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Saturday, December 18, 2010

"They're coming to take me away!"

Gareth Cattermole/Getty Images
I couldn't help but think of the Tiny Tim song when I read last week about how comedian Chris Rock helped a pregnant woman in the mall when her water broke. I'm sure she was embarrassed - most people seem to be worried sick in the last weeks of pregnancy that something like this will happen. In all my years on this planet, though, I have never seen it happen in public, and don't know anyone else that's witnessed it, either.

Apparently Chris made a valiant effort to make the woman laugh and calm her down after the "pregnancy drama," as the Daily Mail calls it. As she was heading for the escalator, she 'started to go into labor,' and as one eyewitness put it, "She recognized immediately who he was and he stayed there until paramedics came and took her away."

Seriously? You'd probably have enough time to finish your shopping, go home and shower, change, eat a bowl of cereal and then walk around until contractions got stronger, then head to the hospital. As of press time, there was no word on the mother's or the baby's condition, but I bet we can guess, judging by the way things got started.

And don't you love the headline? "Chris Rock Rescues Pregnant Woman." They make it sound like she was dangling from a 40-story window and he just happened to catch her or something. Since when is spontaneous rupture of membranes an emergency? What, were they afraid she'd decide to set up camp in the mattress department and give birth in the middle of Macy's?

Side note: I bet Chris Rock would make a great doula.

Saturday, December 11, 2010

The Obstetrical BS Series: My Doctor will Tell me Everything! Part I

"I'm 38 weeks and am going in for an induction
tomorrow. What should I expect?"
Photo credit: Karol 
A lot of times when I hear women asking pregnancy and birth questions, the usual response is, "Your doctor will tell you everything! Don't worry!" I think we can all agree that this isn't the case, most of the time.

Some doctors do take the time to inform their patients, true - but many do not. Many cannot, because they are often limited to the typical 4 1/2 minute visit that consists of little time to go over your aches, pains and other complaints. I remember asking my doctor about having no urge to push during my last labor, and wondered why. His quick, tidy response was "We'll help you with that when the time comes." I wasn't exactly sure what that meant, but it didn't sound like much of an answer to my question.

Later on in the pregnancy I had a lengthy discussion with another doctor in the practice who then asked me, "How do you know so much?" I'd like to think it's probably refreshing for him to see a patient who truly is informed and can make decisions accordingly. I imagine some doctors wish their patients were more informed, and they feel bound by time constraints that prevent them from delving into a topic that can't easily be answered with a "yes" or "no."

As mentioned in my last post about inductions, I am amazed - overwhelmed - saddened - by the number of women who go into something as serious as an induction of labor with no preparation or information ahead of time. Countless women ask at zero hour what they can expect of an induction, with it looming large in the headlights in a matter of hours. Would you prepare so poorly for brain surgery? Probably not. Even my gastroenterologist - her secretary, even - prepared me more thoroughly for an upcoming procedure in more ways than these women are.

Outside the scope of obstetrics, uninformed consent is a huge problem - and the source of more costly procedures that are completely unnecessary. I remember those commercials in between cartoons while growing up in the 70s and 80s - "Knowledge is power!" And if you don't have that knowledge, you've effectively been rendered powerless.

Considering the rising induction/cesarean epidemic, I think more childbirth classes should cover inductions more extensively. While I took a class seven years ago, I don't remember it being given more than a passing mention.

While I don't doubt that some women won't listen to their doctor's warnings about the risks, it sounds like not many doctors are even bothering to mention the risks. I consider what my doctor told me about the risks of primary cesarean - nothing. Had he done so, I'm sure my attitude about it would not have been so casual, that's for sure. I think that's what contributes to the rising problem of inductions - attitudes about them are way too casual because women are simply uninformed about what can and does often happen, and how it can change their perception of "normal" birth. A few women I've talked to don't even realize that an induction ending in cesarean is not really a successful outcome - at least I don't think it is. But unfortunately, there apparently is little criteria defining what a "failed induction" really means.

Perhaps doctors need to draw up a realistic outline of the risks and benefits of labor induction - and have the patient sign off on it. I know this is what I had to do when signing consent forms for doing a VBAC. Of course, this might actually force the physician to be more forthcoming with how he handles inductions, and some aren't willing to admit to more aggressive practices, I'm sure.

When it comes to overall pregnancy and birth questions, perhaps a list of recommended reading would be helpful. Then again, unfortunately not all pregnancy books are the same, and can offer wildly different, sometimes slightly inaccurate, ideas about what's normal and what isn't. And there's nothing saying that patient will actually read them, either.

If anything, I think some doctors mitigate the risks or outright lie about them, simply because they don't want you to change your mind. I've heard some doctors say that Pitocin contractions aren't worse than regular ones, for instance, even though lots of women feel this isn't true. Perhaps for a number of reasons, inductions hurt more because you are more monitored and allowed less freedom of movement, which is no doubt why so many women choose an epi during an induction. If a woman knew that perhaps her labor could be more painful, or at least more intense, during an induction, she might decide against it.

People blather on about "just talk to your doctor" about the risks, but I think you'd be hard-pressed to find one who is up front and on the level about it. Conversely, perhaps not many women ask beforehand (or perhaps their concerns are rebuffed) simply because inductions have been so routine. And sometimes, even when you do try and tell them, it's like they put their hands over their ears and sing, "La la la!" loudly to block you out. They don't want to hear anything negative or that sounds "wrong." They might as well go into the labor and delivery unit with a blindfold on and paper bag over their heads.

I felt badly when a thread showed up from a woman 40w6d who was on the verge of an induction. She wanted to know what to expect, and namely if it hurt more than a traditional labor. She had no cervical dilatation or effacement, and was facing an induction in less than 24 hours. By the time I responded, 11 hours had passed, so I figured she was already well on her way to whatever by then. I looked on, horrified.

It reminded me of that Sally Field movie where the mother is stuck in heavy traffic and on the phone with her daughter. Suddenly the mother can hear something going on in the background, as her daughter is attacked by a stranger in the house. The mother can do nothing but listen, helpless. Sometimes I feel like that - like if only we could better inform patients ahead of time, they might not have to go through this stuff. It's like being on the edge of a cliff, holding on to her shirttail, and you can't get a footing before she goes over the side, tumbling into a cascade of interventions that are probably neither wanted nor necessary.

More reading:
"The Benefits Outweigh the Risks" - My OB Said What?!?
"I highly doubt you have the intelligence to read a medical journal." - My OB Said What?!?

Wednesday, December 8, 2010

The Obstetrical BS Series: The Induction Seduction

Perhaps one of the biggest pregnancy myths circulating today is that "Doctors won't induce unless it's medically necessary!" I wish I had a nickel for every time I hear someone say that. I find that the more people I talk to, the definition of "medical" and "necessary" gets fuzzier and fuzzier. I've even heard medical professionals - labor and delivery nurses, for God's sake! - say this. Maybe not on your watch, or in your hospital. But please get your head out of your butt and put down your Kool-Aid: this is a very real problem that often does nothing more than trade one set of complications for another, all in an effort to prevent them.

It's hard to resist, I know: you're big and huge, cranky and tired, and sick of getting up to pee every 45 minutes all night long. Your ankles are swelling, your mother is bugging you about when the baby is coming, and you just want it over with already. Who, at this point, doesn't?

It's estimated that one in five women is induced, and some numbers suggest it's higher than that. It's probably hard to estimate how many of those are 'social' inductions, but it's not uncommon for a doctor to at least offer an induction at some point during the pregnancy, regardless of medical "need." While most think that a doctor only brings it up as the due date comes and goes, it's increasingly clear that some OB's will discuss it early and often.
“We’ll just make sure you deliver by 40 weeks! Don’t worry, almost *EVERY* woman gives birth before her due date!” – OB to mother.
"At my 39 week appointment, my doctor said she wanted to induce me the next week if I did't go into labor on my own. I asked why and she seem surprised I didn't want to have the baby ASAP...I was also due in late Dec., so it's certainly a possibility that the induction was at least partially for doctor's convenience."
When I asked friends in the birth community what their experiences were, one reader says her doctor brought up induction before she was even out of the first trimester. She thought it was odd, considering how she was going for a VBAC and induction is not recommended.  Out of all the responses I've had so far, only one person said her OB didn't mention it and was respectful of her birth plan not to induce unless it was medically necessary.

The most common reasons cited for induction are "big baby," low fluid, and post-dates. We have great diagnostic tools (sarcasm) that can tell us how big that baby will be or how much fluid there is, only sometimes it's off - by a lot. One reader stated that her baby was estimated at above 11 pounds, and agreed to do a cesarean - later finding out her baby's actual weight was just over 7 pounds. The famous line "Fat squishes!" is true: lots of women find that it's easier to push out a squishy, chubby baby than one who is smaller, with sharper, bonier angles. I think the common misconception is that bigger babies will hurt more, somehow "tear you up" and are generally indicative of miserable deliveries. That idea is probably deeply rooted more in the way labor is managed: your position, as well as the baby's, might have more to do with it than sheer size alone.

I'll never forget the eve of one particularly interesting labor - I could hear the mother crying out while laboring as I made my pharmacy rounds. I was stunned to see that she hadn't ordered an epidural - I mean, doesn't every laboring mother request one? but was relieved because that meant I didn't have to make one, either. LOL Then as I filled her prescription for ibuprofen two days later I looked down across the counter to see her lugging a kid out in his carseat - a kid that already looked three months old - and realized, This woman had no epidural. I can't remember, but I think he was nearly 11 pounds. And he wasn't the first of her big babies, either.

This was probably the first of many encounters that shaped my perceptions of birth. That yes, you can labor without drugs, and you can even deliver a "big baby," too.

Another reader said her friend was being induced because she was tired of being pregnant. Most of the moms I knew were approaching due dates - my neighbor had her first last year and was due around a holiday. A good friend was experiencing heart problems throughout her first pregnancy, but apparently they were not grave enough to exclude her from having a vaginal birth. She was, however, induced at 38 weeks, and told me later that she still doesn't know why. (Her baby was born at the beginning of June, so if you add two weeks to the calendar, that lands you around Father's Day. Perhaps someone didn't want to miss a cookout or outing with dad?) To make up for it, her second was nearly born in the car. :)

In reading some pregnancy books, I find it alarming that some consider an 8 pound baby to be "big." Others give or take at least a pound and a half, thankfully. I wonder what our definition of big hinges on - perhaps it's still a leftover from the days of when women restricted their dietary intake and smoked more, creating smaller babies that were perceived as 'easier' on the mother.

Low fluid - which some pregnancy sites almost approach with dire concern - is increasingly becoming another dubious reason. Gloria LeMay considers it a "scam " and I agree - it seems like one more "medically necessary" reason to move things along and get it over and done with. In some cases, low fluid can be remedied by simply drinking more fluids and making sure you're not dehydrated, which is an easy fix compared to the process of inducing labor.

Another disturbing trend is for women facing inductions to ask strangers on internet chat rooms, "What can I expect when I get induced tomorrow?" Even Dr. Amy agrees that induction is a very serious matter, and isn't something the patient should walk away from the office knowing nothing about. I asked my Memorial Day-induced neighbor if her doctor had told her the risks and disadvantages, and she said she had. But I can still find countless sources where women are completely and totally uninformed about the process, from all angles. When looking for a desirable answer in which to seek comfort, they usually won't choose the one that says, "Don't do it - mine was a disaster because my baby wasn't ready and I had a cesarean!" but will pick the one that says what they want to hear: "I had all my children induced and I did just fine!!"

In this sense, there is something to that old "blame the mother" argument. Women who blindly go into things uninformed don't even know enough to make the best decision for themselves or their babies, and therefore can't really make any decisions - because their doctor has essentially taken that power away from them. Anyone who tries to inform them otherwise is perceived as 'snarky' or branded as the Arm-Hair Braiding Lunatic, which is really unfortunate. If an induction is necessary, I don't think any doctor should allow his patient to go home without first reviewing a list of the pros and cons. That is truly informed consent.

From what I've read, an alarming number of women do not fully, if at all, understand the risks of induction. They do not understand even when they are truly necessary. Some of the more interesting comments I've heard include:
"After all the hoopla of the appointment [heartbeat check, growth check, etc...] and after my internal; he said "Meet me at the hospital at 6 am tomorrow morning." I asked him why and he said "Meet me at the hospital at 6 am tomorrow moprning. Baby's ready. We induce."
"I feel every woman is different and if she is at least 38 weeks she should be able to make her decision rather to get induced. it shouldn't be the doctor's choice as long as the baby is healthy."  
"My second was born at 38 weeks perfectly healthy. Now my doctor wants me to wait 39/40 weeks to give birth to my third baby. I mean, sheesh, what's the hold up? No one should have to wait the whole 42 weeks or more unless due to medical reasons concerning the baby. I agree that we should be able to decide as long as we have made it to 37/38 weeks with no complications."
An overwhelming number of women, when asked about the risks, said they were not sure of the risks, but thought it was "pretty" safe. Only one person said "Run! Run far away!" and gave a detailed horror story of how she was treated like dirt by her doctor and hospital staff, including them ganging up on her and getting her visiting family to push her into it. She added that hospital staff "kicked her mother out of the OR and tried to remove my brother from the hospital when they asked too many questions." (And as if you couldn't guess, her answer received a thumbs down.)

Even more so than that, they realize even less how it could impact their baby. Just because you hit the magic 37 week mark, it does not mean your baby's lungs are fully mature. Studies have shown that babies born by elective cesarean had complications - with one fetal death - up until the 39th week.

And even though elective cesarean and elective induction are two totally different things, they can sometimes lead to the same outcome. Studies have also shown that for first-time mothers, inductions can lead to an increased risk of cesarean, which plants that seed of doubt from the get-go: that my body is broken. That "failure to progress" diagnosis sticks with a patient oftentimes, and can totally change the way birth happens in the future. Rightly so, many women are starting to realize that "failure to progress" often means "failure to wait," and no where does this make more sense than in a failed induction. The mother has no guide - no prior births - on which to base her experience, and therefore doesn't know if she can even go into labor on her own or not. My own sister-in-law, herself a nurse, was socially induced with two pregnancies (because her doctor was going on vacation), and one birth nearly ended in cesarean with suction and shoulder dislocation. By the time she was approaching labor with her third, she had no idea what to expect.

One comment I read came from a mom of five who was expecting her sixth baby. All of the prior births had been induced, and this time she was ready to head to the hospital simply because she was dilated. She admitted that she had no idea what going into labor on her own was like - even after five kids.

While no one is arguing that sometimes inductions aren't truly necessary, the abuse of them is like treating something with a solution when we don't even have a problem. Not only are we fostering a completely false notion of what birth can be like, but we couple it with the idea that our bodies are somehow inadequate, broken, and incapable of handling what is otherwise a normal physiological process.

"Obstetricians have always been trained to believe that pregnancy and labor are disasters waiting to happen." - Dr. Bruce Flamm

More reading:
Why Do Doctors Induce Labor?
Cesarean Deliveries Rise Alongside Rate of Induced Labor
5 Reasons to Avoid an Induction of Labor
Reasons to Induce Labor
Saying "No" to Induction
What is a Bishop's Score and How Does it Relate to Inducing Labor?
Australian woman visited by police after failing to show up for induction

Part 1: The Obstetrical BS Series: Redefining Normal 

Monday, December 6, 2010

The Obstetrical BS Series: Redefining Normal

What is normal birth, anyway?

Whenever I have conversations about birth with people and see comments on pregnancy forums, I'm saddened at how our definition of "normal" has totally been taken off course. I don't know why I'm surprised by this, but am continually amazed at some of the lies, misinformation and half-truths that lurk out there, and how the Reality of Childbirth is one big rumor that just won't let itself be put to rest.

When people think of the "history of childbirth," they probably think that there isn't any: how can one woman getting pregnant and delivering a baby be any different than it was 100, or even 1,000 years ago? How can there be a 'history' to a basic biological function that has taken place in millions, even billions, of women since the dawn of man?

I've decided to compile a few of the things that I consider "BS" when it comes to obstetrical practices, starting with our perceptions of what "normal" birth is. Much of it is rooted deeply in myth, some in fact that has been extrapolated (I love that word!) to include everyone now, even though they often present no symptoms and fit no risk categories. We fail to see ourselves as "birth consumers" and trust our doctors to tell us what we need to know, which in some ways we should. But because we often don't understand the mechanics of birth and how it relates to the capabilities of the human body, or the politics surrounding it, we often trust them in ways that we shouldn't. I suppose it's different for everyone, but I cringe whenever I hear people refer to a vaginal birth as "natural," especially when it's far from it. Natural in the sense that that's the preferred mode of delivery for humans. But that's about where it leaves off. Perhaps they should use the word "normal," but even that's a matter of debate.

If you're like most American women, you get pregnant, find an OB, and think that's the end of it. When it comes to delivery, you know that one of several things usually happen: you are either induced for a variety of reasons, or "allowed" to go into labor on your own time. Occasionally you are "permitted" to go overdue, but not without some level of concern first. You've heard that the placenta can deteriorate after a period of time once the baby reaches a certain gestational age, and it has you worried that you might go overdue .

You've long-since chosen your care provider. In your case, you probably have chosen an OB, because that is usually just the 'thing to do' when you're pregnant. You've heard a lot about midwives , but it just doesn't sound like a good idea to you. After all, what if there was an emergency? Your second cousin had a midwife and it worked out for her, but a neighbor told you that midwives don't know what they're doing and can't be trusted . You figure that's probably true, because so many people see an OB. Besides, your OB's practice doesn't allow midwives, and neither does your hospital. It's probably for the best.

As your due date looms large along with your waistline, friends start asking: "When is your doctor going to induce you?" One friend says she was induced at 38 weeks and two years later, doesn't know why, which leaves you scratching your head. Most of your friends agree that your doctor will only induce you if it's deemed medically necessary , or if you're tired of being pregnant or relatives will be in town . A few other friends say how they were induced and in all but one, had cesareans . "But that's just how it is," says one friend, shrugging her shoulders. "No big deal." You know that one friend was induced because of a baby they thought would be big , weighing a little over 8 pounds. You worry, but don't think too much about it and remain happily pregnant a little while longer, but you are concerned that something might be wrong when your doctor brings up induction at every appointment from 36 weeks on. You ask him about it and he shrugs you off like it's no big deal and says, "See you in two weeks!"

If you haven't been induced by now, you're probably laboring on your own. The next course of action is often to administer Pitocin, sometimes even if you have a regular pattern of contractions . This is often just to speed things up, even though you're doing fine. Assuming that both you and the baby's heart rate look good - detected through external continuous fetal monitoring, of course - you will be "allowed" to continue laboring, usually. If it takes a long time , though (and everyone's definition of "long" varies), other things might be considered, usually resulting in more Pitocin or eventually a cesarean.

If you haven't been sectioned by now, you might be experiencing stronger, more painful contractions. Your doctor might tell you "No, that's not any different than normal contractions," and if this is your first baby, you have nothing to compare it to, so you don't question it. You request the epidural, and you can't get up and move around now that you've been confined to bed. Your hospital dictates that you can't have fluids and food in labor , so you're near exhausted and just want this baby out. However, the epidural is administered - either it doesn't take and they have to give you another one, or you muddle through without it - flat on your back, in agony. The baby is starting to go into distress , which worries you. The doctor looks concerned and tells you it's time to consider a cesarean. At no point has anyone suggested turning down the Pitocin .

Finally it looks like progress is being made. At first you are worried because the doctor says you're "not progressing fast enough," even though you are a first-time mother who has only been laboring for less than 10 hours. You've been pushing for what seems like forever, even though you have no urge  whatsoever. You're seeing stars and getting light-headed from holding your breath and pushing when they tell you to , and it's so hard to push the baby out that the doctor begins to use vacuum extraction. You feel intense pressure and tearing that feels like your insides are being ripped out. And then, the baby is born and it's all over. Thank God!

You hold your baby for a brief moment and then she's whisked away to a warmer. They don't want her to get cold, and after all, there are those very important tests to perform to make sure she's okay. You want to hold your baby, but you know all those tests and everything are necessary, so you watch as nurses huddle around her in the isolette and swaddle and bathe her.

Then you're taken to your room and the baby is finally handed to you a little while later. You try to nurse, but it's kind of difficult because you're a first-time mother, after all. She's not very interested in breastfeeding, likely because you had several doses of the epidural after the first one didn't take. Finally she latches on, but a nurse tells you that you can't do it and your nipples will start bleeding and get excoriated and it hurts too much . What she doesn't tell you is that they've already given her a bottle of formula without asking because your baby's blood sugars were low , and you don't realize she has nipple confusion. The nurse is breathing down your neck, the baby is crying, and there is a huge bag of formula "just in case" you needed it. You decide to use it because the baby seems really hungry , or at least the nurse thinks so.

The doctor comes in and tells you you did a "good job," and that it might be advisable to have a planned cesarean the next time, just in case . You agree, because, after all, he's the doctor and knows what he's talking about.

Fast forward six months. You've had time to heal, you love your baby, and she is thriving. You're at a baby shower for a friend, surround by aunts, your sisters, female cousins, and coworkers. You're sharing stories with each other about birth - and they ask you, since you're the last one to have a baby - how it was. You tell them, frankly, that it was the worst thing in your life, terribly painful, but so worth it for this wonderful daughter you have. Based on your story, most of the room agree that when they have children, they are "definitely getting an epidural!" One says, "My mom had c-sections with me and my brother, I'll probably have to have one, too." Another says, "Yeah, my grandmother had a vaginal birth with my uncle and she nearly died!" Still another says, "I had a natural delivery. They had to give me Pitocin and do an episiotomy, but all I had was Demerol while in labor. It wasn't too bad."

The seed of doubt has been planted. When everyone you know has had the same "normal" experience, not realizing that it's anything but, it suddenly takes on a life of its own. The idea that our bodies are somehow defective has taken hold and runs rampant, like a bad rumor that just won't die and go away.

And so is our definition of "normal" childbirth.

More reading:
Tabby Biddle: Women Speak Out About What's Gone Wrong with the United States Birthing System
Melissa Bartick: Peaceful Revolution: Motherhood and the $13 Billion Guilt