For the record, I don’t hate doctors. In fact, if I had a high-risk pregnancy I would insist on having a doctor at my birth. Why? Because doctors are trained for high-risk situations. The problem is that their “worst case scenario” training often prevents them from seeing birth as it usually is: low-risk, uncomplicated and completely normal. What do we end up with: Reverse alchemy which turns beautiful low-risk pregnancies into high-intervention situations.
America spends a larger percentage of its gross domestic product on health care than any other industrialized nation, yet its citizens aren’t healthier for it. This is especially true when it comes to childbirth. Having a baby is the No. 1 reason for hospitalizations in the U.S., and a Cesarean section is the most common operation. In 2006, $86 billion was spent on maternal and newborn hospital charges, but despite this spending, our infant mortality rate ranks 29th among industrialized nations and our maternal mortality rate is a dismal 36th. (Emphasis mine for all quotes)
Before this gets glossed over as just another statistic let me say it differently. We spend more money to bring our children into the world than just about any other country and yet more babies die here than in 29 other developed nations. We lose more mothers than 36 other nations.
What Are We Doing Wrong?
Too often a pregnant woman goes to a hospital in early labor and ends up feeling micro-managed and undermined. She may have preferences that are completely legitimate but against hospital policy so her wishes are ignored.
For example, many hospitals do not allow women to eat or drink during labor so that if anesthesia is administered they won’t vomit and choke on the contents of their stomach. However, in “three large U.S. studies totaling 78,000 women in their Birthing Time that ate and drank freely, there was not once case of aspiration!”¹
On the flip side, there is a real danger of women becoming dehydrated and losing strength if not allowed to eat or drink. “Fasting causes the mother more discomfort as she cannot focus when her blood sugar is low, and further, fasting can cause ketosis, a weakening of the muscle cells, causing the uterus to work less efficiently.”² As someone who could not keep anything down for 12 hours during labor I can personally attest to the horrible effects of dehydration while trying to birth a baby.
Fit Pregnancy recently published an excellent article on evidence-based maternity care, and it got me thinking: What’s the rationale behind some of our most common obstetric procedures? Are they evidence-based or are their benefits naively taken for granted?
Below are my thoughts (and some actual research) on common L&D procedures, which together are sometimes referred to as the “Cascade of Interventions.’ (By “solving” one problem, these procedures often cause another unintended problem that requires another intervention and so on.)
Step One: Monitor, Monitor, Monitor
If you head to the hospital in early labor your medical team is likely to put a fetal monitor on you even though this restricts your freedom of movement. They will do this even though they know that the ability to walk and move freely helps labor to progress.
*There is NO proven benefit to continuous EFM [external fetal monitoring] over periodic checks of Fetal Heart Tones – birth outcomes have been shown to be the same whether EFM is used, a hand-held Doppler or a non-electronic fetoscope . . . This method does use ultrasound which has never proven safe . . . and may switch attention from the mother to the machine.
Hypnobabies Childbirth Class Manual, p. 87
When labor does not progress as quickly as your doctor would like move to Step Two.
Step Two: Produce or Induce!
Did you know that your baby’s health becomes more precarious right before your doctor’s big vacation in Maui? Okay, maybe not, but far too often doctors pressure mothers into inductions because they want to schedule births around their leisure time. Don’t believe me? That’s fine, but I’ve heard this straight from L&D nurses who really know what’s going on. Of course, such selfish reasons are not likely to fly with you, so they need to make it sound legit. How about “your baby is getting too big to deliver vaginally? If you don’t induce you’ll end up having a c-section.”
I’m not saying doctors outright lie. But either consciously or unconsciously they are more likely to focus on factors that justify an intervention when it suits their schedule.
Here’s the catch: If your body isn’t ready to give birth it won’t respond properly to pitocin. Choosing to induce to avoid a “big baby” could very easily take you down the “cascade of interventions” road, resulting in the cesarean you were trying to avoid. In addition, size estimates are wildly inaccurate. Below are some stories from real moms:
I have a friend who’s OB told her that she had to ‘get her baby out’ due to his ‘large’ size. It was her first baby, he was brought into the world via c/s. She had NO labor at all. Not even a twinge. He was born approx. 9 days early. He was 8 pounds 2 ounces, a completely average sized baby. Boy, was she angry that she had to have major surgery for nothing!
My last birthing was induced, and it turned out that my daughter was seriously premature due to the induction, and ended up in the NICU. She was 6 pounds, but my first two babies were born at 8 lb. 8oz and8 lb. 6oz. She was not ready to come out yet, and to this day it grieves my heart that I let the doctor talk me into an induction, and one so early! The reason for the induction . . . I was having some contractions, had ‘gestational diabetes’ and would probably have a ‘huge baby’! Instead, I had a baby who couldn’t breathe on her own, nearly died in transport to the children’s hospital, and was intubated for 3 days, with a 10 day stay. I’ll take an 11 pounder any day over that! It is still one of the most painful memories of my life.
Blessings, Lisa M
Excerpt from Hypnobabies Childbirth Class, p. 100 and 101
As if that weren’t enough, pitocin reduces the amount of natural oxytocin (the bonding hormone) that your body makes.
If you are given pitocen (which is the synthetic version of oxytocin) to induce your labor, or increase your contractions, this actually reduces the amount of the real oxytocin in your body. You see a woman’s body will recognize the synthetic hormone as oxytocin and will not produce the real stuff (in regular amounts) since the imposter is already present. The downside is that pitocen, since it’s man-made, can’t release the euphoric sense of love and ecstasy in your brain that oxytocin does (Yeah, bummer man). Ya follow? Which is why you really don’t want to be induced with pitocen if you don’t have too. Also, did you know that having in induction increases your chance of c-section by 50%? YIKES. On top of that, an epidural increases your chance of c-section by 40%! Double YIKES!
An alternative way to start the cascade is for moms to request induction. The last few days/weeks are pregnancy can be extremely uncomfortable, so why not skip them? Not realizing that lung function is unlikely to be optimal until they naturally go into labor, moms mistakenly believe that induction is completely safe. Not so, says the Fit Pregnancy article:
Preterm births also contribute to expensive stays in the neonatal intensive care unit (NICU). Now there’s growing recognition that delivering even a few weeks early raises the risk of breathing and feeding problems and difficulty maintaining body temperature, says Sue Gullo, R.N., M.S., director of the Perinatal Community at the Institute for Healthcare Improvement (IHI) in Cambridge, Mass.
Step 3: Epidural Express
Since pitocin causes unnaturally strong (and painful) contractions, the next step in the cascade of interventions is to perform an epidural to relieve the pain. Epidurals can slow down labor and make pushing more difficult, meaning “additional interventions such as Pitocin, forceps, vacuum extraction or cesarean may become necessary,” says American Pregnancy. Hmmm, cascade of what?
Also, evidence links epidurals to early breastfeeding challenges. According to La Leche League International, “Infants whose mothers had no labor analgesia scored higher (x=11.1) on the breastfeeding scale than mothers who had epidurals (x=8.5) or intravenous narcotics (x=8.5).”
Step 4: C-Section Station
Boston University Professor Gene Declercq, who has researched home births for over 20 years, recently described a typical scenario leading to a c-section.
. . . because the contractions as a result of the induction become very strong, then they have to do an epidural to try to relieve the pain from those now stronger than natural contractions. That may slow labor a little bit further and then they have to keep adding intervention upon intervention to the point where at the end somebody says ‘We’re going to do a cesarean. Thank God we’re able to do this cesarean.’ Wherein if they hadn’t started that series of interventions in the first place, we may never have gotten to that point.
I’m not saying every intervention leads to a c-section. I know plenty of people who had vaginal births after receiving an epidural, including my mom. But, according to the Fit Pregnancy article, “Nearly one-third of the 4.3 million childbirths in 2006 were via C-section, compared with one-fifth in 1997.” And the numbers rise every year. There are situations for which I am very grateful cesareans are available. Circumstances in which they are necessary.
All this leads me to ask, if birth outcomes are so poor why do we keep using these procedures on a routine basis? For the record, I am totally support women choosing to give birth in a hospital if that is where they feel most comfortable. My point is that our infant and maternal mortality rates clearly indicate something needs to change.
I am incredibly grateful for hospitals, doctors and lifesaving procedures when they are needed. If a woman wants to be induced or receive an epidural she should, provided she is informed of the increased likelihood that she will need a cesarean. On the other hand, low-risk moms should be given freedom to move freely, eat, drink and refuse interventions without a fight. I know of some cases in which this occurred, but it seems like more of a shining exception than the norm.
There are many ways hospitals could improve L&D outcomes. Some already utilize the assistance of midwives alongside physicians with great results. The benefit of midwifery teams working in hospitals is that they are better equipped to guide low-risk laboring women through the natural laboring process. That’s what they’re trained to do. With their help labor often progresses smoothly, mothers feel safe and attended to, and unnecessary interventions are reduced.
In more complicated circumstances some physicians are stepping up. Some specialize in helping women attempt vaginal births after multiple cesareans even though they have to pay more in malpractice insurance. I know of a doctor that is able and willing to assist in vaginal breech births rather than insisting on a cesarean.
What do you think? Am I crazy? Love me anyway?
Read part 2 of this series: Are Home Births Safe?
Birthing Beautiful Ideas – The C-Section Blame Game
Childbirth Connection – Cascade of Intervention in Birth¹ Hypnobabies Childbirth Class page 90 ² Ibid
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