Reply turned post: The Beauty of OB

You often see posts like "Confessions of a Labor Nurse," or "Why You Need Pitocin in Labor" (I think poor Nurse Jenna removed that post a long time ago) and they're supposed to be touchy-feely, feel good pieces that make you come away with a renewed sense that childbirth is such a special time, that your care provider really does care about you and your child and they only want the best for you. Which sometimes comes at a high price, we know. Sometimes an induction, a cesarean, difficult labor and delivery - they all can happen and are often a rite of passage before entry into motherhood. 

It's hard for me not to be cynical about it. But to cut to the chase, sometimes I think the true beauty of OB is that women still want, and manage, to give birth at all after being subjected to the institutional abuses and misuses that are so typical of modern obstetrics. 

That isn't to say I'm critical of lifesaving measures, or that I'm saying, "All cesareans are unnecessary!" I'm more critical of abuse of care and intervention that is misconstrued as good care, when really, it's excessive and sometimes pointless, sometimes causing the problem you're trying to prevent in the first place. 

But I feel like all these posts have an overtone that says, "You should be thankful. Now shut. up."

The author of this article over at Huffington Post is an L&D nurse. I'm not, and I'm not trying to compare my experiences with hers. But as I see so often in these posts, they really don't get to the heart of the matter. They sort of gloss over, or completely miss, whole areas that are often untouched in our culture of women. The idea that women often come home without a baby, or sometimes never come home themselves, is incredibly tragic. No one is arguing with that. Modern obstetrics has saved many lives, both mothers and babies, and yet the place we are in today is proof of how its overuse can taint our perception of things so much we can't see what's really going on. 

Often the women who are missing, shattered or empty, as the writer mentions, are not only the ones who never survive childbirth or come home to an empty crib. They are often women who look normal and whole on the outside, with perfectly healthy children. We cannot discount their experiences and just assume that everything is perfectly normal and right because we can't see anything broken, or lost. If a woman is subjected to horrible treatment in labor, sometimes resulting in physical injury, how many times does an attorney refuse to handle her case if she seeks prosecution? Because she and her baby both appear healthy and happy on the outside? If no one is physically maimed or dead, they don't even want to talk to you. 

The author mentions staying healthy in pregnancy and waiting for active labor as ways to have a healthy delivery, avoiding induction unless for a medical reason. But unless you know what some valid medical reasons are (and more importantly, aren't) anything that comes out of your doctor's mouth is therefore a 'medical reason' and before you know it, the Pitocin is flowing. Staying healthy is relative, unless you're an illicit drug or alcohol user, and even the healthiest, most informed women can still be subjected to dubious care at times. Oftentimes it never seems to be enough. And often has nothing to do with you and everything to do with an impatient, overbearing care provider who is set in his/her ways and refuses to change. 

She mentions the case of a teenage mother who was induced, with no success, and then sectioned. As a result, she hemorrhaged and her uterus was removed. They lamented, rightfully so, over the fact that she would never have any more children. Do they ever lament over how some teen mothers are degraded and insulted because they're young and often unmarried? Or do they consider for a moment that this young mother's complications were caused in part because of the induction, which carries a risk of postpartum hemorrhage? Why do these happy sunshine articles never, ever candidly discuss what goes on behind closed doors, the whispered conversations or blatant remarks when they don't think a patient is listening - or when they don't care if they are? 

Yes, it's great to do all the "right" things in your pregnancy to encourage the best outcome possible. And sometimes, those things happen despite your best efforts. But when you look at these figures, it's hard to see the "beauty" in OB, only the ugly side that makes it seem like the deck is stacked against you. 

For the original graph and accompanying post, click here. 

Source: Evidencebasedbirth.com,  Rebecca Dekker, PhD, RN, APRN 

Scheduled 11/11 births should expose broken maternity system

Photo: Hilde Vanstraelen/
www.biewoef.be

Yesterday we heard of loads of special births on November 11 - from inductions to planned cesareans to doctors offering cash to patients if they'd deliver on that landmark occasion. Today, the details of these births surface: cue the Pitocin IVs!

A Groton, CT mom delivers her baby after her doctor "decided she needed to have her labor induced." The baby weighed just over 7 pounds. As the clock neared 11:11, her "sisters started yelling, 'Push, push!'" (Side note: they'd make great L&D nurses, I bet.)

A number of births were mentioned in this article, including two "natural" births and one planned cesarean:

But in Colorado, Cayson Childers’ birthday wasn’t left to chance. His parents ensured his arrival by scheduling a Caesarean section for Friday, and then doctors were able to make the operation work right at 11:11 a.m.

The casual attitudes about surgical birth mentioned here almost make me want to puke.

This Syracuse, NY baby was delivered because the doctors thought it was "big." The child weighed 7 pounds, 13 ounces. The delivery was originally scheduled for the following week, but was moved to Friday. Don't want to put on an additional six or seven ounces in the meantime, right? Way to play it safe.

Adriana Jones, of Baldwinsville, was originally scheduled to have her baby, via Cesarean section, next week. But because the baby was big, Jones’ doctor recommended the delivery take place sooner.

The planned C-section was rescheduled for 11:30 a.m. Friday, but Dr. Suzanne Bartol-Krueger was able to get Jones in a little earlier. How kind of you, doctor!

It's important for me to say that really, I'm not so much criticizing these moms. They made their decision to go ahead with induction or cesarean plans, no doubt at the advising of their physician. Did they make the best decision? That's not really for me to say. But stories like this, and the media's reaction to them, make me kind of shake my head a little because it does several things, in my opinion.

First, it is often met with very casual attitudes about surgical and induced births. Both can be perfectly safe, if done for the right reasons. Sometimes, those reasons are clear, and sometimes not.

Many of these articles often feel the need to clarify whether they were vaginal or cesarean births, which is something I suppose readers are dying to know: did this happen all on its own or what? In any other situation, no mom should really have to justify how her baby came into the world. Some would argue that these women shouldn't either, but it should raise some eyebrows about what constitutes "medical necessity" these days. And when a birth wasn't cesarean, the media usually says it was a "natural birth," which we can probably translate as simply a vaginal birth. Is it news when the IV is hooked up and mom is pumped full of Pit in order for that baby to be born, practically dragged kicking and screaming into the world? Or when mom is laboring normally on her own after going into spontaneous labor? While some people will say, "Who cares?" it's clear there is quite a difference.

I can see how these timely births would start a new Mommy Wars debate: Why can't I schedule a birth on a special day like this? Does it have to be natural to count? Why not have a repeat cesarean because of this? Many argue that mom should have a choice of how she gives birth, even if it means something like a planned cesarean section for no reason other than she wants one. Fine, as long as you are well-informed of the risks and benefits of doing so, and get your information from someone other than a well-meaning but clueless friend or a doctor who is happy to oblige because it means he can finally go on vacation. Of course, you'd do it anyway, I suppose, but I can at least respect a truly well-informed decision. Doing it simply because you're effing miserable and 36 weeks and "It's time! The baby is practicing breathing movements!" is just stupid. But to each her own.

Really what this does is expose the often suspect practices in modern maternity care that have escalated exponentially in the last few decades. My mom told me of my 1974 birth, "The doctor told me he absolutely would not induce because of the risks and rushed in from a dinner party to deliver you while wearing a tux." Nowadays we hear, "Induction is perfectly safe. I don't want to have to come from my dinner party and deliver you while wearing a tux." What a change in thinking.

Are we accepting a woman's right to choose where and how she gives birth, but only to a point? If she wants to put her baby and body at risk, there are probably no shortage of physicians willing to accommodate her wishes. I hate to be a party pooper, but blasé attitudes about surgical and pushed births are what makes people say, "So what? Who cares? So she wants to have a cesarean for absolutely no reason. Isn't that her right?" Like in my last post, I think the birth of a baby is always something to be celebrated, but these kinds of births so far remove us from the frame of 'normal' that we don't even know what it means anymore. We can schedule hair appointments, meal reservations and oil changes: why not birth?

Everything in moderation - even birth advocacy?

I have always stood firmly in the middle when it comes to birth advocacy. I am not in the "trust birth!" camp, because I feel that birth can still be predictably unpredictable; our bodies, for all their wonderment, can still betray us and so, sometimes, can our births. I am not a person who believes that every doppler and every ultrasound is bad, nor do I believe that birth is "an accident waiting to happen." I also don't agree with the mantra "Just trust your doctor!", because being burned by doing so is probably what leads many women to seek a home birth (or at the very least, an alternative birth experience) in the first place.

Yesterday I read three articles that stuck in my brain - one, about the Australian midwife Lisa Barrett whom the 10 Centimeters blog lambasted for her seemingly reckless midwifery; one written by labor and delivery nurses on how to have a "natural hospital birth," and one from none other than The sOB about The Navelgazing Midwife's transition out of the NCB community. (That one was especially bizarre, most of us agreed.)

If what the writers over at 10 Centimeters are saying is true, Lisa Barrett has had four baby deaths on her hands recently, two of which occurred very close together. I haven't read much on the subject, but I agree that something sounds weird about that. I question those who align themselves with her, simply because overall her attitude sounds very cavalier, almost. The Navelgazing Midwife commented about the situation and further distanced herself from the "NCB crowd," something I can understand - because it seems like The NgM was very judicious in her practice and someone I respected for her cautious approach to bringing babies into the world (something that has drawn both praise and criticism).

As far as Barrett's behavior, I don't know what to say - I wasn't there. If it's true, then I don't know how birth advocates can support her. I get the feeling that it's very easy to blame the mother (for hiring her), in some bizarre way, blame the baby (because, admittedly, some babies die anyway, right?) - instead of blaming a cowboy-type attitude of the birth attendant (which you see in hospitals, too). I've often wondered how women can not intervene and tell the obviously whacked midwife not to get the F out of the way because I'm calling 911 whether you like it or not, but again, I wasn't there. I wasn't inside mom's head to understand what she was thinking, or even if she really had time to think. The words "I trusted her" come to mind, much like they do for many women in hospital births who feel helpless, powerless to question the authority of a doctor who might be behaving in much the same way, only in the opposite direction. I am not saying no cesarean is every unnecessary, but you do have to step back and question for a moment why 1 in 3 babies are born this way.

On the other hand is the article written by two labor and delivery nurses - who give pointers on how to have a great natural birth while in the hospital. Yeah, that's all well and good, but perhaps the realist in me is coming out. The first one on the list is to "plan your birth," whether you write it out officially or not. That's a good idea, in theory, but as most people will tell you, not all births work out the way we want them to. There's a Catch 22 there, though, because for some women having a "plan" doesn't change the outcome - how many times have we heard that having a birth plan is almost a guaranteed cesarean? Is it because mom's plan is too rigid? Or because her physician sees it as an attack on his knowledge and authority?

That's where the idea of "finding a physician you can trust!" comes in. This is true; but for some, it's harder than others. Some go through multiple physicians and still can't find one who doesn't see birth as potentially catastrophic. What if you're living in a remote area and have one doctor to choose from? Then what?

Other points on the list include "asking for the right nurse" and "bringing your own doula." As they put it,

“There are some nurses who cannot stand to hear a woman screaming and it kills the nurse NOT to put in an epidural." 

Oh, I'm sure it "kills her." Perhaps. And then there are those who just want you to STFU and stop your whining already because you're being a royal pain just by allowing yourself to be in pain, like these:

"There is good reason for birthing couples to be wary. Our hospital epidural rates run over 90% and in most hospitals, over 95%. The nurses in general not only do not know how to support a laboring women, but have no desire to do so. They would scramble to take other patients first, leaving the "natural" moms for whoever was "unlucky" enough to not be at the board first. They sabotage natural childbirth at every turn ("There's no need for this suffering you know--they don't give out medals for this," and on and on). I saw moms thwarted at every turn--no help, no support, no suggestions until moms finally begged for the epidural and the nurses responded with comments like "See--now you'll know better than to try this next time." I helped where I could, but couldn't take every mom wanting a natural childbirth. (Read the entire article here.)

As far as the doula part, they say, "...doulas can do the things we'd love to but can't." Well, that may be true, to a point. But there are lots of hospitals and doctors who don't like doulas, don't want them anywhere near the patient, and don't consider them a help but rather a hindrance.

One that really stuck out was "Be prepared to follow hospital procedure." Then that basically means, be prepared to surrender your rights in some cases, and have a far less chance of getting the birth you want. I guess this is one of the parts that makes me a moderate - while I know you're there for help should you need it, I also realize that much of the hospital's crap policies and procedures make that desired natural hospital birth next to impossible.

The article asks, "What keeps women from having a great birth experience?" The nurses say it's the idea that women are not accepting enough of themselves, and often blame themselves when things don't turn out perfectly.

“We tend to be pretty controlling beings. Having a baby is a rare situation for us [as individuals] because we’re not used to the lack control. For most women, this is their first experience in a hospital or in any real pain.”

That idea of control sticks with me, somehow. I do think that women should be permitted to exercise control during their labors - to a point. You should be able to control some aspects, but if the true need for cesarean arises, you have to surrender some of that control to the physician, unless you plan on doing one on yourself.

It's when sometimes over-the-top advocates over-analyze the experiences of others and tell them what could have been different, what you should have done, this that and the other that I start to be glad I'm sort of sitting on the outside of the advocacy circle, sort of like watching the debacle unfold while sitting on the curb. I think we've all done it, and sometimes it's quite clear what happened and where things went downhill. Sometimes it isn't, though. I've had at least three people feel the need to almost justify their experiences - prefaced with a "I know it's basically everything you disapprove of" - and this makes me bristle. Disapprove? As if I am somehow the Final Judge of All That Is Holy and Right concerning your birth. Not. Although, in explaining the situation, I've realized there is often a lot more going on behind the scenes than I know, and can often understand their position. And sometimes I don't agree (like my neighbor who likely had two births unnecessarily over-managed simply because it was a holiday) but crap, I'm not going to say anything. What business is it of mine? Not my body, not my baby, not my doctor, not my anything. And likewise, I will use my somewhat crazy birth experiences to inform others that yes, there is an alternative. You can still think I'm nuts, but that's your problem.

It's important to be very careful when questioning the experiences of others. There's a fine line between coming off as a know-it-all and basically telling them they're dumb for doing it by the book and simply, respectfully, informing them of their various choices when it comes to birth. I know after having my VBAC and second cesarean that things could have been different - it was after this last birth that I read that "breech and nuchal cord are not necessarily cause for cesarean." Yeah, that doesn't really help me after the fact, though. And who the hell am I to force my doctor to deliver a baby in a manner that he hasn't been skilled in since I was probably a child? No thanks.

One thing I simply cannot stand is the idea that all natural birth advocates are the same: the group at 10 Centimeters does this, as does The sOB. Surprisingly, she had a change of heart about The Navelgazing Midwife after hearing that Barb was leaving the midwifery community because of her disagreement over their somewhat radical views. Strangely, she is now almost aligning herself with Barb.

I was once lambasted in the comments section of The sOB for a post I did on gullibility and the "Trust your doctor!" ideology.  Someone questioned my idea that because it comes from a doctor's mouth, it must be right and true, and asked "How can we stop this?"

I guess this is just another way in which I am a moderate: blindly, completely trusting your doctor is often not a fool-proof way to have a great birth. Neither is throwing all caution and reason three sheets to the wind. There has to be middle ground. I try to be realistic but not scary and ridiculous; I find that some like to practice "fear-based obstetrics" in both directions: there has to be more to the argument than "all birth is dangerous" or "home birth/unassisted birth is the only true option." Many women have been betrayed by their bodies during the birth process; just as many have been betrayed by overzealous midwives who want them to have a natural, intervention-free birth seemingly at any cost; by nurses who sabotage their efforts to have a "safe," natural birth in a hospital; by doctors who knowingly put them at increased risk to either get it over with already or teach them a lesson. By lumping all natural birth advocates together, by shunning those who disagree, or by aligning ourselves on the extreme ends of either spectrum, we are ignoring - and doing a great disservice to - all of those who land somewhere in the middle.

Related posts:
What the "other side" is saying about NCB literature
A bitter birth nerd
He's your doctor...you have to listen to him
My doctor will tell me everything! Part 1
The myth of the emergency c-section
Birth faith

There's a hurricane (and a baby) a comin'

Rock you like a hurricane: Who knew giving birth during
one of the worst storms ever could
be such a normal, natural experience? 

As the nation tenuously waits for Hurricane Irene to make landfall on the east coast, I can't help but think of all the expectant mothers, nervously waiting for their due dates to arrive and praying that it will pass uneventfully: will the baby come during the storm? Will I make it to the hospital in time? Will I be stranded somewhere?

I wouldn't be surprised to hear of a slight increase in the number of cesareans or inductions in the days prior to Irene's arrival, as doctors and patients took a "just in case" approach to avoid any such incidents from happening. It also reminded me of a passage from Jennifer Block's book, "Pushed," regarding Hurricane Charley in Florida - an F-4 storm that was the most powerful they'd seen since Andrew over a decade before. The storm lasted nearly a week, with winds topping out at 150 miles per hour. Pretty scary stuff.

With limited electricity, the hospital was facing measures to treat labor and delivery patients more efficiently given the lack of resources they had. Tracy Lethbridge, a nurse working on the unit during the 2004 storm, was on duty.

"...Hunkering down that evening was a minor interference compared to the week that followed. The hospital's emergency generator kicked in, but, like the rest of the town, the facility lost main power until the following Friday. With only enough generator capacity to run essential functions, there was no air-conditioning and no lab capabilities. That meant that the 13-bed labor and delivery ward wasn't a very comfortable place to either labor or deliver, nor did it have the lab setup required to manage epidural anesthesia safely. Lethbridge and her colleagues had to treat their patients much differently."

With limited power and no access to epidurals, what do you do?

 "We canceled all labor inductions," recalls Lethbridge. Normally, two beds a day would have been reserved for inducing women into labor, an often lengthy process that begins with drugs that "ripen" and dilate the cervix (Cervadil or Cytotec) and contract the uterus (Pitocin). Normally, even women who arrived in early labor – when the cervix is minimally dilated and contractions are several minutes apart – would often be encouraged to stay and would be administered Pitocin to hasten contractions. Lethbridge observed that under normal circumstances, the vast majority of babies were delivered during the day. 

 –––

"We only admitted women who were in active labor – regular contractions and progressive cervical dilation," says Lethbridge. "If they were not in active labor, we'd send them back home." 

Block speaks of this new, relatively unusual situation as an "altered universe" and writes that the nurses on duty during that period started noticing some surprising changes.

"Women were delivering within hours of arriving, even first-time mothers, without any Pitocin," says Lethbridge. ..."We had no cases of fetal distress during labor and no respiratory distress of neonates following delivery..." "We had an incredibly low cesarean rate. Amazingly, the babies were about evenly distributed between day and night shifts."

 "What happened was, women were going into labor all on their own, having good labor courses, and delivering healthy babies. Even the women who were scheduled to be induced that week, three-quarters of them came in and delivered anyway. And basically, they did better than if they had been induced. We thought, wow, this is amazing!"

Block notes that nurses, including Lethbridge, observed during the week period that among the 17 women who gave birth, "one was induced, two had scheduled repeat cesareans, and just one had a cesarean for 'failure to progress.'" Block states, "That works out to a cesarean rate of 17%; excluding the repeat cesareans, it was 6%."

Perhaps this almost informal "study" reveals that yes, birth can be a normal, physiological process if only it's allowed to proceed as such. That, instead of a "94 percent of births are complicated," it's quite the opposite - that 94 percent of births are over-managed, which has completely skewed our idea of what "complicated" means. In other words, that we're treating it as an accident waiting to happen and sometimes creating or precipitating that accident in the process.

As a result of this little experiment, surprised nurses reported their findings back to the charge nurse and hospital officials - who were relatively blase´ about the whole thing. The hospital's lack of action spoke louder than words: "this is not the way we do things because it doesn't make us money." You can't bill a patient for an induction, Pitocin, epidural and cesarean if she doesn't have those things, instead laboring naturally at home and letting her labor unfold by itself, with little to no interventions. Because Mother Nature is completely free - and perhaps not quite as flawed as they want us to believe. Technology can be very useful and life-saving, but only when used appropriately and wisely.

For a number of reasons, including what Lethbridge felt were safety concerns as well as the hospital's lack of support of normal, physiological birth, she quit her job - mostly precipitated by what she saw in women during Hurricane Charley. Within the year, many of the nurses she worked with left their jobs as well, perhaps completely jaded by the system. I don't blame them.

Pushed: The Painful Truth about Childbirth and Modern Maternity Care - Jennifer Block
Why You Need Pitocin in Labor

The "Truth" about Pelvic Organ Prolapse

I'm not a Dr. Oz fan, but couldn't help noticing that he was talking about something not many women like to discuss: pelvic organ prolapse. I also was intrigued not only because of my birth nerdiness, but because I share some of these complaints and wondered: does anybody else?

Supposedly the "last taboo topic" in gynecology (nah, I think that'd be having a homebirth) I was curious, because I too was hesitant to talk about it. With strangers, sure; but friends - I wasn't really anxious to share that info with people I went to high school with (which is why I don't advertise my blog around casual acquaintances - I really don't want them knowing the intimate state of my vagina.)

Anyway, Dr. Oz revealed just how common pelvic prolapse - when your reproductive organs come out through the vagina - really is. The crowd was hushed as women in many age groups looked like they were hanging on to the edge of their seats. We all cruise through the female incontinence aisles at the grocery store (on our way to somewhere else, right?) and know those problems exist, and that they're actually pretty common. (There's even an entire company devoted to sending you your incontinence products, in discreet packaging directly to your house, so as to avoid being spotted at the grocery store.)

The primary risk factors are childbirth (especially after having several children), weight, and age. The problem is, Dr. Oz - and pretty much everyone else outside the birth advocacy circle - don't tell you that how you give birth can impact your risk factors.

If there's one thing I'd like to change about my vaginal birth, it's directed pushing. As one article on Dr. Oz's website said, "You take a genetic predisposition, a 9 pound baby, and three hours of pushing" and it's not a wonder we have these problems.

Back up a minute.

Three hours of pushing - even the one hour and ten minutes I pushed - is probably more common than it should be in hospitals. From my experience, I know I had absolutely no desire to push. Laboring down was not an option, and I wish I knew better to just wait for my body to do it on its own. Even if you were knocked unconscious, your body would still involuntarily contract and push that baby out on its own, but who has time for that anymore? It's rush rush rush to get the baby out (even in the absence of problems) and move on to someone else.

Consider what happens when you're constipated and trying to have a bowel movement. Pushing and straining - much like during childbirth - are probably going to do little more than produce a wicked case of hemmorhoids and even rectal bleeding. But if you wait until you have the urge (which is involuntary, much like pushing out a baby) it's a lot easier with a lot less work. So even though I personally detest the phrase 'it's like taking the biggest crap of your life' to describe childbirth, in some ways it can be compared, yes.

In the process of laboring down, the body can actually stop the labor process altogether, sort of as a last-ditch effort to conserve energy for the big event. And like a bowel movement, most women describe the urge to push as uncontrollable and something they just had to do. Unfortunately, I have never experienced that feeling, the feeling of knowing my body is doing something on its own volition because that's what it's supposed to do - not push a baby out at lightning speed just because somebody told me to.

In reading about the subject, some physicians simply blame childbirth in and of itself for prolapse, while others say traumatic childbirth is a cause. I'm not sure women realize there is any other kind, which is sad. Things like cord traction - literally pulling on the cord to get the placenta to detach from the uterine wall - is another risk factor. Forceps deliveries, episiotomies (again, largely unnecessary but done anyway) and prolonged, directed pushing are other causes, and yet all are considered standard procedure in many labor and delivery wards. In other words, we've experienced this crap for so long that we don't even know it's the cause - and that it's not really as normal as we think it is. We're normalizing the abnormal.

Many times, in an effort to avoid postpartum hemmorhaging after birth, they use cord traction to avoid a "retained placenta" - and cause even more bleeding as a result.

"Retained placenta" is another term I have a problem with. While the standard seems to be around 30 minutes after birth, it seems that, like everything else, it's different for everyone. While I'm obviously not an expert, I'd guess that in the absence of bleeding - and with the presence of breastfeeding right away - leaving it more than half an hour is probably okay. When I did some quick searching on it, I found several who said an hour, two hours - even 30 hours - and she lived to tell the tale. *gasp!*

More often than not it seems doctors are too quick to expect the placenta to come out and rush it with cord traction, which is often quite painful and dangerous if too much force is applied. I've also talked with people who agree their doctor was way too eager to detach the placenta and literally yanked on it - which can cause the very complications you're supposed to be preventing.

One study has shown that injections of oxytocin into the umbilical cord vein does not decrease the need for manual placenta removal; however, you're back to that murky definition of 'retained placenta' again. According to the article, retained placenta is more likely to happen to women in "wealthier nations." Not surprisingly, the study found that among women in the UK, Uganda and Pakistan, the women in the UK were more likely to have a retained placenta:

The researchers also found that the need for manual removal was higher in the United Kingdom (69 percent) than in Pakistan (62 percent) or Uganda (47 percent).

Many are quick to point out how dangerous it is to give birth in third-world nations like Pakistan and Uganda. While there is no doubt some truth to that, giving birth with overloads of obstetrical interventions - like in the UK - is probably just as bad. (Side note: not surprisingly, Uganda is the only nation of the three that doesn't have a relatively low rate of breastfeeding, which is often a good way to encourage the placenta to detach by itself. Incidentally, the CDC has determined that most US hospitals are severely lacking in their breastfeeding support, which could be further contributing to this problem. Add to that the frequent, often prolonged separation of mother and baby immediately following birth and it could add to further reliance on active management of the third stage of labor.)

Ironically, many in the UK scratch their hands and wonder why women in the UK are experiencing this problem, despite having access to all the best care and resources. Dr. Andrew D. Weeks of the University of Liverpool thinks prolonged cord traction might be an issue. Ya think?

Some sites list things like "unusually large babies" as a cause - perhaps it's more the interventions perceived as necessary in delivering that "large" child (and the idea that everyone has a different definition of what a large baby really is) that are key here. It's not uncommon for someone to have a very actively managed labor with a larger baby that results in significant trauma to the pelvic floor. Conversely, we hear of many women successfully delivering bigger babies with little if any tearing - which can depend on the birth setting. (Home birth? Natural hospital birth?) and the attendant (midwife vs. doctor? Someone who is more pro-natural birth?)

Sadly, doctors like Dr. Oz and urologist Jennifer Berman might hand out less-than-helpful advice because they've never actually seen a normal birth in progress. They often see the end result of years worth of obstetrical manipulation and intervention and chalk it up to just plain old childbirth itself, perhaps recommending an elective cesarean to avoid all that damage (even though studies have shown it doesn't). Yes, some women will be prone to this - for a number of factors besides childbearing - despite having an intervention-free birth. Some women get it and they've never even given birth. But until you can compare what often is and what could be, you have no real idea that the process is totally tampered with.

In doing some reading, I came across a very sad post by a nurse who experienced a pretty difficult birth, no doubt precipitated by the fact that she was induced at 37 weeks. The baby sounds like it just wasn't ready, but doctors attempted every means possible to get that child to come out, resulting in some nasty-sounding results. She wondered if she had a case against them because of everything she went through.

Some of the answers she got were quite shocking. Daring to call the normal 'abnormal,' she got berated, told she was a liar, and that what she went through didn't happen as she said it did. She was told that "controlled cord traction" was basically no big deal and an "acceptable practice." Maybe so, but it shouldn't be, especially in the absence of other complications. In the end, another forum user piped up and said "You think you had it bad??" as it to get into a virtual pissing contest about who could tell the most Horrible Birth Story Ever. I felt sad for the woman, not only because these women attacked her for questioning the status quo, but because they echoed what our legal system tells us: that unless you have something permanently wrong with either you or the baby, that you should just shut up and get over it.

After seeing some of the audience members on Dr. Oz's show, you realize that women have basically been giving birth violently for decades, perhaps even more than a century. I didn't see any hippie mamas standing up in the audience saying, "Well, I had a natural home birth and mother-led pushing in any position I wanted to, so I don't have that problem." She'd probably be stoned to death if she did. That, and the number of what we could call near-failed inductions - those where a vaginal birth happens but I'm not sure I'd call it successful, exactly - probably means more women are continuing to suffer.

While Dr. Oz's segment was titled "Suffering in Silence: The Shame of Pelvic Prolapse," I really think the people who should be feeling shame are those who insist on continuing these practices even though it's not in the best interests of their patients.

More reading:
Diagnosis and management of retained placenta after vaginal birth - Dr. Andrew Weeks talks about the risks and complications of retained placenta, but admits:

There is no consensus worldwide as to the length of the third stage after which a placenta should be termed "retained" and intervention initiated.

Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial - This study suggests the use of CCT is beneficial and says that a continuous infusion of oxytocin were given to each patient after delivery of the placenta. I'm curious, though, what percentage of mothers breastfed immediately after birth, and how long were their placentas retained before someone decided to manually remove it?

Controlled Cord Traction During Third Stage of Labor - This study seems to contradict what the previous one said, in that

"Controlled cord traction (CCT) is actively promoted in combination with prophylactic uterotonics for the prevention of PPH. While the administration of uterotonics has been proven effective, there is no evidence of CCT being beneficial or safe. 

The purpose of the study was to determine: 

1. In women having term, single vaginal deliveries in hospital settings, in whom the third stage is managed with prophylactic oxytocin, does CCT produce a clinically significant reduction in the incidence of postpartum blood lose? (sic)
2. In these women, does CCT produce a clinically significant increase in the incidence of severe complications, including uterine inversion or the need for subsequent surgical evacuation of retained placental tissues and membranes (curettage or manual removal)?

Injections Aren't Solution for Retained Placenta: Study - ABC News
Management of the Third Stage of Labor - Medscape

The third stage of labor refers to the period following the completed delivery of the newborn until the completed delivery of the placenta. Relatively little thought or teaching seems to be devoted to the third stage of labor compared with that given to the first and second stages. A leading North American obstetrics text devotes only 4 of more than 1500 pages to the third stage of labor but significantly more to the complications that may arise immediately following delivery.^[1] One respected author states: "This indeed is the unforgiving stage of labor, and in it there lurks more unheralded treachery than in both the other stages combined. The normal case can, within a minute, become abnormal and successful delivery can turn swiftly to disaster."

While that may be true to some extent, why do our bodies have these built-in mechanisms to aid this natural, physiologic process?
Postpartum Hemorrhage - Wikipedia 

A Cochrane database study^[5] suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) of the third stage of labour reduces severe maternal bleeding and anemia compared to expectant management. However, the review also found that active management reduced the baby’s birthweight and increased the mother's blood pressure, afterpains, nausea, vomiting, and use of drugs for pain relief. The number of women returning to hospital with bleeding also increased. Another Cochrane database study^[6], focusing specifically on the timing of the administration of the uterotonic drug oxytocin as part of the active management of the third stage of labour, suggested that administering the drug before the expulsion of the placenta did not have any significant influence on the incidence of postpartum hemorrhage when compared to administering the drug after the expulsion of the placenta.

 Eight Ways to Avoid Pitocin in Labor and Why You Should - Birth Sense blog 

Always the pessimist

"We HAVE to do this
stuff to you because you
just MIGHT die during
childbirth. It's VERY
dangerous, you know!"

It seems that as pregnant women, we spend a lot of time worrying about things that might never happen. We're treated as fragile time bombs waiting to explode, and every medical test and ultrasound imaginable is ordered "just in case." (Conversely, it seems that when mom is truly worried about something happening and shows significant signs and symptoms, she's pretty much ignored.) Such is our climate of "fear-based obstetrics," where risk can be assessed in a nice, neat little box.

I've decided that in obstetrics - really, in most medical fields - our doctors are often very pessimistic. Classic examples include:

• "Well, your baby might get too big, so we'd better induce now." I didn't know that ultrasound machine was also doing double duty as a crystal ball!

• "You will not be able to birth a baby over 8 pounds." Really? How do you know? As our mothers always told us, "You never know until you try."

• "If you attempt a VBAC, you just might have to have a cesarean anyway." What a vote of confidence. When "attempting" a VBAC, women need to know accurate statistics so they can mentally prepare themselves, because nothing shoots down your plans more than being told there is a such-and-such rate of "failure." Just the way they word it, it makes it sound like few women are lucky to succeed (probably because few women are even allowed to) and the rest spontaneously explode. Technically, I had one failed VBAC attempt, because my baby was in an unfavorable position upon delivery - BUT I labored well and without pain medication on my own up until being prepped for surgery.

• "You better supplement with formula, just in case." Someone might have told you your nipples were too big, too small, or that "You'll never..." this that and the other just based on your physical appearance, which is obviously a load of garbage. Just because a certain percentage of women come in to their hospital and then don't nurse doesn't mean you won't - and who would want to with breastfeeding "support" like that?!

• "You should get the epidural since you'll never be able to have a baby without one." Again, that old "You never know until you try" adage. If more women knew how to cope with labor pain, and that many hospital policies actually make your pain greater, they might think differently about it. And if you're a first-time mom (and even if you aren't), you might find that it's really not as painful as everyone made it out to be.

• You're considered high-risk  just because you're 35. Never mind if you are healthy, active, don't smoke or drink and are in excellent shape. Just your age can mean - gasp! - that you're perceived as broken and treated like you'll never, ever get pregnant or that it will take you years. Once you reach that "magic" age you'll probably be bullied into more and more invasive tests (I know I was) even though you are healthy and have no other problems. Sure, certain risk factors increase with age, but that doesn't mean it's a given. Certain procedures such as amniocentesis carry more immediate risks to the baby than just having the baby already, so many women might be better off forgoing it altogether - but that's your decision.

Speaking of which, I recently read about "Kate Middleton's pregnancy plans" now that she and Prince William were married. The doctor basically says that they're not getting any younger, and now is the "perfect time" to start a family since she is approaching her 30s. He then went on to outline the "possibilities" of what can happen if women wait too long to get pregnant, including old eggs and lack of cervical fluid.

We don't know what Kate's "pregnancy plan" is or even if she has one. Technically speaking, it's none of our business. Who knows - she might have three sets of triplets before she turns 35. Who cares?!

• "Birth is the most dangerous thing a woman can do and is like an accident waiting to happen!" This is sort of the all-encompassing thought process of the majority of OBs. Do we walk around in a body cast just in case we get in an accident? No. How about driving in cars, going to the mailbox to check our mail, just living our lives? We do that every day - no problem. If a problem arises, monitor it and if necessary, treat it - but otherwise leave me alone. More interventions to head off potential "problems" often only end up creating more problems in the end!

You may have risk factors, but does that mean it's going to happen? Should you be treated like it's already happening even when it isn't? Nope!

And if it were really as dangerous as they say, then where are all these babies coming from?

More reading:
"Childbirth is one of the most dangerous things a woman can do today" - My OB Said What?!
Mama Birth: Your care provider is psychic! 
A Better Beginning with Natural Childbirth: Munchausen Obstetrics (scroll down)

Seeing dollar $igns

With all this talk about President Obama raising the "debt ceiling," you have to wonder where the spending cuts are being made (or if they're being made). Politics aside, I can't help but think of one way the government could definitely save money: reduce the cesarean rate.

It's estimated that the US could save $3.5 billion a year in healthcare costs if the number of medically unnecessary cesareans were reduced. I don't know if that's just for the surgery alone, so perhaps the figure is much higher when you account for everything that takes place up to the cesarean. Think about the way a typical birth unfolds in the US:
• Mom is approaching 39 weeks in an otherwise normal pregnancy. Since her doctor is telling her it's "dangerous" to go past her due date, she decides to go ahead with an induction. After numerous doses of Cervidil and Pitocin, her labor finally starts, but is slow and very painful. Perhaps pain relief from the epidural is spotty, or they just need to keep giving her boluses because her labor is so long. They finally agree to do a cesarean for fetal distress. After birth, they decide the newborn must spend time in the NICU because her dates were off and the baby is showing signs of prematurity. He spends a week in the NICU and then goes home. Oh, did we mention this mom was giving birth in a military hospital? 
• The mother has already had a prior cesarean, and is scheduled to have another "elective" repeat cesarean. 


(This is just based on some of the stories I hear from mothers. While it obviously doesn't always go this way, it's not that uncommon, either.) 

While it's been said that Medicaid won't pay for unnecessary cesareans, I'm sure they can find other reasons to do them. When you don't even know what constitutes "necessary" anymore, it's probably not all that hard.

As of 2009, certain states were working hard to eliminate any financial incentives for doing cesareans. Washington State was one of them, and saw a 14-48 percent c-section rate, which obviously alarmed some. Before the policy change:

On average, Medicaid pays $5,000 more for a C-section than for a vaginal birth, and private insurance pays a far greater premium. You don’t have to be a cynic to wonder if that could have something to do with the rise in unnecessary C-sections.

Because of that lack of incentive, there is probably more accountability when you are receiving money from a government agency. I won't say there still isn't some form of fraud going on, but it's no doubt easier to get away with if your patient is privately insured. Additional health care costs probably come from extra items tacked onto your bill. Didn't receive an epidural but it's on your bill? Your health insurance company will probably pay for it anyway, even though you've called to complain. One West Virginia OB faces up to 340 years in prison for her part in billing patients for things they never received. Those little "extras" can really add up.

Statistics have also shown that you are more likely to get a cesarean if you give birth in a for-profit hospital than a non-profit one. They have to make their money somehow, right?

While it's glaringly obvious, at least to birth advocates and those who simply want a choice in their births, lowering healthcare costs in this way would require the obstetrical community to basically change the way they practice medicine, which I don't think is going to happen anytime too soon. Our health care industry is increasingly moving away from focusing on the patient and rather seeing dollar signs every time you hop up onto the exam table, for a number of reasons. They have to make their time "worth it," both because of their own personal pursuits and because of rising insurance costs for them that otherwise wouldn't justify them continuing to practice medicine. You are just the little fish - albeit probably one of the most important ones - in the food chain.

More reading:
Take away the incentives for too many c-sections - Crosscut Seattle
"Whatever you try is just going to end in a cesarean section" - My OB Said What?!
"If a baby hasn't engaged by 37 weeks, we need to do a cesarean section" - "My OB Said What?! (same doctor)
Should OBs be investigated for insurance fraud? 
All about the Benjamins? TennCare's call for lower cesarean rates - The Unnecesarean 

The $64,000 question: Why do you "need" Pitocin in labor?

Photo credit: Brian Hoskins

A few months ago I posted this article from a labor and delivery nurse who admitted the real reason why you "need" Pitocin: to free up hospital beds. Over 200 people shared it, and I don't think many people were happy about her piece. When this article was posted on the mothering.com forums, it got the discussion thread shut down. So I guess Nurse Jenna created quite a stir!

I reposted this article on FaceBook yesterday and have been thinking about it ever since. The use of the word "need" irritates most people, including me. But there were some other things that set me off.

It underscores, among other things, the absolute garbage medical practices that pervade in obstetrics that not only put mom at unnecessary risk, but her baby as well. What Nurse Jenna's article does is unintentionally admit that often the best interests of both mom and baby are not in the forefront. In the very opening paragraph of her article, she sets a rather condescending tone:

Many women come to labor and delivery fearing Pitocin, loathing Pitocin, and swearing up and down that “over their dead body” will they have Pitocin to augment their labor.

Truth be told, if anyone knows how miserable Pitocin can be, they've probably heard it from other women who have been there, done that. This winter my niece was facing a (basically unnecessary) induction and everyone on her FaceBook were telling her to "avoid the Pit! It's miserable! You'll hate it! Don't do it!" You would have thought she was contemplating suicide, their tone was so adamant. Did she listen? Nope. (Because, after all, we were a bunch of "uneducated women" and her doctor "knew best.") She ended up getting induced and having a horrible labor, although I still haven't heard the details and am not sure I really want to.

Nurse Jenna sort of tries to absolve the doctors and nurses of their guilt over improperly administering Pit by taking the "blame the mother" approach: moms don't stay home long enough, want pain medication in early labor, and in the comments section, moms "insist" on being admitted before they're actively laboring. No where does she really say that doctors are doing it all wrong, but rather, "We want the mother to stay home as long as possible." She mentions how "we" want you to labor comfortably at home in the early stages, where you have access to food and fluids, supportive family members, a bathtub, etc. Seriously?! (Because we all know that once you enter the hospital, all of those things are often restricted to you, even though they can help progress your labor tremendously.)

While I agree that staying home until you no longer feel comfortable is the best idea, a) this seems to contradict what hospital staff often tell us and b) it doesn't necessarily mean you won't be given Pitocin, regardless of whether you need it or not. According to Dr. Roberto Caldreyo-Barcia, former president of the International Federation of Obstetricians and Gynecologists, "Pitocin is the most abused drug in the world today."

Because there is such widespread misuse and abuse, patients often think it's totally normal. Few are going to tell you "Hey, you don't really need this stuff, you know. You can refuse," and instead make you feel like the bad guy if you don't do it. Your baby is the weapon of choice against you, and a powerful one at that. Nurse Jenna's article also highlights how trusting some are of the medical profession and just put everything in the doctor's hands. Many mothers, especially first-timers with no prior experience, will take their doctor's advice as the gospel and comply, even if it goes against their better judgment or wishes. They don't want to be seen as difficult, and if you appear to be questioning your doctor's judgment it could be a long haul for you as the patient. Of course she doesn't mention fetal distress, the rising rate of cesareans and how induction can contribute to that, especially in first-time mothers. And the idea that, even in a woman who is laboring well on her own, maybe with an irregular pattern of contractions (or not even) you might still stand a good chance of getting it. I wonder if this is less about freeing up beds and more about "Ok, let's get it over with so we can move on to something else."

(Case in point: my neighbor had her second child in May, this time going into labor on her own. Labor had slowed down, apparently, and her well-meaning mother-in-law told me that she was given Pit and "the baby was born 20 minutes later." What?!)

Nurse Jenna's post illustrates the problem our maternity industry has in general: more beds are needed, so let's rush things along over here to make room over there. That is not good medicine, and treats the patient like a number or as if they're giving birth on an assembly line. (Which explains why some maternity units are unaffectionately called "baby factories.") How many women do not even get to this point because their due date falls near a holiday, someone's vacation or other important event? People have criticized the idea that "OB's golf, so they need to induce you so they can be there for tee off." Maybe not golf, but the idea that they do not want to be "waiting around all day/all night for you to deliver" is pervasive, so don't kid yourself. The days of your OB rushing in at 11:30 at night in a tux (like my mom's OB did in delivering me) are long over.

While Nurse Jenna blames mothers on "insisting" they be admitted early, I wonder how common this is. It seems more commonplace to keep mothers who should be sent away because you'll simply Pit them into oblivion. I've also read accounts where they aren't "allowed" to go home, even though they want to. Staying home longer is probably key in reducing your risk of getting Pit, but how many of us have heard, "Well, you don't want to deliver in the backseat of your car/on the toilet/in a public place, now do you?" Many women who are in the advanced stages of dilation but not in active labor are sent directly over to the L&D unit ("Do not pass go, do not collect $200!") to be induced when they don't even want to be, including a woman commenting on Nurse Jenna's post. Just because you're 4 cm doesn't mean "it's time," and even though it's not what mom wants, she somehow feels compelled to cave, often because of pressure from her physician.

I'm sure doctors and nurses grow increasingly frustrated at patients who know little and "insist" on care they think they should be receiving, when really, there is an alternative. Instead of accusing, though, healthcare providers should be informing, and telling patients why you should go home - but I think that would reveal other faults on behalf of the hospital and they're not willing to admit to unnecessarily aggressive induction practices. Conversely, it seems that if you know too much - enough to question and refuse - you're treated like crap then, too.

More women probably stay because they don't realize they have a choice, rather than because they "insist." In my time both as a hospital employee and a patient in L&D, I have never witnessed a mother becoming belligerent because she can't stay. And never, in all my talks with mothers, have I heard someone say "I insisted on staying in the hospital because they were threatening to send me home!" Usually, mom thinks there's something going on, hospital staff say no, and she's sent home, tail between her legs. (Yet all the while with the threat of "You don't want to give birth in the car!" hovering in the back of her mind, right?)

Basically, Nurse Jenna is part of the greater conundrum of "modern" obstetrics: don't stay home too long, don't get here too early. If you want to walk, stay home (one L&D nurse's comment). If you walk while in the hospital, it means you can't be hooked up to monitors and machines, but it could progress your labor - but still, don't walk. If you get here too early, going home is not an option anymore. If you labor at home, you'll be punished for not seeking medical 'care.' If you come to the hospital too early, you'll be punished for seeking medical 'care.' So deal with it. Either way, you can do nothing right and it's your fault. 

Some of the comments on Nurse Jenna's article are interesting, and very telling:

The pitocin seriously made me want to kill myself, even after having the epidural.  It truly was awful.

Unfortunately this woman had come in for induction because her baby had died. After 30 hours of hell, she ended up with a cesarean. (!?)

A failed induction, but hey, thank God for the Pitocin!

i had come in for an induction and had pitocin to get things moving faster the next morning...i didnt care, im not that anal about stuff like that! i know there were other women that needed a bed too! and i am grateful for the pitocin post-delivery/csection to help my uterus contract.. 

At 4 cm but not in labor yet? Who cares! Let's just induce!

I got to the hospital at 4cm, but would have much rather still been at home.  I had a severe headache, and dizzyness, and called the dr's office and they sent me in to have my blood pressure checked.  I wish they would have let me go back home since my blood pressure was fine (I only live 5 mins away), but instead once they checked me and I was a 4, they called the dr., and he decided to just come break my water.  I was so frustrated, because he broke my water and started pitocin and the contractions practically stopped for about 3 hours.  But I could get up or anything since they'd already broken my water.  I was so irritated because it was not my choice to go to the hospital yet.

One commenter kind of blows Nurse Jenna's argument out of the water, and probably many of us can agree:

I certainly was told about "Pitocin-passing" by a nurse.  I was in a car accident when I was 24 weeks pregnant and moving to a new city.  While they monitored my contractions in the hospital I had a great chat with a nurse who gave me the low down.  When I told her I wanted a completely drug free birth she told me which hospital to avoid (named the baby machine hospital because they do so many births and regulate with Pitocin) and which drs. would be sympathetic to a drug free delivery. 

And probably the best comment EVER:

Who is we? The God's of the delivery room? NATURE decides when the baby will come! I'm glad I was informed and confident in my birth not to let a dumbass like you [be] in control! 

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