Evidence-Based Medicine: Labor Induction

What is labor induction?

Artificial induction begins contractions and dilation of the cervix, essentially starting labor before it begins on its own.  Breaking the water, Foley balloons, prostaglandin gels and tablets, and IV synthetic oxytocin (Pitocin) are all methods of labor induction, with Pitocin being the most popular.

Induction was originally used to deliver babies in women with small pelvises (common side effect of Rickets, a Vit D deficiency) and in cases of pre-eclampsia.  Like many medical practices, it was at first very risky, and was only done when it was more dangerous for the woman to remain pregnant than to induce. Now it is relatively safe and quite common, with over a third of all births occurring through artificial beginnings. [1]

What is the current approach to induction?

Once upon a time, obstetricians believed that prophylactic (preventative) inductions should be practiced in all pregnancies.  Instead of being left at the mercy of spontaneous labor, doctors can now schedule it.  And while it is (fortunately) not practiced in all labors, it is a growing trend, and can even be performed without medical indication (elective).  The most common reason given for induction is “post dates,” or overdue, followed by a maternal health problem, a desire to get the pregnancy “over with,” and concern about the baby’s size.  Pitocin is used in 80% of medical inductions, and most women experience more than one induction method, usually breaking the waters. [2] The American College of Obstetrics and Gynecology (ACOG) recommends against induction before 39 weeks in the absence of a medical indication. [3]

What does the evidence suggest about induction?

Pitocin has been approved by the Federal Drug Administration as safe for use, but there is a noted increase in epidural use, interventions, and c-sections when an induction is attempted. [4] [5]  However, inductions are often unsuccessful, even when combined with amniotomy (breaking the water), which may increase a woman’s chance of a cesarean section. The ideal rate, calculated by the World Health Organization (WHO) is 10%.  [6]

One of the most common reasons given by women and obstetricians for inducing is when a woman is overdue or “post-dates.”  Research has shown a VERY slight increase in fetal death after 41 weeks, but the absolute risk is quite low regardless.  This means that the risk of the baby dying without the induction was also quite small, but induction reduced the risk further. [7]  The risk increases even more after 43 weeks, but very few women ever go that long, even without induction. [8]

Another reason some pregnancies are not allowed to go beyond the due date is the fear that the baby will grow too large to fit through the mother’s pelvis.  However, despite this being a common reason given for induction, there has actually been no evidence to suggest that induction due to suspected macrosomia (big baby) has any benefit to mother or baby.  Also, due to the documented inaccuracy of ultrasounds for determining due date and size of the baby [9][10], induction carries the risk of the baby being premature, or at a low birth weight. [11]

What are the risks of labor induction?

Although Pitocin, one of the most common induction drugs, as well as many other methods of induction, have been proven safe to use, the dangers of induction are more about the resulting interventions that may occur as a result.  For example, the stronger and more frequent contractions that happen with artificial induction cause most women to request an epidural, which while relatively safe, does carry it’s own complications.  The contractions themselves may increase “fetal distress,” since the baby does not have the opportunity to recuperate between contractions, and “fetal distress” is more likely to result in an instrumental (forceps or vacuum) or surgical delivery.  Again, it’s not the induction itself that causes the problem, but rather the resulting “cascade of interventions” that can follow. [12]

The unnaturally strong, long, and frequent contractions can put undue stress on the uterus, leading to higher rates of postpartum hemorrhage and uterine hyperstimulation and rupture.  Women attempting a Vaginal Birth After Cesarean (VBAC) should be especially cautious about using any artificial induction methods, as they are at a higher risk of hyperstimulation and rupture [13], which can be fatal.

What is the alternative?

If at all possible, WAIT.  Studies have shown that in the final days of pregnancy, your baby’s brain and lungs are still developing.  Even just one day could make the difference in terms of your child’s long-term health.  One current theory is that, when your baby’s lungs are ready to breathe on their own, they release a protein that triggers labor to begin. [14] Unless it absolutely essential to induce, you should try to give your baby every opportunity to develop.

Natural induction methods would also be an option, such as breast stimulation [15], acupuncture [16], or good-old fashioned nooky[17].

Final Thoughts

I am always just a little bit nervous whenever I know someone who is being induced.  Too many women I’ve known have experienced C-Sections as a result, and too many babies have had complications.  Just because it is possible to plan your baby’s birthday down to the hour doesn’t make it preferable to waiting for natural labor.  The birth process is amazingly complex, and rushing any part of it could have short-term or even long-term consequences that we have yet to understand.  You absolutely have the right to refuse induction if you don’t believe it is in your or your baby’s best interests.

Conspiracy Theory Time:

Inductions are better for business.  Data from the CDC shows an increasing trend toward births occurring during daylight hours Monday through Friday, indicating that inductions are done at least partly for the convenience of the doctor. [18]

Think about it from the physician’s perspective…Let’s say you have a very busy practice, and you’re trying to have a quality of life, maybe you’ve got a young family, you don’t want to be running out every night to deliver a baby, or not coming home in time for dinner, missing everything that your child is doing. So what happens is you try to get all the births in between 9 and 5, and to do that, you have to make sure nobody goes into spontaneous labor; and to make sure of that, you have to induce them all early. Or let’s say this is the day you have to be on call, it’s best then for you to induce three or four people on that day because you can get them all done at once. Those three or four people aren’t going to call you on the weekend, they’re not going to call you in the middle of the night, they’re not going to interrupt your office hours, they’re not going to give birth at any time that’s inconvenient.

Some say scheduling births is all doctors can do to maintain their level of income while larger and larger portions of it are earmarked for malpractice insurance premiums. If a doctor misses a birth, he loses revenue. Even if an induction doesn’t work, a cesarean is waiting. And from incision to sutures, a cesarean takes less than an hour. In addition to time management, the looming fear of lawsuits drives doctors to act rather than to wait. “Doctors are practicing more defensively,” says Bernstein. It’s irrelevant that an induction might lead to a cesarean. “To be blunt, you don’t get sued when you do a cesarean,” he says. “You get sued when there’s a damaged baby. And if they can find any reason that the woman should have been delivered earlier, then it doesn’t matter whether the damage had anything to do with how you managed the baby. All that matters is did you do everything that you could have possibly done? And that causes doctors to say, `Well, it’s got to look like I’ve tried my best. And trying my best would be to deliver the baby.’ So you explain to the mother that the fluid’s a little low.

Jennifer Block. Pushed: The Painful Truth About Childbirth and Modern Maternity Care (pp. 42-43). Kindle Edition. [*]

Resources

Born in the USA: How a Broken Maternity Care System Must Be Fixed to Put Women and Children First (Wagner, 2008)

The Cochrane Library

Listening to Mothers Survey (2005)

Pushed: The Painful Truth About Childbirth and Modern Maternity Care (Block, 2008)


Evidence-Based Medicine: Episiotomy

What is Episiotomy?

Episiotomy is simply a surgical cut intended to widen the vaginal opening.  Its use is meant to prevent severe tears and trauma to the perineum during a vaginal birth.  It can also be used to expedite a birth in the case of fetal trauma, or to allow an instrumental (forceps or vacuum) delivery.  The two most common types of episiotomy are medio-lateral and midline, which basically refers to the angle of the cut — midline (toward the anus) or medio-lateral (diagonal, away from the anus). [1]

What does the evidence suggest about its practice?

More than 20 years of research indicates that episiotomies should NEVER be a routine practice [2][3][4][5], and that a restrictive policy is best.  The World Health Organization recommends episiotomy rates of below 10%.  [6]

What is the current practice?

The practice of episiotomy originated in the 18th century, and became widespread over the next 100 years as instrumental deliveries rose in popularity — widening the opening helped doctors maneuver the baby manually or with forceps.  For a long time, it was  assumed that a surgical cut was better than a natural tear, and that it reduced the chances of incontinence (leaking urine and/or feces) and improved sexual function.  At some points in history, it was a routine hospital birth procedure, with upwards of 70-80% of all mothers experiencing one, with first time mothers more susceptible than others. [7]

In 1983, research showed that not only did episiotomy NOT improve incontinence or sexual function, but that it actually seemed to increase the odds of a woman experiencing BOTH. [8] The American College of Obstetrics and Gynecology (ACOG) changed its stance concerning the procedure, encouraging its members to take more preventative measures, and avoid episiotomy whenever possible [9], but it took over 20 years for the policy to become practice.  Some hospitals still have a policy of routine episiotomies. [10]  In 1997, the rate of episiotomies was 29% of all births, but in 2006, the rate of episiotomy was about 9%, [11][12] just under the <10% recommended by the World Health Organization (WHO). [13]

Today, its use is more restrictive, usually only performed in cases of fetal distress where a quick (usually instrumental) delivery is required. [14]

What are the risks of episiotomy?

Most of the consequences of episiotomy effect the mother, rather than the baby, and while they are generally not life-threatening, they can greatly impact her quality of life and make her birth experience more traumatic.  Episiotomy increases a mother’s chance of blood loss [15] during delivery and rate of infection. [16]  Women with episiotomies have a longer recovery time and experience more incontinence [17][18][19] and painful intercourse [20][21], even after the cut has healed.  And, despite claims that episiotomies reduce the risk of severe tears, the procedure actually INCREASES a chance that she will tear further. [22]  Think of how you might snip a piece of fabric in order to rip it in two — same concept.

Why does episiotomy increase a woman’s chances of incontinence?

When a woman is sutured after an episiotomy, the doctors are essentially sewing together her pelvic floor muscles, which are essential to bladder and bowel control, as well as sexual pleasure.  Some doctors have claimed that a sutured vagina is as good as or “better than new,” but as anyone whose had a c-section or major surgery knows, sutured muscle never heals quite like new.  It is weaker and looser (hence the post c-section “pooch”).  This weakness, this looseness, can actually contribute to incontinence and painful intercourse, not prevent it.

Many surgeons believe a surgical cut to be better than a natural tear, although scientific data has proven otherwise. The misperception stems from the fact that obstetricians are surgeons accustomed to sewing up openings that have been made with a scalpel-that is, cuts that are straight and clean-whereas tears are ragged and irregular. It is perhaps counter-intuitive to surgeons that a tear is better than a cut. What they don’t appreciate is that a tear follows the lines of the tissue, which can be brought back together like a jigsaw puzzle. An episiotomy cut, on the other hand, ignores any anatomical structures or borders and disrupts the integrity of muscles, blood vessels, nerves, and other tissues, resulting in more bleeding, more pain, more loss of muscle tone, and more deformity of the vagina with associated pain during sexual intercourse.

Marsden Wagner. Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First (p. 56). Kindle Edition.

What is the alternative?

Essentially, the natural alternative to episiotomy is tearing, although it is absolutely possible to have a vaginal delivery with neither a cut or tear.  [23]

Take Action!

During pregnancy, exercises such as Kegels and squats have been shown to reduce the chances of a tear by increasing the elasticity of the perineum.  Sexual activity during pregnancy has also been shown to soften the tissue, making it expand easier and with fewer tears.  Perineal massage during the third trimester has demonstrated similar benefits. [24][25]

The choice of birth attendant can also make a big difference as well — Certified Nurse Midwives (CNMs) and younger obstetricians have lower rates of episiotomy. [26][27][28]

The traditional hospital birth position, either lying down or reclined, increases a woman’s chances of tearing or requiring an episiotomy due to the improper positioning of the baby’s head pressing against the perineum. [29][30]

Epidural use, because the woman cannot feel the trauma while it is happening, has also been shown to increase tearing.  She also may be “coached” through the pushing phase, rather than led by her natural urges, which again increases her chances of tearing.  [31]

Instrumental deliveries, such as forceps or vacuum extractions, have also been shown to increase perineal trauma.

Alternatively, laboring and/or birthing in warm water [32], squatting or side-lying positions during pushing, “breathing down” the baby during crowning, as well as the use of hot compresses [33] have been shown to reduce the chances of tearing and episiotomy.

Knowing all this, you have the right to REFUSE THIS PROCEDURE.  In fact, you have the right to refuse any procedure you don’t want.  Exercise that right and get the birth you want! [34]

Final Thoughts

The perceived need for episiotomy seems based in a couple faulty assumptions.  First, that the woman’s body is somehow incapable of giving birth (an assumption rampant in the medical community), and therefore needs help from a doctor in order to be successful.  And secondly, that a cut is better than a tear (which doctors seem to believe are an unavoidable part of giving birth).  Neither of these assumptions are true, and it’s time for hospitals, care providers, and women to consider just who actually benefits from routine episiotomy.

Even though ACOG has recommended against routine episiotomy since 1983, some doctors and hospitals seem not to have gotten the memo.  And it’s not just episiotomy — many practices that have no basis in evidence continue to be routinely practiced in modern obstetrics.  It makes me wonder, just how much time, and how much evidence, do obstetricians and hospitals need in order to stop doing things that hurt women and babies?  Recently, ACOG changed their policy regarding Vaginal Birth after Cesarean (VBAC), but I personally remain skeptical as to how long it will take before attitudes really change. [35]

The rate of episiotomy (and forceps delivery) may be down, but the C-section has risen significantly.  Are we just trading one cut for another?   Is that an improvement? [36]

Conspiracy Theory Time:

When you look deeply into the history of episiotomy, a surprising amount of sexism comes floating to the surface.  Just like many other birth interventions, it is first based on the principal thought that women are incapable of giving birth, that they must need medical intervention.  The benefits of episiotomy are questionable, but the consequences to the mother are devastating — the humiliation of incontinence, a long and painful recovery, and a loss of her ability to feel sexual pleasure.  And still the advocates of episiotomy tout that one of the benefits of the procedure is “re-virginization,” which is clearly a benefit for the woman’s partner, not to the woman herself — because losing her virginity was so great, every woman wants to do it TWICE, right?  Sounds like whoever came up with that line doesn’t have a vagina, if you know what I mean.  Plus, the idea that the only good vagina is a tight vagina, and no man is going to want to be with someone with a used vagina, reduces the woman’s value to one part of her body, and that is blatant objectification.   See, sexism at its finest.
Resources

Avoiding Tears and Episiotomies

Benefits and Risks of Episiotomy

Birth: The Surprising History of How We Are Born (Cassidy, 2007)

Born in the USA: How a Broken Maternity Care System Must Be Fixed to Put Women and Children First (Wagner, 2008)

Cochrane Database

Empower Yourself: Know Your Rights!

Episiotomy and How to Avoid It

Episiotomy: Ritual Genital Mutilation in Western Obstetrics

Ina May Gaskin’s Guide to Childbirth (Gaskin, 2003)


Evidence-Based Medicine: Continuous Electronic Fetal Monitoring (EFM)

What is Electronic Fetal Monitoring (EFM)?

EFM monitors the baby’s heart rate and the mother’s contractions during labor, and alerts medical staff to any distress.  The most common method of EFM is placing two receivers, held in place with two elastic belts, on the mother’s abdomen.  A less common form of EFM involves inserting a receptor into the baby’s scalp.

EFM was originally intended for use in high-risk patients, and was thought to reduce fetal death and brain damage, including cerebral palsy and retardation due to oxygen deprivation. [1][2]

What does the evidence suggest about its practice?

Despite numerous studies on the matter, no benefit has been found from the  routine use of EFM technology. [3][4][5] There has been no reduction in infant deaths or cerebral palsy, which was the technology’s intended (and advertised) benefit. [6]  Because of this, as well as the documented risks of the practice, both the World Health Organization (WHO) and the US Department of Health and Human Services (DHHS) recommend against continuous electronic fetal monitoring. [7][8]  The technology has never been reviewed by the Federal Drug Administration for safety or efficacy. [9]

How is EFM currently used?

EFM is currently used in almost every birth in the United States, as much as 93% of the time.  Some hospitals require at least a 20-minute observation upon admission to check the health of the baby.  [10]

What are the risks?

Continuous use of EFM has repeatedly been linked to higher rates of intervention, including instrumental delivery and c-section, which carry their own set of risks. [11]  There is a slight increase in the rate of infection to the baby, especially when an internal monitor is used, but these are typically mild and easily remedied.  The patterns on the print out are open to the interpretation of the hospital staff, which frequently leads to misdiagnoses (this is called a “high false positive rate,” and is a sign of unreliability). [12]

In addition to its questionable benefit and documented risks to both mother and baby, the use of EFM has been shown to reduce the quality of care — women complain that the machine becomes the central focus of medical staff and birth attendants, rather than the laboring woman herself.  Movement can cause the machine to malfunction, so the woman is confined to labor in bed on her back, a position that is shown to be more painful and less effective for labor to progress.

What is the alternative?

Intermittent listening with a Doppler or fetoscope has been shown to be just as effective at detecting fetal distress as constant monitoring, while at the same time reducing the risk of instrumental delivery and c-sections due to a “fetal distress” diagnosis. [13]  This is the method recommended by the World Health Organization.

Final Thoughts

Electronic fetal monitoring has been accepted as a normal part of maternity care in the United States, despite any evidence of its benefit to the laboring woman and her baby.  And while it provides the appearance that an individual is receiving continuous care, it has in fact made it possible for medical staff to care for more patients simultaneously, meaning a lower standard of care for each patient. Its high false positive rate means that more women are being subjected to unnecessary interventions and surgery because of the misdiagnosis of “fetal distress.”  By confining women to bed, EFM makes labor more painful and less effective than if the woman was allowed freedom of movement.  Despite claims that it would improve outcomes for mothers and babies, EFM has repeatedly shown NO benefit to either, after 30 years of research.  So WHY IS IT STILL BEING USED??

Conspiracy theory time:

EFM has become so normalized that it is frequently used as evidence in malpractice lawsuits, which is why many hospitals now mandate its use — it is their paper trail.  [14]  EFM gives the illusion of accuracy, but is in fact open to interpretation much of the time, hence its high rate of inaccuracy.  Without it, doctors and hospitals would be more vulnerable to lawsuits, but with EFM they can justify their choices.

EFM is a multimillion dollar technology, whose makers implied that a perfect outcome was possible with its use.  Its widespread adoption reduces costs to hospitals by making it possible to care for more laboring women simultaneously, but the resulting interventions (such as c-section) actually make birth more expensive for patients.  Is it possible that those that stand to benefit financially (the EFM industry and the hospitals that use it) are pushing for its continued use?  Is it possible that these groups are more concerned about their bottom line than what is best for you and your baby?

Take Action

You have the right, as a patient, to refuse any procedure, including EFM.  You can request intermittent monitoring instead, which has been shown to be just as effective in detecting problems, but without the associated risks.  You can choose a care provider that prefers a less technological approach, or give birth in an environment where EFM is not routinely used, such as a birth center or at home.  You do not have to accept any risk you are not comfortable taking.  Take your birth into your own hands — know your rights and know your limits.

Resources

Born in the USA: How a Broken Maternity Care System Must Be Fixed to Put Women and Children First (Wagner, 2008)

The Cochrane Database

Ina May’s Guide to Childbirth (Gaskin, 2003)

Listening to Mothers Survey (2005)

Pushed: The Painful Truth about Childbirth and Modern Maternity Care (Block, 2008)


Evidence-Based Medicine: VBAC vs Repeat Cesarean

“Once a c-section, always a c-section.”

Every day, across American, millions of women face this “reality.”  For the last decade, the American College of Obstetrics and Gynecology (ACOG) has supported this sentiment through its policies discouraging VBAC (vaginal birth after cesarean).  But what many women and their doctors view as an unfortunate (and unavoidable) side effect of the growing c-section rate is in fact something that 60-80% of women can avoid.

VBAC became very popular during the late 1980s and early 90s, as an attempt by women to regain their birth experience from the then all-time high cesarean rate of about 24%.  Many women were able to experience vaginal birth during this time, but obstetricians noticed a disturbing rise in the rate of uterine rupture, a phenomenon that is a life-threatening emergency to mother and baby.  It was especially prevalent among VBAC mothers, whose cesarean scars caused weak spots in the uterine wall.

Source: Childbirth Connection

Because of this troubling observation, in 1999, ACOG issued a recommendation to its members that VBAC only be attempted in a hospital where an obstetrician and anesthesiologist were consistently present.  Since women insisted on VBACs, and VBAC seemed to cause uterine rupture, the idea was to be prepared for the emergency.  But what ACOG failed to address was the relationship between the routine use of induction drugs on VBAC patients, which caused hyperstimulation (harder and more frequent than natural labor contractions), thus leading to uterine rupture along the cesarean scar.  So rather than dealing with one of the causes of the problem and discouraging unnecessary inductions (especially with off-label drugs like Cytotec), ACOG decided to instead deal with the fallout of such imprudent practices.

Source: Born in the USA (Wagner, 2008)

BUt while ACOG and its members crusaded against VBAC, striking the fear of uterine rupture into the hearts of pregnant women, they failed to educate women on the risks of the only other alternative – repeat cesarean.  By doing this, they made it impossible for the women in their care to make an informed decision as to what was best for their baby.  If you were given the choice of vaginal birth, with an “increased risk of uterine rupture,” and could lead to hysterectomy, fetal brain damage, or death, or a repeat c-section, which would you choose?  This imbalanced attitude toward educating patients persists with many obstetricians today.

The truth is, repeat cesarean has its own risks, which are frequently downplayed by ACOG and its members.

For the mother, risks of repeat cesarean include:

  • Physical problems for the mother, including hemorrhage, blood clots, and bowel obstruction (caused by scarring), infection, long-lasting pelvic pain, and twisted bowel.*
  • Longer hospital stay, with an increased risk of being re-hospitalized.*
  • Negative impact on bonding and breastfeeding due to separation during the critical first few hours after birth.*
  • Placenta Previa** – the placenta attaches near or over the opening to her cervix; this increases her risk for serious bleeding, shock, blood transfusion, blood clots, planned or emergency delivery, emergency removal of her uterus (hysterectomy), and other complications.
  • Placenta Accreta** – the placenta grows through the uterine lining and into or through the muscle of the uterus; this increases her risk for uterine rupture, serious bleeding, shock, blood transfusion, emergency surgery, emergency removal of her uterus (hysterectomy), and other complications.
  • Fertility problems**
  • Ectopic Pregnancies** – the egg implants somewhere other than the uterus.
  • Placental Abruption** – placenta detaches before birth

For the baby:

  • Breathing problems at birth*
  • Increased risk of asthma during childhood*
  • Prematurity**
  • Low birth weight**
  • Physical abnormalities or injuries to brain or spinal cord**
  • Death before or shortly after birth**

* These risks are associated with cesarean section in general, not just repeat procedures, but the overall likelihood of experiencing such complications increases with each subsequent surgery.

** These risks are more common in repeat cesareans than with vaginal births, and have been shown to increase in frequency for each subsequent surgery.

[Source: Childbirth Connection]

Last year, ACOG changed its tune, lifting the restrictive recommendation.  But a decade of anti-VBAC sentiment has left its mark.  Because of the “increased risk of uterine rupture” that ACOG has repeatedly emphasized, insurance companies have become reluctant or even unwilling to cover the procedure.  An obstetrician who would like to offer VBAC may be hesitant when faced with increased malpractice insurance costs.  In some states, home-birth midwives and alternative birth centers are forbidden to offer the option.  Some women have turned to home VBACs because they were unable to find a provider willing to offer it, and decided they’d rather take the risk of an unassisted home birth over a mandatory c-section.  It remains to be seen how the new ACOG recommendation will affect the choices of women as to how (and where) they give birth.

Let’s hope it’s for the better.

For more information on the safety of repeat cesareans and VBACs:

The Unnecesarean (blog)

Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First by Marsden Wagner (2008)

Ina May’s Guide to Childbirth by Ina May Gaskin (2003)


Evidence-Based Medicine: Are Inductions Safe?

A couple weeks back, I researched the necessity of labor induction.  I learned that, according to the Listening to Mothers Survey from 2005, about 40% of all labors are medically induced.  I also learned that, according to birth experts Ina May Gaskin and Marsden Wagner, induction is only medically indicated in about 10% of births.  This means that about three-quarters of all women who are induced are doing so without medical indication.  If induction is perfectly safe, there would be no concern — so what does the research say?

The stats…

80% of medical inductions were done using a drug called Pitocin, a synthetic oxytocin, which causes the uterus to contract.  Other methods of induction include prostaglandin medications applied to ripen the cervix, stripping/sweeping the membranes, and “breaking the water”  (artificial rupture of membranes (AROM)).  Most mothers included in the survey were subject to 2 or more methods of induction, the most common combination being Pitocin and AROM.

Not only are many labors medically induced, but many are also augmented using the same methods listed above.  When these numbers are included, about 50% of women are given artificial oxytocin to either induce or augment labor, and 65% have their water broken.

The risks…

  • More painful labor — Common induction methods such as artificial oxytocin can lead to longer and stronger contractions that are closer together.  This means more pain for the mother during contractions, as well as a shorter period of time between contractions to recuperate.  This can quickly exhaust a laboring woman, not to mention tarnish her birth experience.  Many women whose labors are induced or augmented find an epidural to be a necessity.

“I went into labor on my own with my daughter, but was induced with my son.  With my daughter, I found that sitting in a warm bath made the pain very manageable, and I didn’t get the epidural until very late — 7 cm, I think.  With my son, I got an epidural at 3 cm — I just couldn’t stand the pain.”  — Annie, 31

  • Prematurity — Miscalculation of due dates can lead to a woman being induced before her baby is mature.  Iatrogenic (doctor-caused) prematurity is on the rise, and with it comes all the risks commonly associated with prematurity, such as breathing problems.  New research shows that the production of fetal lung proteins trigger labor — meaning that the baby triggers spontaneous labor when its lungs are ready to breathe.  Inducing without medical indication means your baby may not be totally ready to breath independently.  Labor should NEVER be induced before 39 weeks for this reason, and should ideally be around 42 weeks as long as the baby shows no signs of distress.
  • Fetal Brain Damage or Death —  The only time a fetus can get oxygen is during the rest period between contractions, so when those periods are shorter, the fetus gets less oxygen.  Lack of oxygen is associated with an increased risk of brain damage.
  • Maternal death —  According to Marsden Wagner’s book Creating Your Birth Plan, induction of labor is linked to higher rates of uterine rupture and amniotic fluid embolism (AFE), both of which are rare but usually fatal (80% of AFEs are fatal — 50% within the first hour after symptoms appear).  C-Section dramatically increases the incidence of both.  Many women who survive uterine rupture undergo hysterectomies and are unable to have any more children, and most that survive AFEs are severely brain damaged.  Fetal death is also common with both of these complications.
  • “Cascade of Interventions”A woman who is either induced or has her labor augmented artificially is at an increased risk of instrumental (forceps and vacuum-assisted) and surgical (c-section) interventions.  So even if the induction drug itself is considered safe (which Pitocin is), the risks associated with all other forms of intervention must be calculated as well.  While the more severe risks (uterine rupture, AFE, fetal brain damage) are relatively rare, the so-called “cascade of interventions” is fairly common.  A woman who is induced more than doubles her riskof having a C-Section.  A woman who goes in to be induced may find her plans for a low-intervention birth go awry very quickly.

 “I got induced at 41 weeks because they thought she was going to be too big too birth otherwise.  First came the Pitocin, then the epidural for the increased pain, which meant I was tethered to the bed with IVs, so I couldn’t move around.  Then my labor slowed down, and they broke my water to speed things up.  I went into labor thinking that I could manage an induction naturally, but instead I ended up with a C-Section because of failure to progress.”— Silvia, 26 

  • Interferes with Bonding/BreastfeedingArtificial oxytocin alters the mother’s natural hormones during and after birth, potentially affecting her ability to bond with or breastfeed her baby.  Any other interventions she experiences (such as cesarean) can also interfere.  

“When my son was born, I felt like he belonged to someone else.  I kept waiting for that overwhelming feeling of attachment I knew I was supposed to feel, but it just didn’t come — I felt like I was just going through the motions for weeks.” — Patty, 29

What is the alternative?

So if induction carries with it the risks listed above, it could be argued that elective induction is not in the best interest of the mother or baby.  So what’s the alternative?  Well, waiting.  Just remember, every day your baby “cooks,” s/he will be a little bit stronger, a little bit healthier.  As we talked about last week, babies can and have been (vaginally) born past their due dates perfectly healthy.   Trust your baby, and trust your body to go into labor on your own — it’s better for both of you!


Evidence-Based Medicine: Are Epidurals Safe?

The next underlying assumption about epidural use is that it is safe, and judging by some women’s sentiments, free of consequences.  Let’s explore what our sources have to say.

Assumption #2: Epidurals are safe.

First, what does “safe” mean?  This is a very subjective term, meaning different things to different people.  To some women, “safe” would mean completely free from consequence.  To others, simply safer than the other available options.  Lastly, it could mean that the benefits outweigh the cost. So according to each standard, how do epidurals stand up?

Free From Consequence?

Last week, we learned that epidurals can interfere with the natural hormones of labor, therefore impeding its progress.  So what is the risk to a laboring woman if her labor is slowed?  In simple terms, a “cascade” of interventions could ensue.

Epidurals are renowned for slowing down labor, which could mean your labor might be augmented with something like Pitocin (artificial oxytocin).  Augmentation carries it’s own risks, which we will discuss in later segments.  According to Marsden Wagner (former director of Women & Children’s Health at the World Health Organization),  longer second (pushing) stage of labor means a woman has a four times higher risk of a forceps or vacuum assisted delivery, and at least a two times greater risk of a C-Section.  This is partially because the epidural block effects the mechanisms that rotate the baby into the proper position for delivery.

Additional risks to the mother include:

  • Drop in Blood Pressure (both mother and baby)
  • Itching
  • Higher risk of Infection
  • Fever (15-20%) — this could lead to some invasive diagnostic tests of both the mother and baby
  • Temporary (1 in 500) or even Permanent Paralysis (1 in 500,000)
  • Urinary Retention (inability to urinate) (15-35%) — could require a catheter
  • Severe Back Pain from Birth (30-40%) up to a Year (20%)
  • Spinal Headache (2%)
  • Death (1 in 5,000)

According to Wagner, approximately 23% of women will experience some complication associated with their epidural.  That’s nearly 1 out of 4 women!  And while many women may be willing to put themselves at risk for the good of their baby, very few are willing to put their baby at risk for their own personal comfort.

Risks to the baby include:

  • slowed fetal heart rate (75%), a symptom of fetal distress
  • poor neurological function at 1 month
  • increased risk of breathing difficulties
  • increased risk of breastfeeding difficulties

Even if this is only a partial list, clearly epidurals are not free from all risk, just like any other choice you make.  So, the next question becomes: Is it worth it?  (the risk, that is…)

Is an epidural safer than the alternative?

So, if an epidural provides any benefit to the mother and baby over drug-free birth, it could be considered “safer” than the alternative.

There are in fact, some situations where an epidural is beneficial to the woman — for example if she has had a long or difficult labor, it may allow the mother to rest so she has the energy to push.  Recent studies suggest that receiving an epidural during labor may even help preserve a woman’s pelvic floor muscles (you know, the ones that keep you from peeing yourself).  Other women claim that their freedom from pain made their experience more enjoyable or less traumatic, so there may be a perceived psychological benefit as well.

But, it could still be argued, since all of the aforementioned risks of getting an epidural are not present when having a drug-free birth, that an epidural, while it may provide psychological benefit, does put you at a marginally higher risk of complications.  Therefore, if your definition of “safe” is that it’s safer than the alternative, an epidural is not “safe.”

So, is an epidural safer than other pain management strategies?

Hospitals, in almost every arena, are renown for turning to medicine to solve every condition.  Labor and birth are no different.  Men and women become doctors and nurses, at least in part, because they have faith in the way medicine and surgery work.  They have faith in technology.  It logically follows that medical solutions are in the forefront of their minds when presented with a problem.  Sometimes, however, there are non-medical or non-surgical methods that provide the same benefits to the patient, but with fewer side effects.

Women who choose drug-free birth aren’t just martyrs, masochists, or thrill seekers.  It’s not that they enjoy pain, regardless of what other people might assume.  When they go into labor, they have a plan for reducing pain just like every other laboring woman — they’ve just taken the epidural off the table as an option.  So what kinds of methods do they use?

  • Hot water — baths, showers, birth tubs
  • Movement — walking, dancing, yoga balls
  • TENS (trans-cutaneous electronic nerve stimulation)
  • Hypnosis
  • Acupuncture
  • Continuous one-on-one attendance

All of these methods have been proven to be effective pain management, with no side effects to mother or baby.  In fact, freedom of movement is one of the oldest methods to manage labor pain, and has been demonstrated throughout history to not only relieve pain but to also properly position the baby for birth.  Many women may feel the urge to get up and move if allowed to labor naturally.

Finally —

Is it worth it to take a risk on the epidural in order to avoid the pain?

The only person who can answer this question is the woman herself.  As the evidence suggests, one out of four women will experience some sort of complication with her epidural.  But that means that 3 out of 4 women don’t.  Some women might consider that pretty good odds.  Perhaps the biggest threat is not the side effects of the epidural, but the so called “cascade of interventions” that could ensue, leading to a loss of control over the birth experience.  Then, it’s not only the side effects of the epidural she needs to think about, but the possible augmentation drugs, the forceps, the vacuum, or even the c-section.  And when you consider that there are other, risk free options available, the pharmacological option may seem a little bit less appealing.  1 out of 4 may sound like “good” odds, but 0 out of 4 is even better, no?

Another issue to consider with epidurals is what to do if you are one of the unfortunate few whose epidural wears off.  I’ve come across a few testimonials where a woman went into labor intending an epidural, and the medicine wore off right before she was pushing. I can only imagine how caught off-guard and unprepared for the pain she must have been, and how scary that would be.  It got me to thinking that, if I were a woman going into labor with an epidural, it might be to my benefit to research some “back-up” strategies…you know, just in case.

Since many women experience complications with their epidurals, it would be to the benefit of the hospital and its patients to educate women on natural pain strategies, and to implement them more frequently, rather than jumping right to an epidural.  Like I said above, I highly doubt woman would knowingly put herself, and especially her baby, at risk.  I’m sure many women would be interested to at least try more drug-free options, and then if those are ineffective, the epidural is still available.  Or, if she is in the unfortunate position of having a negative reaction to the epidural, she could feel more prepared to handle her labor pains.

At this point, many women aren’t even made aware they have other options, and that is a failure of the system.  All the more reason to educate yourselves, ladies.  After all, you’re more motivated to do what’s best for you and your baby more than anyone else.

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Build-A-Birth: Are Epidurals a Necessity?

What better place to start our investigations than one of the most common birth practices in US hospitals — the epidural.

Many women today plan for their birth to take place in a hospital, and of those women, most of them plan to receive an epidural for management of pain.  It’s kind of the assumption that a birthing woman will want relief from pain, and that a pharmacological method is the best kind of pain management.  But is this true?  Let’s see what the evidence suggests.  We’ll start with one very fundamental assumption.

Assumption #1: Pain Management is a “necessity” in labor and birth.

I don’t know how many times I’ve heard women say, regarding labor and birth, “why should I suffer if there’s a way to avoid it?”  The assumption is that if it’s available, any woman (in her right mind) would accept pharmacological relief for labor pain.  Since epidurals are available in most every developed country in the world, if this assumption were correct, it would logically follow that those other countries have a similar attitude toward pain management in labor.  So do they?

According to Marsden Wagner’s Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First, a woman’s culture strongly influences her attitude toward pain, both in what kind of pain she expects and how much she feels is tolerable.  In countries such as the Netherlands and Japan, women accept labor pain rather than view it as something to be numbed, and the rate of epidural use in both countries is much lower than in the US.  So why do American women get epidurals so frequently?  According to Wagner, the way a woman views pain during labor and birth are strongly shaped by how her obstetrician views pain.  He states:

“The two great evils in a doctor’s world are pain and death, and they see it as their job to fight them at all costs.  The physiological fact that pain is an essential component of a normal labor, that it is necessary for the release of hormones that control the progress of labor, is either not understood by most American obstetricians or simply ignored.”

So, part of the American pregnant woman’s mindset is influenced by how doctors, specifically obstetricians, view the role of pain in labor and birth.  But surely doctors aren’t 100% to blame.  Think of all the birth stories you’ve ever heard.  How many of them emphasized the pain of birth, or the fear?  If you’re anything like me, a large portion probably did.  So, the attitudes of other women also play a part in our perception of labor pain.  And what about the media?  If I based my perception of birth on “A Baby Story” alone, I would probably think that birth was always chaotic, scary, and horrendously painful.  And it’s not just reality TV — depictions of labor and birth in dramas and sitcoms are also pretty one-sided.  Shows like this litter the airwaves, and it would be silly to think that we are beyond their influence.

It’s been thoroughly established that birth hurts.  Aside from the fortunate few who experience “orgasmic birth,” most women experience some amount of pain when giving birth.  But, unlike most pain we experience in our lives, the pain of birth does not indicate injury.  It is “pain with a purpose.”  To embrace that idea has the power to increase a woman’s confidence while at the same time reducing her anxiety and fear, which in turn can reduce the amount of pain she experiences.  This is demonstrated by the testimonies of women who have had drug-free births, especially those who have chosen to give birth at home, away from even the possibility of pharmacological pain management.

I think the evidence for this assumption suggests that epidurals are not so much a necessity as they are a luxury.  A shift in a woman’s perspective can strongly influence her birth experience, as is shown in other countries where epidurals are available but less commonly used than in the United States.

“We have a secret in our culture,

and it’s not that birth is painful;

it’s that women are strong.”

— Laura Stavoe Harm