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.


Safe Motherhood, pt. 4

The following is taken from the World Health Organization’s report on Safe Motherhood, Care in Normal Birth: a practical guide. There are a couple of introductory pages and about fifteen pages of references, and the remainder of the 57 pages of this pdf file are devoted to a discussion of the typical practices in birth around the world, finally dividing them into one of four categories: 1) practices which are demonstrably useful; 2) practices which are clearly harmful; 3) practices for which insufficient evidence exists; and 4) practices which are frequently used inappropriately. They arrived at these conclusions from studying birth practices around the world (from the high-tech U.S. to the impoverished third-world countries), citing a plethora of published research along the way. This document is pretty “meaty” or “heavy” reading, but quite understandable. Some of the practices (like using sterile instruments) are obviously always done in the U.S., but other countries need to improve on them. I would encourage you to read the full document, especially to see how they arrive at some of the following conclusions (the numbers at the end of each point correspond to the discussion sections in the document, and they are in chronological order–pregnancy, first stage of labor, second stage of labor, etc.). This discussion is for normal labor with normal women; there are things that could make a woman high-risk during pregnancy, or things that happen during labor that would change the “risk category”. But this is for most of the women in the world. (I will put italicized explanatory notes on some of these; and I will emphasize certain words from the original in bold.) This is part four.

6.4Practices which are Frequently Used Inappropriately

[This section deals with practices which may be beneficial, but it depends on the situation. As with section 3, I strongly recommend that you read the supporting documentation, to understand the reasoning of the authors, as well as how it affects you.]

1.Restriction of food and fluids during labour (2.3). [Most hospitals have this as a strict policy. See my post for more on that, as well as read the WHO document.]

2.Pain control by systemic agents (2.6). [“Systemic” means that it affects the whole body, and includes drugs such as Demerol (pethidine is what the WHO document calls it, which is British, not American), Phenergan (promethazine), and Valium (diazepam). Many women have reported that receiving these drugs only “takes the edge off of pain” while some say that it didn’t affect their level of pain at all–it only made them so drowsy that they couldn’t do anything (even speak), even though they were still in pain.]

3.Pain control by epidural analgesia (2.6). [The authors point out that there are no randomized trials that compare epidural to no pharmacological pain relief–only between different types of epidurals and between epidural and other pharmacological pain relief. Therefore, it is impossible to know for sure what differences an epidural makes vs. “natural” pain relief methods such as emotional support, laboring in water, massage, etc. They also question whether a labor that uses an epidural can be considered “normal.” They also note that first-stage labor tends to take longer; more women require being augmented with oxytocin, and require “assistance” with vacuum or forceps; and that if given in early labor, a C-section is more likely.]

4.Electronic fetal monitoring (2.7). [The authors note that EFM has a high “false-positive” rate (meaning that the machine wrongly signals a problem with the baby), which leads to unnecessary interventions, especially in a group of low-risk women, although high-risk women can benefit from this. The authors end this discussion by noting that often people in the room pay more attention to the monitor than to the mom, and that nurses may not even come into the room, and only monitor the mother from a central location.]

5.Wearing masks and sterile gowns during labour attendance (2.8). [While the WHO document places great emphasis on the cleanliness of the birth attendant, it notes that masks and gowns are “useless” for protecting women from infection. However, if the woman has a disease such as HIV, or Hepatitis B or C, then the masks and gowns can protect the birth attendants from contact with contaminated blood.]

6. Repeated or frequent vaginal examinations especially by more than one caregiver (3.3). [“The number of vaginal examinations should be limited to the strictly necessary; during the first stage of labour usually once every 4 hours is enough.”]

7. Oxytocin augmentation (3.5). [Other of my “Safe Motherhood” posts also refer to this; but here is a quote from the document, “Oxytocin augmentation is a major intervention and should only be implemented on a valid indication.”

8. Routinely moving the labouring woman to a different room at the onset of the second stage (4.2). [Many hospitals in the U.S. now have L&D or LDR or LDRP rooms, which stand for labor, delivery, recovery, and postpartum. Previously–and perhaps still in some hospitals–women would labor in one room, be moved to a delivery room for the birth, then to another room for the immediate postpartum (recovery), and then to a final room for the remainder of her hospital stay. They may still be moved from one room to another, but most of the time, the only time women are moved to a different room during labor is for a C-section in an operating room. Some high-risk women (or if they are known to be carrying a high-risk baby, or a baby with special needs), may give birth in a different room that has all the bells and whistles because of the much higher possibility of actually needing the machines and things. Many women speak of a great deal of shame with being transported on a hospital gurney in a flimsy hospital gown down the halls filled with strangers able to see who-knows-what while they’re either pushing or being told not to push.]

9. Bladder catheterization (4.3). [Most women will be able to go to the bathroom by themselves; and catheterization may lead to infection, or be “difficult and even traumatic” if the baby’s head is firmly engaged in the mother’s pelvis.]

10. Encouraging the woman to push when full dilatation or nearly full dilatation of the cervix has been diagnosed, before the woman feels the urge to bear down herself (4.3). [The authors point out that a woman may be fully dilated for some time before she feels the urge to push; if she happens to have a vaginal exam during this time, it is unknown how long she was fully dilated. Further, there are no trials of normal labor; but a trial of women with an epidural shows that “delayed pushing did not show any hazardous effect on fetal or neonatal outcome. In the early pushing group, significantly more forceps deliveries occurred.” And they further point out that most midwives do not ask the women to push until they feel like it, which shortens the bearing down time and is easier on the women.]

11. Rigid adherence to a stipulated duration of the second stage of labour, such as 1 hour, if maternal and fetal conditions are good and if there is progress of labour (4.5). [The authors cite various studies which show no improvement of fetal/neonatal outcomes by arbitrarily stopping the woman from pushing, and using forceps, vacuum, or C-section to accomplish the birth of the baby.]

12. Operative delivery (4.5). [The authors note an increase in operative delivery world-wide, and wonder if convenience, financial gain, or fear of malpractice lawsuits are driving this increased interference in birth, which is many times unnecessary.]

13. Liberal or routine use of episiotomy (4.7). [You must know what your caregiver’s philosophy of episiotomy is! And “only when I think it’s necessary” is not an informative answer–how often does s/he find it to be necessary is the information you’re seeking. Here is the summarizing information from the WHO guidelines: “In conclusion, there is no reliable evidence that liberal or routine use of episiotomy has a beneficial effect, but there is clear evidence that it may cause harm. In a thusfar normal delivery there may at times be a valid indication for an episiotomy, but a restricted use of this intervention is recommended. The percentage of episiotomies attained in the English trial (10%) without harm to the mother or the infant (Sleep et all 1984) would be a good goal to pursue.”]

14. Manual exploration of the uterus after delivery (5.7). [Used routinely, there is no evidence of benefit; only if a piece of the placenta is known or suspected to be missing is this of any benefit.]