Sunday, January 31, 2010

Healthy Birth Practices: Avoid Unnecessary Interventions

We've been doing an ongoing series about the Six Lamaze Healthy Birth Practices, why they are helpful, why they tend to be used less with women of size, and how that negatively affects births in this group in particular.

The previous Health Birth Practices we've already discussed were:
  1. Let Labor Begin On Its Own
  2. Walk, Move Around, and Change Positions During Birth
  3. Bring a Loved One, Friend, or Doula for Continuous Support
The Healthy Birth Practice to be discussed this time is:

4. Avoid unnecessary interventions

As one study puts it:
In the last 50 years, a rapid increase in the use of technology to start, augment, accelerate, regulate and monitor the process of birth has frequently led to the adoption of inadequate, unnecessary and sometimes dangerous interventions.
"Pushed Births" Are The Norm Now

The typical hospital birth in the USA (and many other Western countries) involves a great deal of intervention. In fact, it is an extremely rare hospital birth these days that does not involve any intervention at all. But is all this intervention a good idea?

Jennifer Block calls overly interventive births "Pushed Births" in her book, Pushed. (If you are thinking about having a baby, you should definitely read this book!)

Here's her summary of what a "pushed birth" is:
A pushed birth is one that is induced, sped up, and/or heavily medicated for no good reason, and all too often concludes with surgery, invasive instruments, an episiotomy, or a bad vaginal tear---outcomes you don't want. Decades of research show that the healthiest birth for you and your baby...is a normal, vaginal birth with minimal intervention and maximum support.
How often are these interventions "pushed"? Merging a quote from the publisher's blurb on Jennifer's book with one from her website:
In the United States, more than half the women who give birth are given drugs to induce or speed up labor; for nearly a third of mothers, childbirth is major surgery---the cesarean section.

1 in 3 vaginal birthers get an episiotomy — surgical scissors cutting your vagina. And most women will put their pelvic floors at risk by lying in a bed throughout labor and pushing the baby out while while flat on their back.

Why? Because most L&D wards aren’t following best practices.
Women's bodies have developed to birth optimally over thousands of years. There is a process of labor that is meant to happen biologically, and when undisturbed, usually happens very well.

Of course, nature isn't perfect and "natural" isn't always better; sometimes things do go wrong, and thank goodness for intervention when that does happen. No one is arguing for no intervention.

But routinely intervening in a natural process often causes unforseen consequences. Sometimes you pay an unexpected price...and most doctors are greatly underestimating the price of the routine interventions they use.

About 1 in 3 women in the USA today have their babies surgically. Some cesareans are medically necessary, but a 30%+ rate is causing far more harm than good. In some states (see page 14), the cesarean rate is near 40%; in some cities and in Puerto Rico, the rate is nearer to 50%. In a few hospitals, the cesarean rate is nearer an astounding 70%.

Even when women have a vaginal birth, about a third will have an episiotomy, according to Block's book; the numbers are far higher in some third-world countries. Episiotomy (plus its repair) is yet another form of surgery. It can have huge effects on women's quality of life too.

Inductions, augmentations, breaking the waters, continuous electronic fetal monitoring, epidurals, IV drips, and urinary catheters are other commonly-used interventions. Again, each has a place and can be useful at times, but routinely used in most women, the cumulative harm can be significant as well.

A Human Rights and Women's Rights Issue Too

"Pushed" births are not just a medical issue, they are also a women's rights and a human rights issue.

Ideally, women are given informed consent about interventions, and their choices are honored. Sometimes that does happen; some hospitals and care providers do well in honoring women's decisions. And some women do choose interventions, which is completely their right.

However, far too often women's decisions are not honored, and their choices are taken from them. Sometimes women are literally bulled into interventions with threats; more often they are seduced into them with misleading information or scare tactics.

Talking people into potentially harmful interventions without fully informed consent and the freedom to refuse the intervention is a human rights violation. Everyone has the right to bodily integrity and to informed decision-making. No one should be able to take that right from you.

The fact that strong-arm interventions are so common in the obstetrics field on childbearing women makes it a women's rights issue as well.

Violence and intimidation against women does not just occur via domestic violence or rape. Unfortunately, it also happens during childbearing, but our society does not view it as an abuse of rights.

It's time to see unnecessary and coercive interventions as the human rights and women's rights violation that they are.

How Common Are Interventions?

It is a rare woman who births in a hospital and is not subject to at least one or more of the following interventions. Some interventions are more risky than others, of course, but all carry some risk of complications.

It is difficult to know exactly how often these interventions are used across the U.S.A.; the CDC collects data only on select interventions. The following figures represent intervention rates from the Listening To Mothers II survey from the Childbirth Connection.

[Remember that rates of interventions vary significantly from area to area, from doctor to doctor, and from facility to facility. The rate of interventions in your area may be higher or lower than these, but this is a good way to get a "snapshot" idea of intervention rates happening today.]

Induction

More and more women today have their labors induced artificially instead of being allowed to start labor on their own. In the LTMII study, 41% of mothers reported induction attempts by a caregiver. That's nearly half of mothers being subjected to the risks of induction.

Labor Augmentation

Even when they go into labor on their own, many women's labors are strengthened or speeded up artificially ("augmented") with synthetic pitocin. In the LTMII study, 47% of women received pitocin to speed up labor.

Many hospitals routinely augment virtually all women, across the board, as their standard of care. They find that this speeds up labor and gets the doctors home faster, but such convenience for the providers comes at a price for the mother, because induced and augmented labors are much more painful and mothers request pain meds at higher rates. They can also cause fetal distress and necessitate a cesarean.

Artificial Rupture of Membranes

Most women also have their water broken artificially at some point. Ostensibly this can speed up labor slightly, but it can also have risks (see the next section). In the LTMII survey, 47% of mothers had their waters broken artificially after labor began.

Epidural or Spinal Analgesia

Many women choose to have an epidural for pain relief during labor. This is their right and no one should be made to feel guilty for choosing it.

However, many women who do not want to have an epidural are strongly pressured by staff to have one during labor so that they are quieter and less demanding as patients.

Other women would like to go natural but find that they cannot handle the pain of induced or augmented labor without help. As is so common, one intervention often leads to another, each with accumulating risks.

In the LTMII study, 76% of women had epidural or spinal analgesia.

Urinary Catheters, IV Drips

In the LTMII survey, 56% had a urinary catheter at some point, and 83% had an IV drip. This makes it difficult to move around freely and basically tethers most women into bed, flat on their backs or sides. This makes it difficult to cope with the pain of labor and makes it difficult for women to maneuver to get the baby out most efficiently.

Electronic Fetal Monitoring

In the LTMII survey, 94% of mothers had Electronic Fetal Monitoring (EFM). This is alarming because EFM is a classic case of an intervention that has little benefit in normal labor, and clear evidence of significant harm.

As Dr. Christiane Northrup, OB-GYN, says in her recent Huffington Post article, Reclaim Your Right To Birth Right:


Data indicates that the only thing EFM has done reliably is increase the rate of Cesarean section (C-section) births.
Episiotomies

For years, episiotomies were used routinely on nearly all birthing women. Doctors did them to get babies out faster (in the days when all birthing women were heavily drugged and tied down) and because they thought that a straight surgical cut would heal better than a jagged tear.

However, research has since shown that routine episiotomies in fact cause great harm. In most cases, women tear far more seriously after an episiotomy, sometimes all the way from the vagina into the rectum. Most of the time, women fare better if an episiotomy is not done, because any tears that do occur are usually small and heal better than a surgical cut.

Yet in the LTMII study, 25% of women who birthed vaginally still experienced an episiotomy.

Cesarean Sections

In the LTMII survey, 1 in 3 women experienced a cesarean section, in line with the U.S. national cesarean rate.

More than three-quarters of c-section mothers in the survey reported pain at the site of the incision 2 months after birth, and 33% cited this pain as a major problem. 18% had ongoing pain at the scar at least 6 months after giving birth.

For many women, a cesarean section is hardly the routine and easy operation that it is usually portrayed to be.

The Road to Hell is Paved With Good Intentions

Most doctors think they are doing well by women when they employ their interventions.

Used when truly needed, they probably are helping. However, time after time, research has shown that routine use of interventions tends to worsen outcome, not improve it.

It's time to trust women's bodies to work well. It's time to trust the birth process that has evolved over thousands of years to work well.

It's okay to have interventions available, on reserve, so that in the small percentage of cases where something does go wrong, outcomes can be improved. But it's time to stop utilizing them routinely, across the board, for most women.

As the Healthy Birth Practices Care Practice Paper notes:
In many hospitals, obstetric interventions such as restrictions on eating and/or drinking, intravenous lines, electronic fetal monitoring, augmentation (speeding up labor), and epidural analgesia are used routinely on all women, even without a specific medical reason, "just in case"....

These interventions, when used routinely, have unintended consequences that ultimately increase risk for mothers and babies. The routine use of these interventions does not make birth safer for women and babies. In fact, unless there is a clear medical reason for the use of technology or other interventions, interfering with the natural process of labor and birth is not likely to be beneficial and actually may be harmful.

It is safer and healthier to allow labor to unfold and not to interfere in any way with the natural process, unless there is a clear medical indication to do so.
Common Interventions in Women of Size

Women of size are often subjected to an even higher rate of interventions than women of average size.

Sometimes these interventions are necessary but often they spring from the belief that the bodies of women of size are defective and cannot/will not labor and birth "properly."

Even many birth attendants who otherwise belive in natural birth do not believe that a fat woman's body can birth properly. Therefore, it can be difficult for women of size to find a truly non-interventive birth attendant, even in the "alternative" birth community. Even there, a number of care providers utilize or promote interventions like these for women of size.

Inductions

We've already
discussed how labor is artifically started (induced) in women of size more often than in women of average size, and how induction raises the cesarean rate compared to spontaneous labor.

A high induction rate is probably one of the most significant factors in the extremely high cesarean rate seen in "obese" women in modern obstetrics.

It also probably leads to many problems with their babies after birth. One Welsh study found that induction was the beginning of many problems in the babies of "obese" women. The logical conclusion to this (but one ignored by the study) is
maybe we shouldn't be inducing this group so frequently!

Aggressive Augmentation of Labor for "Dystocia"

Even when labor starts on its own, many women of size in the hospital have their contractions augmented with artificial labor drugs and their bag of waters broken early. They often have these interventions at
increased rates compared to women of average size.

This is because "obese" women are generally seen as having slower, more ineffective labors, so the need for labor augmentation is anticipated in this group and often initiated extra early.

Of course,
some research does show that women of size do have slower labors on average, but usually, all that's needed for this is a liberal tincture of patience, not an automatic initiation of early labor augmentation. Immersion in water can also be effective at helping speed up labor without use of automatic interventions like augmentation or breaking the waters.

Furthermore, the rate of malpositions like occiput posterior may be
higher in women of size, and malpositions are known to slow the progress of labor. Instead of automatically breaking the waters or augmenting labor, it may be more effective to investigate proactive repositioning of the baby instead. One recent study on manually turning posterior babies showed that proative repositioning of the baby lowered the cesarean rate from 34% to 2%.

Being more proactive about fetal position might help avoid the unnecessary use of interventions in women of size, and lower the cesarean rate to boot.

Internal Monitors

Because electronic fetal monitoring can be more difficult in "obese" women, a
higher rate of internal monitors are used with women of size. Some hospitals even encourage early placement of internal fetal monitors in women of size.

But while this may help monitor the baby more easily than an external monitor, it also has drawbacks. Placing an internal monitor necessitates breaking the mother's bag of waters and that brings its own risks with it (see below). Prolonged use of internal monitors is also
associated with a higher risk for infection.

Breaking The Waters

Breaking the mother's waters (a.k.a. amniotomy or AROM), especially early in labor, places her at greater risk for
infection. Furthermore, breaking the water early in labor may also increase the risk of cesarean section and/or a diagnosis of fetal distress.

Yet the routine use of early amniotomy is often found in the labors of "obese" women.

Early Placement of Epidurals

Many hospitals encourage "obese" women to get early epidurals because of the difficulty placing them in women of size.

To be fair, epidurals are harder to place in women of size because they have more back fat and it can be difficult to predict just how far in the needle must go in order to get to the right space in the spine. Multiple tries are often needed to place epidurals properly in women of size.

Furthermore, women of size have a higher rate of cesareans as well, and many doctors see fat women as a cesarean waiting to happen --- or at least a case of fetal distress waiting to happen. Therefore, they often
recommend that obese women have an epidural placed early, before the hardest part of labor and before any emergencies occur.

If an emergency were to occur and they had to use general anesthesia, this presents a higher risk for complications, and especially so in the presence of obesity. So to avoid even the smallest possibility of needing to use general anesthesia in a fat person, they recommend drugging ALL fat women very early in labor, just as a precaution.

The problem is that placing an epidural early in women of size automatically starts restricting their movement and
may encourage a malpositioned baby. It may increase the risk for slow or non-progressive labors (labor dystocia). It definitely increases the risk for instrumental delivery (forceps or vacuum extraction), probably because of the malposition issue. And with forceps comes an increased rate of episiotomy, which increases the risk for severe perineal damage.

So the recommendation for routine across-the-board early epidural placement in "obese" women---while well-intentioned to prevent emergency general anesthesia (which is riskier in people of size)---may actually cause more harm than good.

Again, it subjects ALL "obese" women to a significant level of risk and further problems in order to try to avoid a rare complication that might occur only in a few.

An Alternative Approach To Preventing Labor Dystocia in Women of Size

Shields et al (
2007, Am Fam Physician), discussing women of all sizes, suggests that although augmentation of labor and other interventions have their place, prevention of operative delivery due to slow or obstructed labor may also need to be proactive:
Prevention of dystocia includes encouraging the use of trained labor support companions, deferring hospital admission until the active phase of labor when possible, avoiding elective labor induction before 41 weeks' gestation, and using epidural analgesia judiciously.
Unfortunately, most of these (avoiding induction, judicious instead of routine use of epidurals, and deferring hospital admission until the woman is well-established in labor) tend to be actively discouraged in management of women of size.

In women of size, many midwives find better results by:
  • Encouraging spontaneous labor
  • Encouraging laboring at home for as long as possible
  • Encouraging women of size to utilize water, upright positions, and mobility during labor
  • Leaving the waters intact whenever possible
  • Avoiding routine use of internal monitors or early epidurals
  • Applying a tincture of patience for longer labors
  • Being vigilant and proactive about fetal malpositions in labor
Research is urgently needed to prove which care protocols improve outcome in women of size and which harm it, but until that happens, the above model (which honors the innate wisdom of women's bodies----including fat women's bodes) should be the norm.

Following the physiologic model of birth, the one developed over thousands of years to be the most efficient for the most people, should be the norm for ALL women, including women of size. It is the intervention that should have to be proved to be of benefit and free from harm, not the physiologic model.


Women of size should not be automatically subjected to increased levels of interventions merely on the basis of their size. Many women of size have discovered that the natural process works for them too----if they are given a realistic chance at it.

Conclusion

Many interventions in childbirth can be life-saving. No one is saying that interventions should never be used. Clearly, in some situations, it is completely medically appropriate to use interventions, and at times, they can lower the cesarean rate or even save lives.

This is true for women of all sizes.

But just as clearly, some interventions are overused and present more risk than benefit. Sometimes they even cause great harm.

This is particularly true for women of size.

Today, more and more women are experiencing "pushed births" because such births are more convenient for care providers, provide more billable services (and profits) for hospitals, and are perceived as good "defensive" medicine to protect from legal liability. And women of size experience "pushed births" even more often.

"Pushed births" are better for hospitals and doctors and their bottom lines, but are they really better for mothers and babies?

As Maureen Corry, executive director of Childbirth Connection says:
The typical childbirth experience has been transformed into a morass of wires, tubes, machines and medications that leave healthy women immobilized, vulnerable to high levels of surgery and burdened with physical and emotional health concerns while caring for their newborns.
Here is the Lamaze/Injoy video about Avoiding Unnecessary Intervention. You can see birth practice papers (with research citations supporting their conclusions) here and videos discussing each of the Healthy Birth Practices here.



4 comments:

maggiemunkee said...

having done absolutely ZERO research into this, and being inspired by this entry, i have to wonder: has anyone done any research into the seeming correlation between the increasing use of birth interventions and the increase in autism? granted, correlation does not equal causation, but i still can't help but wonder...

Lori said...

Thank you for this series! I'm delivering in about six weeks, and it's been six years since I've given birth, so I'm trying to get myself prepared again!

When I had my son, I had a terrible time with my second stage of labor, and I still wonder how much of that was due to having my membranes ruptured. I got to about 6 cm extremely fast, and then my labor slowed considerably. When I was around 7 cm they didn't think I was progressing fast enough and broke my water, and from there things went REALLY fast. I think it was maybe an hour from that point until I was pushing. But I wonder if, because it came on so fast and hard, I ended up feeling the need to push faster than I should have, because it ended up taking me 4-1/2 hours actually push out my son. Now, granted, he had an enormous head (16" circumference) and it was my first time giving birth, but it still seemed like an awfully long and difficult process--even for labor!--and I do think that if I'd been left to progress on my own, it might have been less difficult.

Dionna @Code Name: Mama said...

In my research on the "routine" (and unnecessary) birth interventions, I was shocked and saddened by the numbers of women who have no idea that there are negative consequences to birthing with excess interventions. I wish more women would trust their bodies!
Great post!

labortrials said...

Great stuff as usual, Mama! I agree that "pushed" birth is the norm here in the states with "traditional" care. Even when you get very caring attentive prenatal care, you may still be at risk of having an interventive birth. In my town the OBs share call, so you never know who you're going to get. Scary!