareans is now over 30%, and that there is a great deal of debate as to why this is.? However, they then go on to say:

Although a pregnancy is considered full term after 37 weeks, the American College of Obstetricians and Gynecologists recommends that elective repeat C-sections occur no earlier than 39 weeks to make sure the baby has fully developed. But some women opt to deliver a little earlier for a variety of reasons, including being eager to see their baby, being tired of pregnancy or for convenience.

The article here suggests, with no data or studies to back it up, that the women themselves are convincing their OB’s to disregard their instructions from ACOG, go against evidence based care, and put the babies at risk in order to give in to the mothers whims.? I find it very curious that women hold so much power in this regard, when most other choices they make in childbirth in a typical hospital would be disregarded.? If doctors are so concerned for mothers choices, even when it means breaking their own rules and putting babies in harms way, then why aren’t the choices that women make for their labors and births that do not infringe on any rules or cause harm to their babies respected?? I doubt very much that doctors are truly allowing women to make an informed choice on this.? Perhaps women who are getting a repeat elective cesarean are showing an interest in an earlier delivery, but, are they then given the risks, benefits, or alternatives to delivering early?? Did they make a truly informed choice?? Or are they making a decision based on the belief that their baby is “full term” and is ready to be born?? In the absence of any cited study on the subject, it is my feeling that the article is making quite the presumption.

Here is all the study really had to say about the matter:

Of 24,077 women who gave birth through a repeat C-section between 1999 and 2002, 13,258 were clearly elective — meaning the researchers could find no evidence that the baby or mother was in distress or any other medical reason the woman could not attempt to deliver through labor. Of those, nearly 36 percent of the deliveries occurred before 39 weeks.

It is unclear from the study why there were so many “elective” cesareans performed.? It is not clear to me whether the researchers considered a repeat cesarean to be elective or not.? If the researchers didn’t consider a previous cesarean as a medical reason as to why the mother should have another one, then that would explain the large number of scheduled “elective” cesareans.? It doesn’t seem that any data was provided as to whether the mothers or the doctors were selecting the time in which these cesareans would be scheduled.

The articles goes on to talk about the findings in the study about the true risks of a scheduled cesarean before 39 weeks:

More than 15 percent of the babies delivered at 37 weeks suffered a complication, such as problems breathing, low blood sugar, infections or conditions that required intensive care, compared with about 8 percent of those delivered at 39 weeks. About 11 percent of those delivered at 38 weeks experienced complications. Babies born at 37 weeks were four times as likely as those delivered at 39 weeks to have breathing problems.

It seems very clear cut, but then another angle is presented:

While other experts agreed that the study provides important information to help women and their doctors make decisions about timing C-sections, some said the risks of complications are relatively low and need to be weighed against the small but not insignificant chance that waiting a week or two would result in more stillbirths.

The article does end with a voice of reason though:

But Spong said the magnitude of the risk of stillbirth from waiting is unclear, and the new study shows the risks of complications from early delivery is significant.

“It’s hard to advocate doing a Caesarean at 37 weeks to try to prevent a stillbirth when we don’t really know the true risk,” she said.

Overall, I feel this is a very good study that has been done.? Many babies and new parents will be saved the possible traumatic experience of the NICU.? Many doctors, who already had some research and guidance from ACOG to tell them not to schedule repeat cesareans before 39 weeks, will now have this additional comprehensive study that clearly shows the impact of doing so.? This also may bring to women’s and doctor’s consciousness that cesareans themselves are not perfectly safe for all involved no mater what.? They need to be carefully planned and managed and only performed in cases of true emergency, or they could possibly do more harm then good.