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?

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It’s Distressing

Part of my “summer busy-ness” included going to the backside of nowhere, with no internet for nearly two weeks. You probably didn’t notice it much if at all, because I was able to set up enough posts to keep active (and I could get online at the library… as long as I could get to the library), but I sure noticed! I am so addicted to the internet! 🙂 In addition to a plethora of emails, I had a huge number of posts from blogs I subscribe to, to catch up on, since coming back. It’s really almost insane — I need to cut back… but I don’t want to miss out! 🙂 So, I missed out on the whole “Pit to Distress” viral blog posts.

I did read N is for Nurse‘s original post which seemed to start it all — in fact, her refusal to “pit to distress” was one of the things I was thinking of when I wrote the post about laboring women having and needing a patient advocate. The remainder are in no particular order, except perhaps the order in which I read them. A few of the links will be to blog posts that have multiple links in them, so I may end up linking to a single post more than once, while inadvertently leaving out another post, thinking I’d already linked to it. So, I’m human. If there is a good post you know about that is not included in these links, feel free to post it/them in the comments!

The first one I read was from Jill at The Unnecessarean, followed by part two (which also includes multiple links). Then, Keyboard Revolutionary has another set of links; with Rixa at Stand and Deliver having two posts — the first has an interesting set of comments after it, because Rixa has a graph of fetal heart-rate with a graph of maternal contractions, and asks L&D nurses who read her blog “what should you do in this instance?” — and gets a multitude of answers, which leaves one commenter saying, “Funny thing about the EFM commentary here. It *perfectly* illustrates how constant EFM is total crap–because nobody can agree on what they are seeing!!” [That may be what Pinky was referring to in this post. And fwiw, here is one post and another post on ACOG’s refining fetal heartrate monitoring guidelines.] The second post has multiple links as well. Jenn from Knitted in the Womb weighs in with her tales of being a doula at some Pitocin-induced/augmented births, as does Sheridan at Enjoy Birth. One of the contributors to our Independent Childbirth educators blog posted this.

From the nurse/midwife side of things: Ciarin at a Midwife’s Tale; Reality Rounds (NICU nurse), on nurses declining to follow a doctor’s order that they disagree with; a triad of posts from L&D nurse Melissa at Nursing Birth — Pit to Distress part 1, part 2, and understanding the pitocin dosage; former L&D nurse now new CNM Rebirth Nurse; and finally, Nicole at It’s Your Birth Right weighs in. In addition to the posts, I’ve read most if not all of the comments on them, which are also very interesting.

Then there is this article — not exactly on “Pit to distress,” but it does tangentially discuss the topic.

This is frustrating, because aggressive dosing of Pitocin, even if not given the term “Pit to distress” (even in jest), can harm mothers and babies. Obviously, contractions that are too strong and/or too close together can distress babies, since it reduces their oxygen supply. But it can also cause a mom’s uterus to rupture, even if she has an unscarred uterus — i.e., no history of C-section or other uterine surgery. Of course, this is not typical — but it can sometimes happen. As one of the posts said (I think it was “Nursing Birth”) — Pitocin, like many other drugs, can have different effects on different people — for some, a tiny amount of a drug will be enough to knock ’em out or make him loopy, while another person can take a bottle of it and barely get drowsy. A tiny amount of Pit may put some babies in distress or hyper-stimulate a uterus, while other women and babies will hardly have any effect from a maximum dose.

Does “Pit to distress” happen? Yes. How often? No clue. Anybody’s guess. It probably varies like every other statistic or factor, like epidural rate, induction rate, C-section rate, etc. In other words, some docs are going to be horrible, and others are not. I remember reading something somebody wrote about birth plans — this nurse or midwife basically said that it was nearly embarrassing to read some birth plans that specified “no pubic shave” or “no enema” or such like because these practices were nonexistent any more. Then several readers chimed in with their own personal stories of them being on the receiving end of these practices which were supposedly “not happening any more.” In my area, I could see stuff like this happening because of what I know of the nearest hospitals’ typical practices in certain things. [My mom was given routine general anesthesia, a pubic shave, and episiotomy — without her consent, and even specifically against her will — for all 4 of her births in the 70s, even though the “natural birth” movement really caught on in the middle of the decade, and many hospitals had modernized their services and practices by the time I was born. A friend of mine only barely escaped being given a routine enema when she gave birth at a different area hospital in 1996. The only way she avoided it was that she had an attack of diarrhea [as part of the normal birth process, not from actual illness] when she was being admitted.) So, some things may not happen in most hospitals — but if it’s even 1% of hospitals, that’s probably 30-60 hospitals where X is still occurring on a routine basis, even if the other 3000+ hospitals aren’t doing it any more. If these hospitals have only 1 birth average per day that’s still 11,000-22,000 women annually who are routinely submitted to these antiquated and archaic procedures. Or to overdosing on Pitocin. I’ve never personally known a woman whose uterus ruptured under any circumstances — but that certainly doesn’t mean it can’t and doesn’t happen! So, even if the majority of “birth people” and nurses say that they’ve never seen it happen at their hospital, doesn’t mean it doesn’t happen anywhere.

Of course, Pitocin, like every other drug, should not be used unless necessary or medically beneficial. If a doctor — or midwife! — is using Pitocin to speed up your labor simply so they can get done and get gone, that is *ahem* not a medical reason. Some doctors tend to have the idea that labor should never plateau, go slow, sputter, or even stop. That tends to be not allowed. “The labor curve must be followed, at all costs!” [Only slightly tongue-in-cheek.] Some doctors use Pitocin on all women — a few of the stories in either the blog posts themselves or the ensuing comments mentioned this — one doula said that her client was told sometime towards the end of her pregnancy, before labor even began, that she would be started on Pit when she got to the hospital; another L&D nurse expressed frustration that Pit orders were written up for a woman before she was even admitted and assessed (the doctor did it when s/he called to tell them the patient was on her way).

What can you do about it? First — trust your doctor. Seriously — pick a doctor or midwife you can trust. This will entail more than just picking a name out of the yellow pages, or from your insurance company’s “preferred provider” list, or asking your friends who they went with. You wouldn’t have agreed to marry your husband based solely on someone else’s recommendation, nor picking a name at random from a list of “available men”; you probably wouldn’t buy a car just from a description, without even test-driving it, so why on earth would you choose the birth attendant based on such little information? Ask questions, and look for red-flag answers, including such nebulous answers as “only when necessary.” As some of the posts have showed, some doctors apparently consider a 100% Pitocin rate to be “necessary.” Unfortunately, some care providers merely provide a bait-and-switch — appearing to be one thing during prenatal visits, and morphing into somebody completely unrecognizable during labor and birth. Not much you can do about that, except being aware that it can happen, and trying to make sure it doesn’t happen to you. Of course, another possibility is that your favorite care provider will be unable to attend your birth, leaving you with someone else who may not share his/her philosophy.

Second, make nice with your nurse. She will be the one actually managing your labor (or being hands-off), so having her on your side can make the difference between having your wishes followed and having them brushed aside as unimportant. You don’t have to call it “bribery,” but you’ll catch more flies with honey than with vinegar. Something like candy bars (perhaps Snickers, “packed with peanuts” or some other thing that has protein in it) is quick and easy for you to have in your room, to give to your nurse when she first meets you in your room — greasing the wheels and all that. Of course, if she’s on a diet, that might not be the best; but you could think of something else that might go over well that’s not just a carby, starchy, sweet thing to eat (mixed nuts? shrimp tray? — a little difficult to get if rushing to the hospital, but if you’ve got the time, you’ve got more options). If she’s going to advocate for you, you don’t want her weakening due to an empty stomach! 🙂 [Also, if you’ve got food in your room, it’s easier for you to eat it without appearing obvious, in case your hospital has rules against moms eating while in labor. Just note, that may be their rules, but not necessarily your rules.]

Third, educate yourself — know how Pitocin is administered and what you should be looking for when having it — not just the negative side effects like contractions too close together, but also the desired effect of contraction strength and/or pattern. Ideally, you shouldn’t have to do this, but it wouldn’t hurt to know. Know also that you can ask that Pitocin be stopped and/or turned down — it is not at all unusual for labor to continue on its own and in a good pattern after having been jump-started by Pitocin. If you are contracting at an adequate pace, and/or are dilating sufficiently (although I will stress that dilation is not the only way for labor to progress), but a nurse is continuing to up the Pit, you can ask why and/or request that she stop increasing the Pit and perhaps even reduce it or turn it off. Certainly you should know the symptoms of your uterus being overstimulated, so you can be more effective when requesting or demanding that the Pit be turned down. I’ve read several stories (including some comments on these posts I’ve linked to) of women who were hyperstimming, but didn’t know they could ask that the Pit be turned down — some even thought that their level of pain and/or contractions was normal, since “labor is supposed to hurt.” If your nurse won’t turn it down even though you are clinically contracting too frequently, request a new nurse or to speak to the nurse in charge. Of course, if you’re in labor and particularly if you’re having back-to-back contractions, this won’t be easy for you to do, so this is where a doula or other labor attendant (husband, etc.) comes in.

Hopefully, you will never need this information. But if you do, I want you to know it.

Unnecessary inductions lead to problems

Here is the link to an article about a recent study in Australia which concluded that when an induction is done without a medical reason, both mother and baby are at higher risk of problems than if labor begins spontaneously. These problems include a higher incidence of use of forceps or vacuum, Cesarean section, hemorrhage in the mother, admittance to the nursery for the baby, and resuscitation in the baby.

Thanks to Dr. Jen for the link.

Gardening and Birth

This analogy popped into my mind as I was thinking about something a friend of mine once said. She was an L&D nurse at the time, and said she didn’t understand why in the world a woman would want to go through labor without an epidural if she didn’t have to. (She went on to complain about women who declined epidurals, specifically about the amount of noise they made while laboring and bringing forth their children without drugs. As if women declined epidurals just to make her job hard.)

Anyway, although she still has the same idea, Becca now knows personally why some women decline epidurals — her own epidural in her first birth gave her the dreaded “epidural headache” (one woman described it as if a helicopter were landing in her head every time she sat up, for a week), and she also ended up with a C-section. The baby’s head was stuck on her pelvic bone — she actually had a line on her forehead from it, when she was born. Since Becca was numb from her epidural, she could make no changes in position to help the baby move into a better position which would allow a vaginal birth. But, hey, she still is a fan of epidurals for laboring women. That’s fine — it’s her opinion.

But in answer to her rhetorical question of why a woman might refuse an epidural, in addition to the increased likelihood of fetal malpositioning and C-sections, as well as a little thing about a sudden drop in maternal blood pressure which leads to the baby “crashing”, etc., I will answer her question with a question — why have a garden, when you can just go to the store and get whatever vegetables you need?

You see, it often comes down to personal preference in many matters. Some people love to garden, while others hate it. (I have a black thumb, and like to have a garden full of vegetables, but don’t often get it.) There is no one “right” way, but only preference, based on a variety of things, including one’s personal opinion and tastes.

Some people hire others to clean their houses for them, because they’d rather spend money than time. Others live by “a penny saved is a penny earned” so will do things themselves rather than pay others to do it, even if it takes them twice as long and saves them only a meager amount. It depends on what your goals and preferences are. If your goal is to save as much money as possible, then it doesn’t matter if your “hourly rate” for gardening is 25 cents an hour, well that’s a quarter more than you would have had if you bought it at the store. (I think mine this year is even less than that, counting the cost of trying to mix good-quality soil and buying plants that ended up dying — from either too much water or not enough — I’m still not sure — I doubt I broke even with my handful of tomatoes and bell peppers. Sigh…)

This reminds me of a chart that was in one of my favorite books — The Tightwad Gazette, by Amy Dacyczyn (I bought mine at a used book store for $5!). In this book, she talks about “hourly wage” (how long it takes her to do something, and how much money she theoretically “makes” per hour by being frugal), and why she does certain things — and it’s about balance. While her primary goal is saving money, she also had other reasons for doing things. For instance, it took a lot of time to refinish furniture, but it was something she truly enjoyed. Since I’m in the middle of stripping a dresser with at least 6 layers of paint, I fail to see the enjoyment in it, and wish I’d just painted it again. While I will like the end result (I hope!), I am not enjoying the process — but some people do, and that’s okay. So, even if she was “making” (or saving) a measly dollar per hour to refinish furniture, she enjoyed the process and the end result, so it was worth it to her, even if she could have made (saved) more money by doing other things. She spent a lot of time designing home-made cards, when she could have bought a card for a dollar or two, but she found a great amount of satisfaction in her craft.

For a lot of people, these frugal things just aren’t worth it — they’d rather earn money than save money. That’s fine, because on their “personal enjoyment” chart, their jobs may be rated 4 or 5 stars. Some people hate the jobs other people love. For instance, my husband is a teacher, but he wouldn’t want to teach kindergarten — the kids are just too immature. Most kindergarten teachers would shrink back with horror at teaching middle school (which is what my husband prefers).

When it comes to birth, you can’t let other people’s preferences and attitudes choose for you, any more than you would work at some job just because your sister or friend liked it. Would you marry your sister’s husband? I would hate to be married to either of my sisters’ husbands, and they’d hate to be married to my husband. I personally place a high emphasis on giving birth without taking drugs; most people place a higher emphasis on personal comfort than drug avoidance. Some might prefer to go without drugs, but when it comes right down to it, they’ll pick the drugs. That’s fine. I’ve had two births, one of which I thought a lot about having an epidural — if I’d been in the hospital, I daresay I would have had one, simply because it would have been available, and it wasn’t available at home.

So, when you tell someone that you want X, Y, or Z during your labor or birth, and she sneers (visually or audibly) and says, “Why?!” you can just say, “because I want to!”