“Safety net” or trampoline?

What if there were no C-sections? What if that simply wasn’t an option? Do you think doctors would practice differently? I do.

No one discounts that C-sections can be beneficial, saving the lives of mothers and/or babies. However, our country is currently experiencing its highest C-section rate, with maternal mortality increasing right alongside the C-section rate (not saying necessarily that it’s causative; however, if these C-sections were life-saving to the mother, one would expect the maternal mortality rate to be decreasing or at least staying the same), and perinatal mortality not doing that much better either. [If you want some state-by-state breakdowns, Jill at the Unnecesarean has compiled several, with the most recent one being California.] Most people agree that the C-section rate is too high, and could safely be brought down. There are many factors going into the increase incidence — some of which may be valid and beneficial reasons, but others that are not.

Carla Hartley recently wrote a note in which she cleared up some misconceptions that have apparently been told about her and “what she believes.” Among other things, it appears that some have said that she thinks midwives ought not take Pitocin with them to home births (for postpartum hemorrhage). She said (paraphrasing), “But what if you as a midwife had no Pitocin in your bag? Would that change your practice style? Knowing that you didn’t have that as a backup, would you be less tempted to act in a way that might cause a postpartum hemorrhage?” That’s food for thought.

Taking this out of the birth realm, we see that when there is a safety net, it changes people’s behavior — how many of you would walk across a tightrope without a safety net below? Some do; but far fewer people would risk crossing if they knew that there was a real risk of death, as opposed to a slight risk of death and a real likelihood of safely bouncing on a net if they fell. There are always adventurous people, daredevils, pushing the envelope — doing things that are dangerous or downright deadly, just because they can. But most people only do something if they think or know that there is a reasonable chance for them to succeed and come back alive.

In another, much more mundane vein, we see banks and other companies loaning people money for various reasons, including education, buying a house, buying a car, etc. The more collateral you put up, the more they’ll lend you; the more you earn, the more they’ll give you; or if the government guarantees that they’ll pay the loan should you default or die, they’ll gladly loan you the money you ask. Why? There really isn’t that much risk involved, if the government is the guarantor; and the risk to the lender is dramatically lowered if you have something valuable that they can take if you can’t pay your bills. It’s a safety net for them.

Back to birth — I wonder how it would affect doctors’ practice style if they knew that there was no “safety net” of a quick, easy, safe Cesarean. I’m reminded of something one of my email doula friends said — she’s attended hundreds of births, many of which became necessary C-sections, but none of which were necessary at the outset of labor. This is not to say that the only time C-sections become necessary during labor is if they were interfered with — sometimes the most natural labors end up requiring C-sections, and sometimes interventions can help preserve a vaginal birth when otherwise a C-section might be necessary; but frequently, it is the interventions which lead to a C-section then becoming necessary. We all have heard of “Pit to Distress” — the practice of increasing the dosage of Pitocin until the baby is born, or becomes so distressed by the unnatural labor that the doctor then has a reason to call for a “necessary” C-section. What if doctors didn’t have easy access to surgery, in the event the baby was distressed? Do you think they’d be so quick to give Pitocin to a baby that is tolerating labor, just to speed things up? I don’t. It’s relatively easy to say that it’s no big deal if the baby becomes distressed due to X, Y, or Z, because “she can always be given a C-section.” But what if she can’t? Then, if the baby becomes distressed because of something the doctor did, it’s all on him if the baby is injured or dies.

If there were no C-sections, doctors would still be taught how to best manage vaginal breech births and vaginal twin births. I think of one snippet of media coverage I saw in the aftermath of the Haiti earthquake. An American woman (probably an OB, maybe not), was attending births in the street “hospital,” and a Haitian woman was in labor. Probably the baby began “crowning,” except that it wasn’t the head, but the rump that was presenting. The American wailed, “It’s breech! I don’t know what to do!!” She had probably never seen a vaginal breech birth before — even assuming she was a trained and practicing obstetrician, she likely was trained in100% C-section for breech, rather than how to safely assist a vaginal breech birth. All well and good for America, with plenty of hospitals and operating rooms, technology and antibiotics — but when the OB is removed from all of that, what skills does she really have to help make birth safe?

If there were no fetal monitors, doctors would not feel safe with administering Pitocin, particularly in high doses, because they would have no way of knowing how the baby was tolerating it. If there were no C-sections available should the baby become distressed, doctors would be more cautious to keep the baby from distress, don’t you think?

I’m afraid that our safety net of technology and interventions has become more of a “trampoline” — rather than being used only to save someone’s life or health in rare events, it is being used on a regular basis, as if it’s meant to be bounced on. And, no, I’m not calling for a complete ban on the use of Pitocin, C-sections, or any other intervention — they have their place. However, if they were reduced only to what was necessary (which we as fallible humans cannot know with 100% certainty which are truly necessary and which are not, so we could not truly reduce the rate of unnecessary intervention to zero; but looking at some things like mortality and morbidity with and without C-sections, and retrospective studies showing that most inductions were not medically necessary [and failed inductions certainly increase the rate of C-sections], we can see that it certainly can be reduced), we would see a very different (and, I think, better) picture in labor and birth, compared to what it is now.

One time my sister was talking to a police friend of ours, and sort of complaining about getting pulled over for speeding tickets. [At the time, she did have a “cop magnet” — a sweet little black T-top Thunderbird.] And our friend said, “Always drive like there’s a cop behind you.” That’s good advice, isn’t it? We often don’t — relying on radar detectors just to keep from getting caught; but if we drove safely and cautiously, within the speed limit, and obeying all laws, we’d likely never get a traffic ticket, and we’d reduce the likelihood that we’d end up in an accident. Maybe if doctors, midwives, and nurses would “practice like there are no C-sections,” we’d be able to safely reduce the C-section rate much closer to the minimum necessary.

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Induction or Augmentation?

When a woman’s labor is started artificially, it’s considered an induction — whether elective or medically indicated. When a woman’s labor starts on its own, but for one reason or another is put on Pitocin to strengthen the contractions, it’s considered an augmentation of labor. But what is it called when a woman’s water breaks but contractions don’t start immediately, and she goes to the hospital and is put on Pitocin? Is it an induction or augmentation?

My first pregnancy, my water broke about half an hour before contractions set in; one of my sisters had rupture of membranes followed by no labor for 18 hours, at which point she went to the hospital for… an induction, or augmentation?

Usually, when a woman’s water breaks before labor begins, contractions are not far behind; but sometimes, some time passes before it happens. I think of stories I’ve read of women who have had “high leaks” or even a full “water breaking”, but either the tear resealed itself, or the baby was so premature that even with ROM, it was better for him to stay in utero than to be born (as long as the mom didn’t have an infection or any other medical reason for the baby to be born then). Most of the time, however, either the baby needs to be born early, or the woman is at term or close enough to term that the doctors want to start or speed up labor, out of fear of infection.

Elective Induction Brochure

The Agency for Healthcare Research and Quality has recently issued a brochure on elective induction [ok, it looks like it went 404 on me, but here is a webpage with I think the same information on it, just not in brochure form]. The Family Way Publications has a good response about what’s wrong with the brochure. I would merely add that any time you choose an elective medical procedure, it only serves to introduce risk without a balancing or over-riding benefit. I agree with the rebuttal that the risks should be talked about in stronger terms, unless the brochure is not intending to dissuade women from an elective induction. I agree with being “fair and balanced” and trying to present both sides of the story, if that’s possible; but sometimes it’s not possible. What this brochure is doing is making it sound like a coin toss between waddling around for a few more days or weeks (which as far as I know, poses only mild and short-term discomfort for most women, and no long-term medical problem; if there is a medical problem necessitating induction, then that’s not elective), or choosing a medical procedure with known risks (including iatrogenic prematurity, more problems for both mother and baby during and after labor and birth, an increased risk of C-sections in first-time moms or those with unfavorable cervices) for no medical benefit. It shouldn’t be a coin toss. Weighing both sides of the issue in a balance, elective induction is a clear loser, and women should be dissuaded from that. The brochure does not seem to do that. It mildly mentions that women should wait until 39 weeks to be electively induced, but without a strong demonstration of the reasons why that is the best choice (certainly for the baby, who faces a doubled risk of NICU admissions, etc., at 38 weeks and a quadrupled risk at 37 weeks), women are left with the idea that the risks are about equal to the benefits, when that’s just not the case.

In fact, I wonder why they even put together this brochure at all. It seems to me that the only reason to do so would be to dissuade women from choosing an elective induction — after all, if the doctor suggests an induction, most women would think there would be some medical reason or benefit to doing it, and at the least would just be following the doctor’s lead. That may fit the definition of “elective” in that anything that is undertaken for no medical benefit is “elective”; but it doesn’t fit the narrower definition, of it being the mother’s choice, and I might add, the mother’s idea. Rather, it is the doctor’s idea, and the mother acquiesces. If I were to put together a brochure about elective induction, it would be with the idea of giving it out to women who are contemplating asking their doctor or midwife to end their pregnancy early, to dissuade them from so doing, not to leave them with the impression, “Six of one, half-dozen of the other.”

Iatrogenic Prematurity

This month is Prematurity Awareness Month, and although I missed the “calling all bloggers” Prematurity Awareness Campaign for Nov. 17 [I just didn’t feel like writing about it — sorry — nothing “sparked” in me at the time], since that time, I’ve gotten “sparked” about iatrogenic prematurity. If you’re unfamiliar with the term, it just means “doctor-caused” prematurity.

The March of Dimes is the main organization leading the Prematurity Awareness campaign, but I have to admit to being a little perturbed that they didn’t speak more strongly about the one cause of prematurity that could be most easily changed — iatrogenic prematurity, caused by elective inductions and C-sections.

It’s possible that “iatrogenic prematurity” might include necessary or beneficial cases of babies born by induction or C-section too soon — for instance, a baby who suddenly stops moving at 34 weeks and is obviously compromised. But for my purposes, I’m restricting it to medically unnecessary inductions and C-sections.

Here is one link: Why do women deliver early? Did you catch the discussion on elective inductions and C-sections? No? Not surprising — it receives only the briefest of mentions. However, this March of Dimes article, “Why the last weeks of pregnancy count” does dwell on the topic a bit more. Elective C-sections and inductions are (thankfully!) not one of the four main causes of prematurity, but iatrogenic prematurity could be stopped tomorrow. And I think that’s important to note.

Some doctors have a laissez-faire attitude about inductions and C-sections, and have no problem with either as soon as the mom hits 37 weeks. Perhaps that attitude is changing a bit, since research has demonstrated that infant outcomes are much worse in several different areas if the baby is born unnaturally at 37 weeks, compared to 38 and especially compared to 39 weeks. [And when I say “unnaturally,” I’m meaning, by induction or C-section — babies born to women who go into labor naturally at 37 weeks do as well as those born at 38 and 39 weeks, naturally — it’s the unnaturally early births that are the problem. When the woman goes into labor, that is an evidence that her baby is actually ready, as opposed to having reached some arbitrary date on the calendar.] Some doctors may even do an elective induction or C-section at 36 weeks. I read a story some time ago about a woman who had a late-term fetal demise in her first pregnancy, so opted for an elective induction at 36 and a half weeks. She thought he was ready “enough” — that it was “close enough” to term for him to be born. Her baby was in the NICU for 6 weeks, and had long-term health problems (mostly related to his lungs and breathing), because he was not ready.

A woman’s dates can be off, which could really cause problems with her baby, if she electively induces or has a C-section at 37 weeks (or even later). What if her little one would have been born naturally at 41-42 weeks? That’s 5 weeks early. And if her dates are off, it may be even earlier. There’s a lot of brain, lung, and body development that happens in those last few weeks, that ought not be circumvented without an awfully good reason. Although rare, “superfetation” — conceiving a second baby many days or even a month after the first baby was conceived — is also a possibility, as Abby Epstein found out. What if she had gone by “I thought I was pregnant a month ago,” even though that baby died, and her later-conceived baby lived? Perhaps they were conceived at the same time, and this was just “vanishing twin,” but perhaps some of these super-long gestation times one occasionally reads about were actually due to undiagnosed superfetation with a hidden/missed miscarriage. Could happen. I remember in reading through some of the causes of death listed on the CDC linked birth-death certificates, that one hospital-born baby born at 42 weeks died due to “extreme prematurity.” It could be a typo — perhaps it should have been “24 weeks”; or maybe the code was entered wrong. Or maybe the mother’s dates were miscalculated. Or maybe she happened to skip a period prior to conception, so she thought she was at 42 weeks, when she was 6-8 weeks earlier. I wonder, though, if she was induced because she was “42 weeks” and her baby was nowhere near ready. Unlikely, but possible.

Then there’s this little gem of an article: Many Women Miscalculate Time to Full-Term Birth. One paragraph reads,

“About one-quarter of new mothers surveyed in the study considered a baby born at 34 to 36 weeks of gestation to be full term, while slightly more than half of women considered 37 to 38 weeks full term.”

Only problem is, that’s not what the question was. Here’s the actual question (also from the article):

“What is the earliest point in pregnancy that it is safe to deliver the baby, should there not be other medical complications requiring early delivery?”

It didn’t say “when is full term?” It asked “when is it safe?” Ok, so define “safe”. Most babies will do fine born electively at 34 weeks. Obviously, not all will — some will die that would have lived; of those who live, some will have long-term negative effects related to their prematurity. If safe is some sort of “beating the odds” — well, 90% of babies born at 30 weeks survive, and the odds go up every week. Many (perhaps even most) of these babies will not suffer long-term negative effects (like cerebral palsy, blindness, etc.) which used to be so common at this age, but now are more common with preemies born at earlier gestational ages; and the risk goes down with age. Even fewer babies born at 37 weeks will have problems, than those born at 36, 35, or 34 weeks. Does it mean it’s “safe” for them to be electively induced or sectioned then? Well, sure, compared to preterm babies; but not compared to 38-weekers, or 39-weekers. But again, babies are naturally born at 37 weeks all the time and have no long-term problems compared to babies naturally born at 38, 39, 40, 41, etc. weeks And if a woman goes into labor at 36 weeks, doctors will not try to stop the labor. I daresay that many people would say, “If the doctor won’t stop labor at 36 weeks, then it must be safe for the baby to be born then.” Is that a wrong supposition? Yes, if you’re talking about elective inductions; perhaps no if you’re talking about natural labor.

I will also note that the question was not, “When is the earliest point in pregnancy that an elective induction or C-section should be used?” Had this been the question, I would have answered “never” if that was a possibility 🙂 or else “39-40 weeks,” if that were the latest time frame given. However, in the question that actually was used, I probably would have answered 37-38 weeks, because that’s “term”; or possibly at 36 weeks — if the woman goes into labor at that point, the doctor won’t stop it, after all. Not because it is best for the baby to be born at that point, but because I don’t know if it totally meets the threshold of “unsafe” for the baby to be born early. Not optimum, but perhaps “safe.” Is it “safe” to drive a car? Almost everybody would unhesitatingly say “yes!” but people are injured and killed in car wrecks every day. And some people are injured or killed as pedestrians, who would have lived had they been in a car. “Safe” does not necessarily mean “absolutely no risk,” because as probably everybody over 12 understands, there is almost nothing in life that is completely risk-free.

Although there were several good parts of it, this article was irritating on a few points, including the following:

Misconceptions about what constitutes full gestation and how soon it’s safe to schedule an elective induction or cesarean delivery are contributing to increasing numbers of premature births in the United States, said lead study author Dr. Robert L. Goldenberg, professor of obstetrics and director of research at Drexel University College of Medicine in Philadelphia.

Ah, yes — blame the mother! I feel so sorry for these poor spineless doctors who just can’t stand up to the strong woman who demands an early end to her pregnancy, regardless of how much damage it does to her baby. You know how thoughtless and uncaring women are! They don’t give a rip about the baby they’ve just spent the last 8-9 months of their lives growing! Odds are, they’ll leave the baby at the hospital and just walk away!

Ok, so maybe the sarcasm was a little heavy in that last paragraph, but seriously, folks!! It makes me want to scream! Sure, some women are selfish and truly don’t care about their babies — after all, some women abuse alcohol and use illicit drugs while pregnant. But I daresay that if doctors tell most women that their baby will be twice as likely to die (or whatever the actual rate is), if born electively prior to 37 weeks, or even in the early term period, and will be 3-4x more likely to have serious morbidity, that would put a curb on elective inductions. Some women may have legitimate or quasi-legitimate non-medical reasons for induction — husband home from Iraq for two weeks, previous stillbirth in the term period, severe pregnancy discomfort, and maybe others. [The  McCaughey septuplets just celebrated their 12th birthday (I remember because they were “due” the same day my sister was due with her first child), and they were born two full months early. In an interview soon after the birth, their mother, Bobbi, said that she just couldn’t stand the nausea and other side effects of the pregnancy itself and the drugs she was on to maintain the pregnancy. She held on as long as she could, knowing that every day they were inside her, it would be better for her babies; but finally she just couldn’t take it any more. That doesn’t apply to most women.]

So, yeah, educating women about prematurity and the problems babies have when born too early (by the babies’ clocks, even if not by the doctor’s calendar!) will help, because it will likely reduce the number of women wanting an early end to their pregnancy, and those who look at their due date as an expiration date. But women could not induce if doctors did not allow it! Inductions and C-sections don’t schedule themselves. Last time I checked, women can’t call the hospital and set up an induction or C-section without their doctor’s approval. They also don’t perform themselves — doctors (and nurses) have to perform an induction or a C-section. So, why does this article have such a strong tone of “it’s all the women’s fault!”?

I’ll say it again — iatrogenic prematurity could be stopped tomorrow, if doctors wanted to.

What’s the Rush?

Reality Rounds has been posting on different issues with her role as a NICU nurse, and a recent comment inspired this post. The post itself was on the realities of prematurity, and the struggles that the babies (and their parents, nurses, and doctors) face when they’re born too soon.

The comment was from a mother whose two children were both born early — at 30 and 31.5 weeks. She relates:

As a side note, one day when my second was still in the NICU, I was taking the elevator up to the NICU floor and another NICU mom was in there with me. There were a couple of pregnant women going to see their OBs on a higher floor and they were lamenting that they wished their babies would just come *now*. As the elevator doors opened at the NICU floor, the other NICU mom and I gave each other knowing looks and as we walked out the door, we simultaneously said “No, you don’t.”

Yes, indeed! I remember what it’s like to be “great with child,” getting anxious for the pregnancy to be done, to meet the baby, to no longer have him kicking you 24/7, to get your body back, to not have your back hurt any more, etc., etc. But you don’t really want your baby born too soon!

I think it may would probably cut down on the numbers of elective inductions (and requests for early inductions or C-sections that are not medically indicated), if women were to be given a tour of the NICU sometime in their second trimester (much like they might take a tour of the L&D unit prior to giving birth), so that they could see the realities of premature birth. And it doesn’t even have to be really preterm birth — even slightly preterm may have problems, as At Your Cervix attests:

A [fetal lung maturity] test was done and showed “mature” levels for a recent “near term” gestation infant. Baby was delivered. Guess what? Baby had respiratory distress shortly after birth and was sent to the NICU. Baby was NOT ready to be born. The lungs were NOT fully ready for life outside the confines of his former uterine home. One can only wonder how much brain growth and development was also lost, from not having the last few precious weeks in the womb.

[Make sure you read all the comments at AYC, especially “Lonely Midwife.”]

Plus, there is research to show that babies born by elective C-section at 37 weeks have double the risk of problems as those born at 38 weeks; and the 38-weekers have double the problems of those born at 39 weeks. So, what’s the rush?!?

I don’t know. Have we gotten so arrogant, that we are doing what Jeff Goldblum’s character said in Jurassic Park? — “Your scientists were so preoccupied with whether or not they could, they didn’t stop to think if they should.”

Obviously, doctors will not induce before 36 weeks for no maternal or fetal indication. At least, I hope that would not be the case! So, it’s not like most preemies are intentional. Yet, if a baby is born before his due time, but is born just because “well, it’s term, and you’re tired of being pregnant, so why not?” he will likely have complications that he would not have had, had birth started naturally. While the worst and most difficult NICU stays are likely to be unavoidable, there are some that could be avoided — like the one AYC mentioned — by waiting on nature. What’s the rush?

Let Labor Begin on Its Own

Science and Sensibility is having a blog carnival on the Six Healthy Birth Practices, starting, quite naturally, with the first, which is Let Labor Begin on Its Own. Of course, there are sometimes reasons why labor should be induced, or skipped altogether and the woman given a C-section; but primarily it is best for both mom and baby for labor to begin on its own.

Some months ago, I read a blog or article or email about induction, and the author used a phrase that really struck me between the eyes. We know a lot about pregnancy, fetal development, labor, and birth, but we’re still a little fuzzy on what exactly starts labor — some complex interaction between baby and mother, with it seeming that the baby starts labor by some hormonal or chemical signal to the mom that he’s ready to live on the outside. Now comes the poignant phrase. Until the time that labor naturally begins, attempts at inducing labor are more likely to fail because the mother’s body is protecting the baby from being born too early. When an induction “fails” it is because the mother’s body is succeeding at gestating her baby a little longer (probably for his own good). Now, that’s a different way of looking at things!

One childbirth educator I know had two students due about the same time. One or both were being threatened with induction, and the educator was more concerned about one than about the other, because the second woman had a cervix that was far more “ripe” than the first woman, who was barely dilated or effaced at all. However, what happened was that the first woman went into labor prior to her scheduled induction, and had a smooth labor and birth; while the second woman was induced, and had a long, hard, highly-medicated labor, perhaps ending in a C-section. Which shows the importance of naturally going into labor. If judging solely on Bishop’s Score, the second woman should have had an easier labor and birth, because she had a “head start” on the other woman, judging on dilation, effacement, and other signs of a ripe cervix and “labor readiness.” But her body and her baby knew better.