Empowering Birth Blog

Unfortunately our doctors don't always tell us the truth...

I just wrote the below post on the moms listserv to which I belong.  It was prompted by a discussion on induction...

I wanted to respond to a recent message in which a mom mentioned that her doctor said induction did not increase the risk of cesarean.  Unfortunately doctors often say things that are not evidence-based.  I suggest reading the book Pushed, the Painful Truth about Childbirth and Modern Maternity Care by Jennifer Block, www.pushedbirth.com, for countless stories of caregivers practicing non-evidenced based care.  On that note, let me quote the below paragraph from Pushed on induction.

"Gary Hankins, MD, professor and vice chair of obstetrics and gynecology at the University of Texas Medical Branch at Galveston and chair of the obstetric practice committee of the American College of Obstetricians and Gynecologists (ACOG), says nobody should be doing inductions without a good reason. 'That's not good medicine.'... Hankins says he personally never induces for convenience. 'An induction absent a solid indication absolutely increases all risk to mom and baby,' he says.  Laura Riley, MD, medical director of labor and delivery at Massachusetts General Hospital and Hankins's predecessor as chair of the ACOG practice committee, which releases guidelines on such practices, agrees. 'Ideally you wait for natural labor,' she told me. 'Just by the mere fact of induction, you've now intervened in a pregnancy that otherwise would have continued, and you've already increased the risk of a c-section.'" (pg. 8, Pushed, the Painful Truth about Childbirth and Modern Maternity Care, by Jennifer Block).

The book makes a great case for doing your own research rather then blindly following your doctor's suggestions during pregnancy.  I HIGHLY (can't say it enough) recommend that you read Jennifer Block's book whether you are pregnant or not.  It is very easy to digest and full of loads of well-cited information about birth in the U.S.  If you are happy with your induction, that is fine, but the hard-core fact is that many many women are being encouraged to be induced for "controversial reasons" that are not supported by research and the results can be harmful to mom and baby.  And I am absolutely not saying that induction or a bit of pitocin to speed things along is never warranted.  But induction for a "suspected big baby," for example, is not supported by either ACOG OR the literature (see Pushed page 8).

Be informed but follow your intuition

It is studies like this one that remind us to be careful when looking at the research.  So high consumption of caffeine might lower our risk of ovarian cancer.  Wonderful!  Lets all go out and up our caffeine intake!  If for one LOVE lattes (my weakness).  But be careful before you run out that door, however, caffeine is also linked to miscarriage.  I think the same is to be said for GBS testing, and many other topics.  One study might encourage you to call your doc and schedule the test or request a particular intervention but another study will call for judicious use of testing/interventions and warn of unintended/harmful side effects.  Do the research but don't forget to check in with your intuition. 

Pre-eclampsia is linked to poor diet

Science continues to catch up with what midwives have always known.  Many conditions in pregnancy, including pre-eclampsia, are strongly affected by diet.  Two articles in the past week explore the possible link between increased risk for pre-eclampsia and diet.  One article, "Maternal vitamin D deficiency increases pre-eclampsia risk" noted that "vitamin D deficiency at less than 22 weeks gestation was a strong, independent risk factor for pre-eclampsia."1  In the second article "Diet, gestational hypertension and pre-eclampsia" researchers found that higher intakes of fish appeared to lower the risk of pre-eclampsia.2  To date science claims no known cause of pre-eclampsia while midwives (and some physicians) have seen clear links between pre-eclampsia and diet.

More thoughts on pre-eclampsia and diet follow from Dr. Michel Odent.  Please click on the link to read Dr. Odent's full comment on prenatal nutrition in Midwifery Today's E-News.

Where preeclampsia and eclampsia are concerned, we are able to establish links with several controlled trials of the effects of fish oil supplementation during pregnancy (although eating fish should not be confused with taking capsules). Our research also reflects statistics associated with the comparatively low rate of preeclampsia in countries where the diet is rich in sea fish. My theoretical vision of human preeclampsia also takes into consideration studies of fatty acid profiles of red blood cells, which mirrors the dietary fat intake over a two to three week period. According to a study conducted in Seattle, women with the lowest levels of omega 3 are 7.6 times more likely to be preeclamptic than those with the highest levels. I propose a hierarchy between the numerous biological imbalances associated with preeclampsia. The central imbalance, in my view, is the enormous discrepancy between the blood levels of DHA (the molecule essential for brain development) and the other polyunsaturates. In preeclampsia, the level of DHA remains stable. It does not drop dramatically like the level of other polyunsaturates. The price is an imbalance inside the family of omega 3 fatty acids and finally in the whole system of prostaglandins (I would need pages to enter into all the details). Such data suggest that brain development is a priority among humans: whatever the circumstances, the levels of one of the most important molecules for brain development remain stable. In order to simplify very complex phenomena, I propose to distinguish two critical phases in the genesis of preeclampsia. The first phase is in relation to the response of the maternal immune system at the time of placental implantation (this is confirmed by the fact that a previous miscarriage, a previous blood transfusion, or a long sexual cohabitation before conception reduces the risks of preclampsia). The second phase--the one that is influenced by nutrition--occurs later in pregnancy, when the fetal brain development is the most rapid and the demand in specific nutrients, and in particular long chain fatty acids, is maximum. Then the onset of a vicious cycle is possible, that is to say the disease preeclampsia. Preeclampsia appears as the price some human beings must pay for having a large brain while the nutritional supplies are not appropriate. 3

If I were a researcher, I would follow midwives around and document their work.

(Please note, you do have to sign up for www.ORGYN.com's article's but it is free and WELL worth it.)

1 Diet, gestational hypertension and pre-eclampsia, Issue 18: 3 September 2007, Source: Annals of Epidemiology 2007;17:663-8, from ORGYN Online Magazine, http://www.orgyn.com/en/webzine/2007/Issue_18/Diet__gestational_hy.asp, accessed Sept. 14, 2007.

2 Maternal vitamin D deficiency increases pre-eclampsia risk. Source:Journal of Clinical Endocrinology and Metabolism 2007;92:3517-3522, from ORGYN Online Magazine, http://www.orgyn.com/en/news/2007/Week_37/Day_1/Maternal_vitamin_D_d.asp?C=71129393396790162037, accessed Sept. 14, 2007.

3 Midwifery Today E-News, January 9, 1999 Volume 1, Issue 2, http://midwiferytoday.com/enews/enews0102.asp, accessed Sept. 14, 2007.

Things that make you go hmm....

I have had the honor of participating in 11 births so far (not counting my own).  Odds are that I should have been present at a cesarean birth by now but I have not yet had that experience (silent prayer that my "luck" continues).  The chances of having a cesarean weren't always so high.  Here is an interesting bit of information from an even more interesting book:

Alfred Rockenschaub, MD, professor of midwifery and  physician in charge of the midwifery service of the Ignac Semmelweis Frauenklinik in Vienna, oversaw the delivery of 44,500
babies from 1965-1985. During that time, the cesarean section rate hovered just over 1% and the infant mortality was below the overall rate in Vienna at the time. The cesarean rate rose sharply after Professor Rockenschaub retired, and in 1999 stood at 19%.1

Wow!  One doctor left and the cesarean rate rose from 1%-19%.  And we know that on The Farm in Summertown Tennessee, out of 2,028 pregnancies from 1970-2000, only 1.4% ended in cesarean.2  If I was a doctor and I knew about those kind of statistics and my cesarean rate was 30%, I would do some serious soul-searching.

1 David K. Cundiff, MD., Money Driven Medicine, Tests and Treatments that Don't Work (David K. Cundiff, MD., 2006), http://www.doctormanagedcare.com/ (accessed August 9, 2007)

2 Ina May Gaskin, Spiritual Midwifery (Summertown,Tennessee: Book Publishing Company,2002),468.

ACOG is not God

Henci Goer's piece, When Research is Flawed: the Safety of Planned Vaginal Birth after Cesarean, uses solid evidence-based research to support vaginal birth after cesarean.  The student in me has always believed that good research can bring enlightenment.  If they only knew the facts I would sigh, designing some intricate regression to justify the importance of believing in impoverished communities.  Yet I suspect that in this case as well, research is not going to change ACOG's position.  The reality is that according to Goer's analysis of the research, approximately one in ten thousand babies won't make it when uterine rupture occurs and ACOG, blind in their pursuit of birthing all babies with perfect apgars, is willing to risk the lives of future babies and the health of mom to save the life of one baby now.   So ACOG's stance seems to be more about power then good research. 

ACOG is not God.  All babies were not meant to stay with us in this world.  My parent's lost their first-born at age two and the loss has weighed heavily on our family at times.  But there is also the thought that without the loss of the first child, the third child might never have been born (my parents planned on having two children), and who could imagine life without my amazing and dearly loved little sis.  Somewhere within sorrow there is always birth.  It may be the birth of a new child (I was conceived about a week after the loss of my sister, but that is another story) or it may be the birth of a new found strength as you weather a loss that at times threatens to tear your heart apart.

For those of you wondering why I am flinging my frustrations at ACOG, it is thanks to ACOG that we have many hospitals who will not perform VBAC.  According to the ACOG practice bulletin1 "“VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available.”  The problem lies within the phrase "immediately available."  Small hospitals don't have the resources to keep surgical teams standing around on the maternity floor waiting for the very unlikely event of uterine rupture.  And according to  Dr. Marsden Wagner, there is ZERO data to support ACOG's position. 

Since there is no data, all I can assume is that ACOG insists on being the valiant knight, blindly brandishing its sword to save the frail princess locked in the tower (babies, like women, are often much stronger then our culture will acknowledge).  Whether you are VBACing, a first time mom, or a mom of four, birth can end in death and not even ACOG can save us from that reality.  The good news, is that most pregnancies in the US end in healthy beautiful babies.  If you are pregnant, repeat after me, I will have a beautiful and normal birth.

1 ACOG Practice Bulletin. Vaginal birth after previous cesarean delivery. Number 5, July 1999 (replaces practice bulletin number 2, October 1998). Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists.

Pelvic Adhesions and Cesareans

Sometime I sincerely wonder if any doctors subscribe to the obstetrics update newsletter put out weekly by www.orgyn.com.  The site is clearly for OBs, not pregnant moms or aspiring midwives.   But at least every other week (sometimes weekly) I hear a story about a doctor pushing a cesarean (or an unnecessary induction which leads to a cesarean).  The research I am reading weekly in my in-box would encourage me, if I was an OB, to do some serious thinking about how to lower my cesarean rate.  Take the title of one of this week's mini articles: "Cesarean section adhesions linked with delayed delivery" (remember registration with www.orgyn.com is free and provides you with a wealthy of information).  Apparently the more cesareans you have the greater your chance of pelvic adhesive disease, and we aren't talking small numbers here either.  Almost half of the moms, 46%, who had a second cesarean had pelvic adhesive disease, 75% of the moms who had a third cesarean and 83% of the moms who had a fourth cesarean.1  AND (as if that wasn't enough) in this study it was found that pelvic adhesive disease increases the time it took to deliver the child and with each cesarean, the delay increased.  So I did a little research on pelvic adhesive disease (I had never heard of it, don't remember reading anything about it in the fine print when I consented to my cesarean...).   Apparently pelvic adhesive disease can cause chronic pelvic pain, painful sex, obstructed bowels and even infertility.  If pelvic adhesions are new to you, you might want to read this article. 

1 Cesarean section adhesions linked with delayed delivery, Source: American Journal of Obstetrics and Gynecology 2007; 196: 461.e1-e6, posted May 30, 2007, accessed June 2, 2007 from http://www.orgyn.com/en/news/2007/Week_22/Day_2/Cesarean_section_adh.asp?C=5561639236113125

Cord-Clamping

At last!  The word seems to be getting out that clamping the cord immediately is not an evidenced based practice.  This beautiful little article was sitting in my in-box last week "Early umbilical cord clamping risky" from www.orgyn.com.  Apparently research from the University of Granada says that this new practice lacks studies to confirm its benefits (hmmm, deja vu, can we say eipisiotomies and continuous fetal-heart-rate  monitoring anyone????). 
Let's make our babies' transition into this world a peaceful one!  Having Dad/partner cut cord after it has stopped pulsating or once the placenta is out is a simple way to promote gentle birth.

Re-Framing The Discussion on Choice

While we are on the subject of choice, the Spring 2007 Issue of Midwifery Today (p. 60) directed me towards this excellent article written by two physicians "Patient-Choice Vaginal Delivery" (Accessed May 9, 2007).  The author's ask "Why is cesarean delivery and not vaginal delivery framed in the language of choice?"1  Very good question!!!!  A woman should be able to "choose" an elective cesarean but cannot "choose" a VBAC (vaginal birth after cesarean) or a vaginal breech delivery?

The authors warn that elective-cesareans, like episiotomies, continuous fetal monitoring, and prophylactic forceps, maybe widely adopted despite the lack of research showing evidence of benefit to mother or infant.  Yet there is plenty of research showing the negative effects of cesarean on mom and baby.

There are some good comments at the bottom of this article.  Henci Goer offers a way to move beyond the issue of "choice" by re-framing the issue.  She argues that it is time to talk about "conventional obstetric management vs physiologic care NOT elective surgery vs planned vaginal delivery."2  People who are quick to talk about freedom of choice are missing the point.  Normal birth (physiologic care or care that supports the normal functioning of the birth process) is disappearing and unless we speak up, the picture that Dr. Leeman and Dr. Plante paint, where vaginal birth is no longer a choice, could become a scary reality.

This article is so good, I will forgive the comment that VBAC at home is less safe then VBAC in a hospital.  I am sure that a good talk with Michel Odent would bring Drs. Leeman and Plante around.

1 Lawrence M. Leeman, MD, MPH and Lauren A. Plante,MD, Patient-Choice Vaginal Delivery, Annals of Family Medicine 4:265-268 (2006)

 2 Henci Goer, Time has come for an RCT of conventional obstetric management vs physiologic care NOT elective surgery vs planned vaginal delivery, September 20, 2006 comment to above Leeman and Plante article.

Stay Out of the Operating Room (OR)

The sister-in-law of a dear friend is pregnant with twins.  She recently found out that she will have to deliver in the OR, just because she is having twins.  Hmmm.... Just read the below summary of a recent report from ORGYN Weekly, a Weekly News Review published online Tuesday April 24, 20071 at www.orgyn.com.  And I quote "they found that labor took two to three times longer" (italics mine) when mom labored in the operating room.  YIKES!  No wonder moms are getting epidurals!   Though I can't help but wonder, what are the docs doing with this research? 

"Theatre or labor room?
Scientists have shown that perhaps the Royal College of Obstetricians and Gynecologists guidelines on instrumental delivery in theater need some improvement.

They found that labor took two to three times longer if conducted in theatre rather than the labor room.

If the guidelines had been followed, 107 of 229 operative vaginal deliveries would have been attempted in theatre. Of the 60 that were transferred to the operating room, only eight actually required a cesarean section.

The BJOG editor commented: "Transfer to the operating room produced a substantial delay in delivery, probably resulting in substantial stress to the mother and to a lesser extent to the fetus and staff.""

I highly recommend signing up for this review (go to www.ORGYN.com).  It is free and easy to sign up.  Remember moms, you are the consumer, it is your birth.  Gather the information you need to make an informed choice about your birth and then birth with power and passion.

1http://www.orgyn.com/en/authfiles/opp/opp_login.asp?u=http://www.orgyn.com/en/news/weeklynews.asp&dec=3&