Bet she will!

What if you found out your doctor and nurses had a bet going on as to when you’d give birth, if you’ll end up with a C-section or episiotomy, etc.? Do you think that would have some bearing on the kind of care you receive? If your doctor thinks that all first-time moms and most subsequent moms need an episiotomy, what do you think your chances are of coming through childbirth uncut? If your doctor has you marked out for a C-section, do you really think he’ll try to ensure that you will have a vaginal birth, just because that is what you wish?

No, I don’t really think that doctors and nurses really have a betting pool on their patients (although, years ago, I did hear of a Las Vegas hospital or nursing home that had to fire some of its employees, after it was discovered they were betting on when their terminal patients would die), but does it really matter whether the doctor has money riding on it or not, if he has prejudged you as needing a C-section?

This is more than just a thought-provoking post. This post was inspired by numerous posts I’ve read recently that have come together in my mind in a new way. The main “other post” I read was by a woman who feels like she was railroaded into an unnecessarean. Of course, I only have her point of view to go on, and can’t ask her doctor’s opinion. While she has some legitimate beefs with the care she received, if her perspective is correct, she did fit several risk profiles (including being overweight and having diabetes and having a 9lb+ baby — although these in and of themselves do not require a C-section), and she may have been unaware of something that happened in labor from a clinical perspective, so it is also possible that her cesarean was indeed necessary and kept her baby safe. She does not think so, and is planning a home VBAC if she gets pregnant again, because of the care, or lack thereof, she received at the hospital.

But in reading her birth story, she relates that the doctor had strongly encouraged her to choose a C-section before she went into labor, and even said that she’d end up with a C-section anyway. It didn’t matter that she wanted a vaginal birth; it didn’t matter that she wanted to give birth without any medication at all. Her doctor grudgingly allowed her to go into labor (as if he really had a choice to force her into an elective C-section), but there was a thread running through her birth story of consistent undermining of her wishes and desires to have a vaginal birth. So while I was expecting the story to end more along the lines of, “so I ended up having a vaginal birth despite my doctor,” I was not too surprised to see the doctor keep pushing a C-section, and the woman finally consenting, without any indication of a real medical reason. (Although, again, she may have been unaware of something that had happened to indicate a C-section.) The actual diagnosis given was “failure to progress,” with the explanation being that she was too fat for the baby to descend into the pelvis, and the baby was also too big to descend lower into the pelvis and dilate the cervix. Of course, I would have just suggested that she be given more time, as long as the baby’s heartbeat was fine, but that suggestion would not have been taken well. You see, the doctor had determined that she ought to have a C-section before she even went into labor. So, the doctor was ultimately proven right. Or was he?

The fact that she ended up with a C-section does not necessarily indicate that the C-section was necessary to save either her or her baby’s life or health, any more than the fact that I give my kids peanut butter and jelly sandwiches for lunch when they ask for pizza is an indication that PB&Js are necessary for them. Reading her birth story indicated to me that the doctor had made his mind up to perform a C-section on her, and he had a “don’t bother confusing me with the facts” attitude. So, no, I don’t really trust that the doctor did what was medically indicated. Rather, I think he decided that she should have a C-section, and chose every opportunity he could to force-feed her a C-section, until she finally gave in and submitted to it. That is certainly the impression she has.

The other stories are mainly L&D nurses’ stories of patients they’ve taken care of — they advocated for them to have a vaginal birth and some succeeded, while others did not. Some of the stories make my blood boil, because the doctors just don’t care. Sometimes they are knife-happy; other times they are just selfish and want to go home and stay home, and not have to be called back out to catch the baby later; and sometimes they have just marked out a woman for a C-section, and jump at the earliest opportunity to coerce her into one by telling her that her body has failed. Hearing these stories from mothers who have gone through this experience, but may miss clinical reasons that truly indicated a C-section, so feel like their C-section was unnecessary, but are wrong, is one thing; hearing these stories from experienced L&D nurses who can unequivocally say, “I know her C-section was unnecessary,” is another.

So much depends on your care provider’s philosophy! Do not underestimate how important it is to choose your midwife or doctor and birth-place wisely!!

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High-Tech vs. High-Touch — Consumer Reports on Childbirth

In an article titled “Back to basics for safer childbirth,” and subtitled “Too many doctors and hospitals are overusing high-tech procedures,” Consumer Reports finds the same problems with modern birth practices for low-risk women that natural-birth advocates have been reporting for years: overuse of high-tech, often invasive measures, and underuse of high-touch, usually non-invasive measures.

Overuse of high-tech measures

  • Inducing labor. The percentage of women whose labor was induced more than doubled between 1990 and 2005
  • Use of epidural painkillers, which might cause adverse effects, including rapid fetal heart rate and poor performance on newborn assessment tests
  • Delivery by Caesarean section, which is estimated to account for one-third of all U.S births in 2008, will far exceed the World Health Organization’s recommended national rate of 5 to 10 percent
  • Electronic fetal monitoring, unnecessarily adding to delivery costs
  • Rupturing membranes (“breaking the waters”), intending to hasten onset of labor
  • Episiotomy, which is often unnecessary

Underuse of high-touch, noninvasive measures

  • Prenatal vitamins
  • Use of midwife or family physician
  • Continuous presence of a companion for the mother during labor
  • Upright and side-lying positions during labor and delivery, which are associated with less severe pain than lying down on one’s back
  • Vaginal birth (VBAC) for most women who have had a previous Caesarean section
  • Early mother-baby skin-to-skin contact

They also have a link to a true-false quiz on maternity care (I scored 100%).

Now that Consumer Reports has jumped on the natural-birth bandwagon, maybe, just maybe, all those people who denigrate natural birth advocates will shut up. Hey, I can dream, can’t I? 🙂

My thanks to Empowering Birth for the link to the article!

Pro-life nurse sued for removing IUD without patient’s consent

Here is the court document, which is pretty short and to the point: a woman went into a facility to have an adjustment made to her IUD, and the nurse practitioner “accidentally” pulled out the IUD.

As that happened, Defendant Olona stated “Uh oh, I accidentally pulled out your IUD. I gently tugged and out it came.” She then explained, “I cut the string than went back and gently pulled and out it came. It must have not been in properly.” Olona then stated, “having the IUD come out was a good thing.” She asked Ms. Van Patten if she wanted to hear her “take” on the situation. Without receiving a response, Defendant Olona stated, “I personally do not like IUDs. I feel they are a type of abortion. I don’t know how you feel about abortion, but I am against them. What the IUD does is take the fertilized egg and pushes it out of the uterus.” Defendant Olona stated, “Everyone in the office always laughs and tells me I pull these out on purpose because I am against them, but it’s not true, they accidentally come out when I tug.”

As much as I agree with the NP’s beliefs — that IUDs are abortifacient and that Mirena (the IUD in question, which has a hormone to prevent ovulation) may not always prevent ovulation, so may also be abortifacient — I cannot agree with what she did.

Assuming that what is in the court document is true, if this NP always “accidentally” pulls out IUDs when she tugs, then she needs at the minimum better training in how to properly place or maintain them. If she is against IUDs, she needs to be in another branch of the profession so she won’t have to deal with them, or have other measures in place to assure that she won’t be called on to violate her conscience by properly maintaining an abortive device. If she thought the woman was ignorant of the possible abortifacient qualities of Mirena, then she can educate her with the IUD intact, and then remove it if the woman wants it. And if the woman doesn’t want it removed, then the NP can remove herself from the room and get someone else to serve the woman.

Now, onto what I think is even more important, and that is the Civil Battery charge against the NP:

27. Defendant Olona intentionally removed the IUD without Ms. Van Patten’s consent to do so.
28. Defendant Olona’s conduct fell below the standard of care in the medical industry, which requires consent by the patient prior to conducting any procedures.
29. Defendant Olona’s conduct and actions constituted a civil battery upon Ms. Van Patten.
30. The intentional removal of the IUD proximately caused Ms. Van Patten damages and injuries.
31. Defendant Olona’s actions arose out of the negligence in the performance of medical treatment.
32. Defendant Olona’s actions were intentional, malicious, willful, and wanton.
WHEREFORE, Plaintiff requests compensatory damages against Defendant, including loss of consortium for her and her husband, Peter Van Patten, together with all costs and attorneys’ fees.

I would like to see something of this sort brought against every birth attendant who performs “any procedure” without “consent by the patient” — especially ones that cause unnecessary pain, bleeding, or “loss of consortium” (the woman can’t or won’t have sex). If removal of an IUD (which causes a little bleeding and menstrual-like cramps; and led this couple to abstain from sex for fear of pregnancy) without a woman’s consent constitutes battery worthy of a lawsuit that will compensate for the pain and loss of sex, how much more justified is a lawsuit because a woman’s vagina is cut against her will (episiotomy), or she is coerced or threatened into or given a C-section against her will? I’ve never had any of these — IUD removal, episiotomy, or a C-section — but I daresay the pain and loss of consortium caused by intentional cutting into a woman’s vagina or abdomen is a great deal more than that which is caused by the unwanted removal of an IUD.

This is not to minimize what this woman went through. Just to say that the comparatively small amount of pain and bleeding and lack of sex (either two weeks until the DepoProvera shot became effective, or 4 weeks until she got another IUD implanted — the court document says both, but only one can be true) is nothing compared to the amount of pain and loss of sex caused by an unnecessary episiotomy or C-section. When 73% of women whose vaginas were cut during birth were not given a choice about it (Listening to Mothers Survey – II, p. 19), then something needs to change. If enough lawsuits are filed on behalf of these women and their husbands and their babies due to the unnecessary and possibly “intentional, malicious, willful and wanton” use and overuse of unwanted interventions, then birth as we know it may change.

Provider Bias

When a woman has a procedure such as an induction, episiotomy, forceps or vacuum assistance, or a C-section, what is the likelihood that the procedure was truly necessary? It’s common knowledge that some doctors and midwives have much higher incidence of interventions than do other care providers, even with a similar patient profile. If you have a doctor who feels more comfortable with performing a C-section than with handling the unpredictability of normal, natural labor, then the odds that you’ll have a C-section are fairly high, even if you are low-risk. A few generations ago, doctors were trained to cut episiotomies in every woman. Even today, there are some doctors who will cut more women than not, although there is little to no evidence of any benefit and quite a bit of harm from its routine use.

These doctors were trained with the belief that episiotomies were either necessary or beneficial. So they cut, even when the dictum to cut women’s vaginas was made with absolutely no evidence whatsoever. And they trained their students to cut, just because that’s what they had been taught. An episiotomy is necessary to insert forceps, but forceps are rarely necessary in women laboring spontaneously and undrugged. Yet even after the extremely high forceps rate dropped, the high episiotomy rate stayed, probably because so many doctors had never or only rarely seen an actual spontaneous birth over an intact perineum. So when the vagina was fully stretched to accommodate the baby’s head, doctors thought the woman was going to tear, so they cut her, as they had been trained was usually necessary. There are a few reasons to do an episiotomy, but in most instances, they are done simply because the provider was trained to do it, regardless of the evidence.

Many times when I see that this or that doctor has a high rate of any given intervention, I wonder how many of them were actually necessary, and how many were due simply to his or her having been trained to view them as necessary or beneficial. Here is a case in point, the press release of a study which shows that Asian women who have white husbands are much more likely to have a C-section (33.2%) than white women who have Asian husbands (23%).

Because birth weights between these two groups were similar, the researchers say the findings suggest that the average Asian woman’s pelvis may be smaller than the average white woman’s and less able to accommodate babies of a certain size.

However, it’s also likely that the doctors of these Asian women saw their larger (white) husbands and concluded at the first hiccup in labor (or maybe even before labor started) that their babies were too big for them to birth. I remember watching “A Baby Story” once in which the doctor wanted to induce the mom because her husband was big and tall while she was short. So she was induced a few weeks before her due date because the doctor was afraid the baby would be too big. I can’t remember for sure whether she ended up giving birth vaginally, but I do remember that the baby was small — in the neighborhood of 6 lb. Ah, but you see, the doctor saw “big husband” and concluded “big baby,” with no other evidence supporting his conclusion.

When doctors suspect a big baby, they are more likely to remove it surgically than allow the woman to give birth vaginally — irrespective of the baby’s actual birthweight, or the mother’s ability to actually birth larger babies. This video (one of my favorites!) is “Dedicated to all the care providers that told us we weren’t able to birth our babies.” It’s a streaming slideshow of women who were diagnosed with CPD (cephalopelvic disproportion — the baby’s head is too big to fit through the mother’s pelvis) and went on to vaginally birth larger babies — some of them were a pound or more bigger than the babies that were supposedly too big. Question CPD.

Because of the much higher C-section rate with suspected big babies (compared with babies who actually were that big, but were not predicted to be big), without any decrease in shoulder dystocia or fetal injury — the main worries with large babies — the researchers in this study concluded,

Ultrasonography and labor induction for patients at risk for fetal macrosomia should be discouraged.

Prejudice is a big topic in America today, and is a loaded word. Nobody likes to be called “prejudiced” nor to be the victim of prejudice. You wouldn’t accept prejudice over the color of your skin, so why accept prejudice because of your body type or the estimated fetal weight, which may be fairly inaccurate, especially at high suspected weights?

This is why it’s so important to know your care-provider’s biases before going into labor. If you’re comfortable with the idea of having an unnecessary C-section, then don’t worry about your doctor’s C-section rate. But if you’d really rather avoid a C-section unless it’s necessary, then you should ask your doctor about his or her C-section rate and philosophy. And don’t accept, “I only do C-sections when necessary,” because he might find — as the doctors of yesteryear did with episiotomies — that they’re “necessary” in the majority of cases.

 

This poll is multiple-choice so you can choose more than one answer, if you had more than one care provider for your birth(s).

All women should be offered a midwife

That is the conclusion reached by a team of researchers that looked at

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led or other models of care during pregnancy, and where care is provided during the ante- and intrapartum period in the midwife-led model.

Since the allocation was random, it means that all of the women were low-risk at the start of pregnancy, and all could have had midwifery care. And those that did have the model of care most associated with midwives had better results than those who were randomly assigned to obstetricians or family physicians.

These trials included over 12,000 women, and found that,

Women who had midwife-led models of care were less likely to experience

  • antenatal hospitalisation
  • the use of regional analgesia
  • episiotomy
  • and instrumental delivery

and were more likely to experience

  • no intrapartum analgesia/anaesthesia
  • spontaneous vaginal birth
  • to feel in control during labour and childbirth
  • attendance at birth by a known midwife
  • and initiate breastfeeding

In addition, women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks’ gestation, and their babies were more likely to have a shorter length of hospital stay. There were no statistically significant differences between groups for overall fetal loss/neonatal death, or fetal loss/neonatal death of at least 24 weeks.

Let me reiterate — these women were randomly assigned to either midwives or obstetricians, so they were not biased by self-selection. There may be a vast difference between the super-crunchy, all-organic, no-vaccinating, cloth-diapering hippie mama who embraces homebirth as the best way to ensure a natural birth, just as she works hard to ensure a natural everything else in her life, and a typical mainstream mom who does not. [And just for the record, I’m not denigrating either choice, and find myself somewhere in the middle, but closer to the “mainstream mama.”] These women did not choose midwives out of some personal preference — they were chosen to have midwives randomly. And fewer of them had a miscarriage or otherwise lost their baby prior to 24 weeks of gestation.

This is in addition to all of the other benefits listed above.

I’ve previously written about the difficulty in studies comparing midwives and doctors, and home-birth and hospital birth, because of different criteria that midwives may have, while doctors accept both low- and high-risk women. I wished out loud for a study which compared identical client profiles of both midwives and doctors to see how they fared under the two different models of care. “Ask and ye shall receive,” I guess.

Let me repeat the authors’ conclusions:

All women should be offered midwife-led models of care and women should be encouraged to ask for this option.

My thanks to Lisa for first blogging about this and bringing it to my attention.

R – E – S – P – E – C – T

It’s more than the name to a catchy tune. In real life, it matters quite a bit. Unfortunately, so many people just don’t get it. That’s not an intentional pun, although it could be a play on words: many people don’t understand that despite their education and training and knowledge, they still need to treat others with respect; and many people do not get the respect they deserve.

Let me give you an example.

My sister had an abnormal Pap. A nurse at her gynecologist’s office said she had to have a certain procedure — no ifs, ands, or buts — no other options. My sister fired her gynecologist — the doctor who had attended the births of her last two children — because of this basic lack of respect. She went to her family doctor (who had had training in obstetrics and gynecology, but practices family medicine because it is less hazardous to his malpractice insurance costs), and while he came to the same conclusion, he did it in a different, more respectful way. Had the gynecologist’s office practiced this way, she would have remained with him. The family doctor explained the reasons why she had to have this procedure — what it did, why there really was no other procedure for an alternative, etc., etc. Since she felt she had full information, she had no problem with submitting to this necessary procedure. She accepted it from a doctor who was respectful of her, but refused it from someone who just expected her to be a good little girl and follow orders without question.

Inductees in basic training learn how to follow orders without question. They learn how to be subordinate; to do as told. They are dressed uniformly, as a part of the “breaking down” process in order to act uniformly. While these actions and this behavior are perfectly suited for the military (their lives, and the lives of their comrades may be lost by hesitating at a command given by a superior), is that what birthing women are supposed to act like? Allowing the doctors and nurses to think for them? Never to question the opinion of the medical establishment?

I was made to think along these lines, not simply because of my sister’s experience, but because of a recent commenter’s story. She had had a miscarriage, and the doctor told her she had retained products of conception, and the only choice she had was for an emergency D&C. She ended up with Asherman’s Syndrome, and impaired fertility. She asked about alternatives (including medications) and was told her only choice was a D&C. She tried to get a second opinion, but no gynecologists would make time for her, saying the earliest appointment was some months future. Although she didn’t want to have the surgery in which the walls of her uterus would be scraped with a knife — wanted to miscarry naturally or take a pill to complete the miscarriage — she was given no alternative, so submitted to the D&C, which took away her ability to have a child. She was not told of that possibility at the time of the operation.

Why did the doctor treat her like that? Although I haven’t read a whole lot about miscarriages, use of medications (such as misoprostol or mifepristone) to complete a miscarriage, D&Cs, etc., I read up on the subject while discussing it with this woman. Apparently, misoprostol is most effective (with the least side effects) in the first two months of pregnancy; and the further along in pregnancy a woman is, the less effective it is. It’s possible that her doctor took it upon himself to decide that in her case, the medication would not work, and she would end up needing a D&C anyway, so issued an edict that she just have it. But that wasn’t his call to make — it was hers! It was her uterus, which ended up being scarred! It was her body, not his, which cannot now bear children (unless surgery to remove the adhesions is successful in her case).

Although I may have some of the particulars wrong — I’m not a gynecologist, and as I said, only have passing knowledge in this area — this is what I envision could have happened, had her doctor been respectful: “Mrs. Smith, I regret to tell you that your baby has died. From the ultrasound, it looks as if the baby stopped growing a few weeks ago. We can wait, to see if you will miscarry naturally, but the risk of infection goes up the longer it takes for the pregnancy to pass. You can take these pills, which may induce a miscarriage, but at your stage of pregnancy, there is a slight risk of uterine rupture, and the pills may not work. I’m recommending a D&C — a procedure in which we artificially dilate the cervix and scrape the walls of the uterus with a curved knife, to remove all of the products of conception. The risks of this procedure include [fill in the blank, including telling her about Asherman’s syndrome, and the risk of infertility]. The longer the time from fetal demise until we do the D&C, the more likely you are to get Asherman’s syndrome. Since the pills may not work, and you may not miscarry naturally, I’d like to do a D&C, so that we can reduce both the risks of infection and of having to do the D&C at a later date.”

I’m not suggesting that D&C is the way to go, by any means! In fact, I rather suspect that D&Cs are much overused, just like C-sections, episiotomies, and hysterectomies. These are old, well-established procedures, and many doctors are trained to use them as the first resort, or as a sort of cure-all. Any female problem can be solved by removing the uterus, right?, so why not just take it out at the first sign of trouble? Except that a hysterectomy is not easy on a woman — the surgery takes weeks of recovery, and the sudden removal of the female organs plunges a woman overnight into full-blown menopause. (The term “hysterical” is derived from “hysterectomy”, to describe women who had undergone that procedure and had periods of apparent uncontrollable emotions.) Nor does a hysterectomy solve all female problems: by removing the uterus the source of one problem may end, only to have the lack thereof lead to other problems. There is disagreement and ignorance about the full roles that female hormones play — every year it seems that some new study is released with a flourish proving the benefits of hormone replacement therapy, only to be contradicted the next year by a study showing that HRT leads to this or that risk — the risk of one cancer may be reduced, only to have the risk of another cancer increased, for instance; or the risk of some already rare cancer is reduced but the risk of osteoporosis is greatly increased.

With all the confusion and uncertainty, it is all the more important for women to be given full knowledge of all the known risks and benefits of all courses of treatment, and not just the doctor’s favorite treatment, or what is most commonly done. What might be right for one woman may not be right for another. It’s your body; know your options; demand respect.

Comfort

We’ve had a cold in our family for about a month now–it started with my husband and hit him hardest, then I got one, and just this past day or two, my kids have both started coughing. My younger son (19 months) woke up last night, and I started to nurse him back to sleep like usual, but he was so congested he couldn’t breathe through his nose. He felt like he had a fever, his throat sounded sore, he was coughing, and I’m sure his mouth was very dry from having to breathe through it. I got him some water, and tried to clear his nasal passages (which didn’t work), but there wasn’t anything else I could do for him, so I just held him. He was quiet and content–even though he must have felt awful. I did very little to relieve his physical symptoms, yet he didn’t complain. My touch, my presence, was enough to comfort him. He must have felt better from just being held, but it clinically didn’t make his symptoms any better: he didn’t suddenly start breathing through his nose, nor did his fever miraculously abate.

What does this have to do with birth? During labor, you will likely have some pain during contractions–although I have heard of women having painless labors and births (most notably using Hypnobabies, but some just naturally have pain-free or low-pain labors). Yet, just as my son felt better for my being there even though his symptoms didn’t go away, so you can feel better during labor even if your contractions or your pain doesn’t go away by the presence of someone to comfort you. In the old days, that would have been your mother (or possibly an aunt, grandmother, sister, or friend); but in our era of clinical birth and hospital settings, your mother may not be able to comfort you with her presence.

Many reasons exist for this–my mother gets extremely nervous around birth, and is more likely to irritate than comfort me. I think this stems primarily from the way she gave birth–against her will, she was completely anesthetized, and woke up with her pubic hair shaved off, and a large episiotomy cut and sewn back together–she has no memory whatsoever of any of her four birth experiences, and consequently is of little help when any of her daughters are in labor. Another reason may simply be that your mother lives too far away to come when you give birth. Or your hospital may have a strict one-person rule (which you may be able to successfully fight). Your mother may not be nervous, as my mother is, but she may be so negative about birth or your wishes, that she actually undermines your desires and your birth experience. (If your mom frequently tells you birth “horror stories” “just so you know what to expect,” then be cautious of how she may intrude her fears and negativity into your labor and birth.)

You may not be able to count on any of your close acquaintance–may even feel uncomfortable having a friend there with you–after all, you’ll be partially naked, and just might feel weird about it. But you can hire a doula. Check out DONA, CAPPA, and ALACE to see if they have a certified doula near you; or do other internet searches to look for doulas in your area–not all doulas are certified, and not all are certified with these organizations. Not all doulas are the same–there may be personality clashes, for instance–so make sure that whoever you choose would be someone you could be friends with. The benefits of using a doula are verified by many studies, and they include shorter labor, less pain, fewer requests for pain medications, less use of interventions (like Pitocin to augment labor, or episiotomies), fewer C-sections, and better maternal birth experience. (One study randomly assigned women admitted to the hospital to having nobody or having a woman just sit in the room without interacting with her, and it still showed superior results to the presence of a woman versus being left alone.) Doulas are knowledgeable about birth–most have given birth themselves, and have attended many births–so can be an important resource for you and your husband. Doulas do not take the place of dads. Rather, they can help support both mom and dad, giving your husband tips, tricks, and tools to help you, letting him take a break if he needs it, or just being a “safety net” so that if you or he run out of ideas, you can ask her.

The comfort of another woman in labor has been documented to have great benefits and no risks. And just as my son felt better just for having me there to be with him, so you will feel better when you are in labor and have someone there just for you.