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Friday, February 25, 2011

A Pregnancy Book Primer: The SOB's guide to pregnancy

Even though this book is
out of print, you might find
the deep discount over-stock
copies to be cheaper than
toilet paper. (Hey, this is the age
of recycling, after all.)
If you're like me, you've probably heard that The Skeptical OB wrote a pregnancy book, How Your Baby is Born. She touts it on her blog page and says, "You can order it through Amazon!" Well, I checked there, and lo and behold, it's out of print. (Apparently there are several copies starting at the bargain price of 11 cents if you're interested.)

Rather than waste the money, I saw that there is a PDF copy available through her advice website, "Ask Dr. Amy," or you can just peruse the headings on the website. (If you have a pressing question, you can actually go through PayPal and transfer funds in exchange for advice. Considering she's not technically practicing medicine anymore, is this even legal? It kind of reminds me of Lucy's advice stand in The Peanuts comic strip.) Anyway, there are four major headers with a few points in between, which leads me to believe this is a very short book.

Considering her rather acerbic nature on her blog, I was curious to see her take on things like vaginal breech birth, VBACs, epidurals and if she even touched on home birth at all in her book.

I had a laugh when I read her take on pain relief:
There is probably no area of obstetrics that generates more anxiety and more controversy than the subject of pain relief. That's not surprising when you consider the reputation childbirth has for being so painful. The truth of the matter is that the reputation is well deserved.
Really? That makes it sound like everyone's pain tolerance is the same, and everyone will (and should, because if you don't there's just something wrong with you) find it the most excruciating experience of their entire lives. She throws the NCB crowd a bone in saying that if you are prepared, it might not be as bad, and to be prepared, you have to be informed. (by reading her book, perhaps?)
Unfortunately, to promote natural childbirth, some of its supporters have claimed that using the breathing techniques makes childbirth, at best, painless or, at worst, only slightly uncomfortable. Neither scenario is true.
It's obvious that she is concentrating heavily on the Lamaze method, where breathing is key. But it involves so much more than just hoohoo-haahaa, and I wonder if she perhaps reached this conclusion by watching Dr. Huxtable deliver babies on The Cosby Show. She sort of sets it up by saying that labor may not be what you expect, insinuating that you'll soon ditch your plans for a natural birth and probably scream for the epidural - never that it happens the other way around. I find her stance on natural birth, especially her vehement opposition to it on her blog, to be perplexing, consider it's rumored that she gave birth naturally to two of her four children (something she rarely mentions). So it must not have been that bad, then, if you did it not once, but twice, right? She does, to her credit, mention the risks of epidurals and says they "are not trivial."

(Click here and you'll find useful natural birth techniques that include much more than just breathing, which does help, by the way. It certainly beats hyperventilating.)

In the heading under "Fetal positions," she gives brief mention of breech positioning, laced with her authoritative tone and scare tactics:
A baby cannot breathe until the head is successfully delivered. Therefore, strenuous efforts must be made to deliver the head as quickly as possible in a breech presentation. Unfortunately, these same efforts, which are required to save the baby's life, may cause serious, permanent injury. This is the main reason that breech vaginal deliveries are considered hazardous.
She does mention, thankfully, that a baby in breech presentation prior to 36 weeks is nothing to worry about. Even after that, though, a baby can and often does still turn. I wonder how many primary cesareans could probably be avoided if practitioners would just wait for labor to begin, in giving the baby a chance to turn even at the last minute.

She also mention cervix checks, but there is no mention that perhaps they are unnecessary or that you even have a choice in the matter. (I wouldn't expect many mainstream pregnancy books to address this, either, unfortunately.) She adds that while the initial check might be uncomfortable if the cervix isn't dilated very much, "each additional exam" will be easier for mom as she makes more progress. Is this the "Cervical checks, early and often!" approach?

One of the problems with multiple cervix checks is that it can make you feel let down and disappointed if you're not progressing fast enough for your doctor while in labor. Not only that, but repeated exams can introduce infection. Dr. Amy says, as part of the procedure, "You watch him or her don the sterile glove." (More on that here.)

On things like prenatal testing, she mentions the AFP test and that it should be used more to determine risk factors, not absolutes. While this is true, I was unimpressed with her failure to admit that it has caused more false positives and stress in a pregnancy than necessary, leading many to question its role in prenatal testing. She also mentions amniocentesis, and while she argues that it can do more harm than good to certain women, those for whom it might benefit are those who receive an abnormal result on the AFP test. Aside from the risk of injury because of obvious needle jabs during the procedure, she also fails to mention that amniocentesis also increases your risk of infection or miscarriage, which is about 1 in 400 to 1 in 200. Depending on your situation, you may want to forgo that altogether, especially since more advanced, less invasive ultrasounds can often give you accurate results.

Moving on to induction of labor: The SOB, in typical shock fashion, states that the "mortality rate of babies born after 43 weeks is double that of babies born on time." (On time being a relative term, I suppose.) For those after 44 weeks, "the mortality rate is triple." Unfortunately, this fear is why many women are induced for post-dates when they're literally only one day past their "due date." This thinking seems, no doubt, to lead to many questionable inductions and probably even more unnecessary cesareans. And while the risks of going that far past dates does sound scary, it doesn't mean it's the same for everyone, and there are things you can do to check on baby's status without agreeing to an induction. This is a very personal decision and one subject to much scrutiny from just about everyone. (And let's not forget to mention that many educated, informed women do go past their due dates and deliver healthy, live babies.)

Perhaps what The SOB should talk about are the very important reasons you might be that late, like your dates were off or your cycle is different from that of others. Not everyone, contrary to the due date wheels at your OB's office, ovulate at the same time and have a perfect 28-day cycle.

While she does mention testing like non-stress testing and biophysical profiling, I see more and more people saying their doctor is ordering an NST out of the blue well before the baby is even overdue. (Just one more way of turning the normal into the abnormal?)

She does add that sometimes things like AROM to induce labor does not always produce contractions, and the longer the water is broken, the greater the chance of infection. Unfortunately, what neither she nor many other books will tell you is that those crummy vaginal exams every hour on the hour will increase your risk of infection. And while the old "24-hour rule" is normally in place, some physicians give you less than that. (I read that one doctor routinely gives a measly eight hours. Seriously? How pathetic.)

As far as rupture of membranes, she states that "in almost every pregnancy, the membranes will rupture naturally at some point before the baby is born." I find this hard to believe, considering the popularity of AROM to speed up labor, whether it needs it or not. Although I couldn't find exact figures, some estimate that roughly half of women received an amniotomy in labor, and another link suggested that only 10 percent of women have spontaneous rupture of membranes.

I had AROM with my VBAC labor, and while my daughter's head was engaged, I was not fully aware of the risks of the procedure. Nor was I asked; it was implied that it was something that would be done as a matter of course, regardless of how I felt about it.

Some studies suggest that among those who received amniotomies, it did not speed up labor as compared to the group of women with SROM. Although, of course, The SOB disagrees:
It is well known that when the membranes rupture during the active phase of labor (either naturally or artificially induced), the contractions often become stronger and more frequent. Sometimes, this is all that is needed to speed up a labor that has been making minimal progress over many hours.
A citation, please?

It is also well known that the bag of water shouldn't be used to jump start labor in the absence of contractions, although that still doesn't stop doctors from doing it too soon. There is also the risk of cord prolapse, where the cord comes out before the baby's head, causing fetal distress. Unfortunately, she doesn't mention this risk, but rather says it can be used to detect fetal distress or check for meconium in the amniotic fluid. (insert guilt trip here) "Rupturing the membranes artificially can provide valuable information for taking proper care of your baby." Or not. What it could provide is a speedy trip to the OR for an "emergency" c-section, if nothing else.

And of course, it seems every mainstream book I've read either lists absolutely no risks of inductions, including Pitocin, or glosses over them. The SOB's book seems to be no exception, and it seems she has a way of filtering the truth because of her own rose-colored view of obstetrics.
Pitocin is administered initially in minute quantities, and the amount is gradually increased over 20-minute intervals until contractions begin. The fetus is monitored during administration of Pitocin to make sure that the amount given does not cause the baby stress or contractions that are too frequent. If labor has not started within 12 to 24 hours after application of prostaglandin gel, the mother is readmitted to hospital to receive Pitocin through an intravenous line.
I think the only part of that statement that I'd consider remotely true most of the time is that you'll be monitored. The downside to all that monitoring? You'll be confined to bed, and won't be allowed to labor comfortably or move around much, if at all, which is a natural coping mechanism that many women find helpful. Because of restricted movement and increased monitoring, more induced women tend to ask for epidurals, and thus the "cascade of interventions" begins.

I wish more pregnancy books would be upfront about the truth about Pit - that in some cases, it can be a good thing, but not enough to justify its widespread use. To augment labors that are already progressing normally, albeit a bit slow (by the doctor's standards) - not every slow labor is a sign that something bad is happening. And the idea that every doctor only "administered it in minute quantities" is probably the biggest lie I've ever heard.

Fetal distress from Pitocin is barely mentioned in passing, and inductions can lead to greater numbers of cesareans, especially in first-time mothers. Strangely, this is not mentioned, but The SOB does write about it on her blog, which I do remember caused much head-spinning among members of her camp.

Not only that, but I've also heard from many women who were strongly encouraged not to go home or were not even given the option. There is the risk that a failed chemical induction can lead to a last-ditch effort to jump start labor through AROM, suddenly you're on the clock for contractions to start, and you're in for the long haul.

While The SOB does go into some risks of Pitocin, they're not given much emphasis. She mentions that careful monitoring again, to make sure contractions aren't too close together, blah blah blah. "It is easy to decrease the frequency of contractions just by lowering the dose of Pitocin," she claims, but it seems like few doctors do.

The best way to detect fetal distress in labor is apparently through fetal monitoring, which
is the best method of monitoring your baby during labor. It is the one piece of equipment that is routinely used in all labors, both normal and abnormal.

Since The SOB loves to cite studies so much, perhaps she'd like to look at this one, which suggests that continuous EFM isn't quite what it's cracked up to be, often failing to detect true cases of fetal distress and leading to increased cesarean rates because of false readings. And when she says it's "routinely used" even in normal labors, it's like saying, "This is what's done, despite the conflicting evidence you've read, so get over it."

Every once in awhile, though, The SOB surprises me and appears quite rational about some things. About cesareans, she does note that while lifesaving, they appear to be more common than is normal, and that about 1 in 5 women will have one "recommended" to them. The most common reason, she cites, is CPD, even though, she adds, the only way to tell that is once labor has started. She actually uses the phrase "unnecessary c-section," which shocked me - and says that "there are undoubtedly some unnecessary c-sections that are done presumably because of CPD," (which some sites state is "quite rare.")

She adds that a number of unnecesareans are done because of suspected cases of fetal distress that really aren't, but doesn't mention the fallibility of the much-revered EFM in leading to those cases. And while she does say that fetal distress is a common cause of c-section, she doesn't blame the oft-misused Pitocin as a culprit.

And in case you were wondering, searching for "home birth" on her site won't produce many results, unless you want to be directed to her biased (and now abandoned) website devoted entirely to blasting it.

Like many other mainstream pregnancy books, they may be useful if you don't want to "birth outside the box." Unfortunately, while under the guise of informing women, they do much the opposite, which can be very confusing for someone who isn't sure of what her options are. This book, like so many else, will probably leave the reader with the idea that she doesn't have any at all.

More reading (much of which contradicts what you'll read in this book):

Cesarean Deliveries Rise Alongside Rate of Induced Labor - Time
Reasons to Induce Labor - Giving Birth Naturally
Test Leads to Needless C-Sections (regarding EFM) - Stand and Deliver blog (excerpted from the original article at The Philadelphia Enquirer, which has been removed)
Your OB (Midwife) Still Does What? #5: Cervical Exams - Birth Sense
How Likely is an Infection After Water Breaks?