What the Midwife Heard "I would like to share some comments overheard in the doctor’s lounge and at the nurse’s station over the last few days. I share these not to disparage physicians and nurses, but to help women understand that what you are hearing from your doctor’s lips very likely is not what he or she is saying behind your back."
The Food and Drug Administration and the Physician’s Desk Reference, the bible of information on drugs, recommend against elective inductions.31,35 The FDA “disallows” it; the PDR says, “Since the available data are inadequate to evaluate the benefits-to-risks considerations, Pitocin [the trade name for oxytocin] is not indicated for elective induction of labor.” By contrast, the American College of Obstetricians (ACOG) includes “logistic factors” such as “risk of rapid labor, distance from hospital, psychosocial indications” on its list of indications for induction. Inductions for these reasons would be elective inductions(ACOG 1999).1 And, by ACOG’s lax standard, “tired of being pregnant” would undoubtedly qualify as a “psychosocial indication.”
Problems with inductions stem from two sources: the physiology of initiating labor and the side effects of the procedures and drugs. First, despite common belief that they can, obstetricians cannot switch labor on at will. Starting and intensifying labor involves a complex cascade of feedback mechanisms that mutually reinforce and limit each other. It is an elegant and delicate dance of hormones and other substances between the baby, who initiates and controls the process, and the mother. Dumping in oxytocin—with or without cervical ripening procedures—often won’t initiate progressive labor unless labor was on the verge of starting on its own. This is the main reason why studies consistently show that inducing labor, apart from the reason for induction, considerably increases the likelihood of cesarean section in first-time mothers.2,8-9,23,28,32,36,42,45 (Some studies have concluded otherwise. The reasons why are instructive and will be discussed in the next section.)
5 Hospital Procedures That Ruin Your Birth - Cafemom.com
Here are the topfive myths associated with hospital procedures that change your birth experience.
Myth 1: You need a monitor on your belly the whole time you're in labor.
Fact:You absolutelydo not. Intermittent monitoring is shown to be just as effective, and actually allows the woman to focus on things other than her contractions. Consider that women are often made to lie down and stay relatively still with the monitors on as well, and you're put in a position where you have nothing to do but focus on and internalize any pain of contractions.
In fact, constant fetal monitoring often leads to unnecessary concern, and even intervention, including c-sections, so says theAmerican Academy of Family Physicians,notsome holistic home birth website, for those of you in doubt. In fact, only monitoring the baby's heartrate and your contractions every30 minutes during early labor, and every 15 during transitionand pushingis the current recommendation, but one that you almost never see actually practiced.
After less than two hours in the maternity ward, with her boyfriend, his mother and a nurse-midwife by her side, Jacquelynn Torivio gave birth to a five-pound, five-ounce son with his grandmother's dimples and a full head of shiny black hair. As she held him, Ms. Torivio's spirits clearly matched her Hopi name, Nuquahynum - "a feather flying high."
It was the kind of birth that many women in the United States could only wish for. Ms. Torivio had a vaginal birth, even though her previous child had been delivered byCaesarean section. Because of that prior surgery, many hospitals would not have let her even try to give birth vaginally, but would have required another Caesarean.
TheTuba City Regional Health Care Corporationis different. Its hospital, run by the Navajo Nation and financed partly by theIndian Health Service, prides itself on having a higher than average rate of vaginal births among women with a prior Caesarean, and a lower Caesarean rate over all.
As Washington debates health care, this small hospital in a dusty desert town on an Indian reservation, showing its age and struggling to make ends meet, somehow manages to outperform richer, more prestigious institutions when it comes to keeping Caesarean rates down, which saves money and is better for many mothers and infants.
This week, theNational Institutes of Healthwill hold a conference in Bethesda, Md., about the country's dismal rates of vaginal birth after Caesarean, or VBAC (pronounced VEE-back), which have plummeted since 1996. "I think it's the purpose of this conference to see if we can turn the clock back," said Dr. Kimberly D. Gregory, vice chairwoman ofwomen's health care quality and performance improvement atCedars-Sinai Medical Centerin Los Angeles.
Tuba Citywill not be on the agenda, but its hospital, with about 500 births a year, could probably teach the rest of the country a few things about obstetrical care. But matching its success would require sweeping, fundamental changes in medical practice, like allowing midwives to handle more deliveries and removing the profit motive for performing surgery.
Changes inmalpractice insurancewould also help, so that obstetricians would feel less pressure to perform Caesareans. (The hospital and doctors in Tuba City are insured by the federal government, and therefore insurance companies cannot threaten to increase their premiums or withdraw coverage if they allow vaginal births after Caesarean.) Patients, too, would have to adjust their attitudes about birth and medical care during pregnancy and labor.
The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that ahealth care overhaulis supposed to address. Even theAmerican College of Obstetricians and Gynecologistshas acknowledged that the operation is overused. Though there is no consensus on what the rate should be, government health agencies and theWorld Health Organizationhave suggested 15 percent as a goal in low-risk women.
"VBAC" has become a battle cry, with fierce advocates on both sides-women who insist that they should not be forced into surgery versus doctors and hospitals who insist on repeat Caesareans, citing the risks of labor and concerns about liability and insurance.
Originally, the mantra was "once a Caesarean, always a Caesarean" because of fears that the scar on the uterus would rupture during labor, which can be life-threatening for both the woman and the child. But after an expert panel in 1980 declared it safe for many women, vaginal birth after Caesarean had a heyday: in 1996, the rate reached 28.3 percent in women with previous Caesareans.
Then, there were some ruptures, deaths and lawsuits. The obstetricians' group issued stricter guidelines, and the rate sank. It is now below 10 percent, and some experts think the pendulum has swung too far the other way.
In Tuba City last year, 32 percent of women with prior Caesareans had vaginal births. Its overall Caesarean rate has been low - 13.5 percent, less than half the national rate of 31.8 percent in 2007 (the latest year with figures available). This is despite the fact that more women here have diabetesandhigh blood pressure, which usually result in higher Caesarean rates.
The hospital serves mostly Native Americans -Navajos, Hopis and San Juan Southern Paiutes. Four other hospitals in New Mexico and Arizona, run by the Indian Health Service, also offer vaginal birth after Caesarean to some women (it is not safe for all) and have relatively low Caesarean rates without harming mothers or children, whose health in the first month after birth matches nationwide statistics. Doctors say there is no scientific evidence that Native American women are more able than others to have vaginal births.
"There is a significant lesson here about the ability of most women to deliver vaginally," said Dr. Jean E. Howe, the chief clinical consultant for obstetrics and gynecologyat Northern NavajoMedical Centerin Shiprock, N.M.
Nurse-midwives at these hospitals deliver most of the babies born vaginally, with obstetricians available in case problems occur. Midwives staff the labor ward around the clock, a model of care thought to minimize Caesareans because midwives specialize in coaching women through labor and will often wait longer than obstetricians before recommending a Caesarean. They are also less likely to try to induce labor before a woman's due date, something that increases the odds of a Caesarean.
In the rest of the country, nurse-midwives attend about only 10 percent of vaginal births, though their professional society, theAmerican College of Nurse Midwives, hopes that will grow to 20 percent by 2020.
Dr. Kathleen Harner, an obstetrician in Tuba City, said: "Midwives are better at being there for labor than doctors are. Midwives are trained for it. It's what they want to do." Dr. Amanda Leib, the director ofobstetrics and gynecologyat Tuba City, said: "I think the midwives tend to be patient. They know the patients well, and they don't have to leave at 5 to get home for a golf game or a tennis game. As crass as that sounds, I do think it has some influence."
Donna Rackley, a nurse-midwife in Tuba City, said that at a previous job in North Carolina, doctors who did not want to work late would sometimes set an arbitrary deadline and declare that if a woman did not deliver by then, she would have to have a Caesarean. "I found myself apologizing to patients," Ms. Rackley said.
In Tuba City, she said, if labor is slow but there is no sign offetal distressand the patient wants more time, the doctors will wait. Something that has led many other hospitals to ban vaginal birth after Caesarean poses less of a problem at Tuba City.The American College of Obstetricians and Gynecologistsrecommends that an obstetrician and an anesthesiologist be "immediately available" during labor for patients who have had a previous Caesarean in case something goes wrong.
Many hospitals, especially small ones, say they cannot afford to pay these specialists to wait around. But in Tuba City, doctors live on the hospital grounds or just minutes away, and they are immediately available even if they are at home. Doctors and midwives here earn salaries and are not paid by the procedure, so they have no financial incentive to perform surgery. (Doctors earn $190,000 to $285,000 a year, and midwives $80,000 to $120,000.)
"My colleagues here truly want to practice medicine and help people," said Dr. Jennifer Whitehair, an obstetrician. "That's not true everywhere. Here they're not thinking, how much can I make off this procedure?"
The hospital and doctors are federally insured against malpractice, in contrast to other hospitals, where private insurers have threatened to raise premiums or withdraw coverage if vaginal birth after Caesarean is allowed. As a result, Dr. Leib said, doctors in Tuba City are free to "think about what's best for the patient and not what covers our butts." Some of Tuba City's success probably arises from Navajo culture and customs. Couples often want more than two children, but repeated Caesareans increase the risk of eachpregnancy, so doctors and patients are motivated to avoid the surgery. Also, Navajos regard incisions as a threat to the spirit, something to be avoided unless necessary. "I've had 12 family members in the room," said Michelle Cullison, a nurse-midwife. "I've frankly never seen a place like this. Whoever that woman wants to be there is there. It's something I would take out to the community." . Can the rest of the country learn from Tuba City? Doctors say they are intrigued by the model but not sure how transferable it is. Dr. Gregory said it would not be easy to lower the Caesarean rate because of entrenched practices that raise it, like labor induction, repeat Caesareans andin vitro fertilizationprocedures that producemultiple births. Obesity also drives up Caesarean rates.
"I believe that a 15 percent rate is possible and not unreasonable - as a researcher," Dr. Gregory said. "As a clinician, if you factor in patient autonomy and the number of interventions we do, it's not likely to be possible if we keep doing what we're doing."
Disputed Territory: A doctor reviews “Birth Territory and Midwifery Guardianship: Theory for practice, education, and research”
Author Katharine Hikel, MD. Dr. Hikel Peer-trained in women’s health clinics is a graduate of Harvard and the University of Vermont College of Medicine
Excerpts below:
"Labor and birth are whole-being experiences; the autonomic nervous system will shut the whole process down if the woman perceives stress, threat, or danger. In typical hospital settings, with shift changes, strangers walking in and out, bright lights, confinement to bed and monitor, and restricted oral intake, it is no wonder that the process doesn’t go as smoothly as it could. “Failure to progress” – the diagnostic reason given for 50% or more cesareans – is largely an environmental issue."
"Obstetrics is statistics-based, not relationship-based; obstetricians know that the average due date is 40 weeks from the last menstrual period; they know that if a woman is laboring (in a hospital) with waters broken for over 12 hours, her chance of infection skyrockets; they know that the Friedman labor curve shows that the average progression of dilation is one centimeter per hour; they know that the average pushing phase is under two hours. They are under pressure to make everyone fit those statistical norms, and they have the tools to make it so; and that’s what they do."
"The territory of obstetrics residents is largely devoid of patient-relationship considerations; it is rather consumed with concerns about on-call hours, clinical rotations, numbers of procedures, and one’s place in the departmental hierarchy. The knowledge itself is based in pathology – ‘problem-oriented’– a diagnostic/treatment approach that assumes there’s trouble, and goes about finding it. This works well in the rest of medicine, which is really about disease; but colors the teaching approach to the normal, healthy event of childbirth."
"the hormone of love, bonding, social interaction, birth, and lactation – they describe the effects of this natural hormone:
[T]he higher the level of Oxytocin, the more calm and social the mother; thereby stress is reduced; levels of the stress hormone cortisol drop; pain threshold is increased… body temperature is regulated… and heart rate and blood pressure are lowered… Women’s response to stess may not be the automatic ‘fight or flight’ response seen in men, but is more likely to be the ‘calm and connection’ system integrated by Oxytocin.
"Oxytocin is thought to be the source of women’s power to endure labor and birth; and its pathways are the most likely to be deranged by the institutional birth environment – the lack of oxytocin-facilitating relationships of trust and love, as well as the routine administration of oxytocin-blocking drugs such as epidurals and Pitocin – a form of artificial oxytocin that has never been proven safe in long-term outcome studies. Blocking oxytocin, whether through fear, disturbance, or Pitocin, leads to disrupted or painfully difficult labors. These authors suggest that disruption of normal oxytocin pathways, and supplanting them with intrapartum Pitocin exposure, may also result in serious mental health problems on the love-and-relationship axis: schizophrenia, autism, drug dependency, suicidal tendencies, and antisocial criminal disorders. It’s not just the mother who’s affected by the birth territory."
Co-published by Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund
Synopsis
Effective maternity care with least harm is optimal for childbearing women and newborns. High-quality systematic reviews of the best available research provide the most trustworthy knowledge about beneficial and harmful effects of health interventions. A large, growing body of systematic reviews is available to help clarify effects of maternity practices, yet these valuable resources are grossly underutilized in policy, practice, education, and research in the United States. Practices that are disproved or appropriate for mothers and babies in limited circumstances are in wide use, and beneficial practices are underused. Rates of use of specific practices vary broadly across facilities, providers, and geographic areas, in large part because of differences in practice style and other extrinsic factors rather than differences in needs of women and newborns. These gaps between actual practice and lessons from the best evidence reveal tremendous opportunities to improve the structure, process, and outcomes of maternity care for women and babies and to obtain greater value for investments. This report points the way to achieving these gains for the large population of childbearing women and newborns and for those who pay for their care.
Framework for Evidence-Based Maternity Care
Evidence-based maternity care uses the best available research on the safety and effectiveness of specific practices to help guide maternity care decisions and to facilitate optimal outcomes in mothers and newborns. Various care paths that might be pursued in a specific situation can involve very different benefit/harm profiles. Evidence-based maternity care gives priority to effective care with least harm.
A rigorous, well-conducted systematic review of original studies yields the most trustworthy knowledge about beneficial and harmful effects of specific interventions. Randomized controlled trials are especially valuable original studies, but have some important limitations. Other types of study designs are often needed to help answer important questions. Many factors shape both views about suitable care and patterns of care, which often do not reflect the best current research. Thus, it is always important to ensure that policy and practice are in fact guided by the best available research. Informed decision making should consider safety and effectiveness as well as values and circumstances of individual women.
Although most childbearing women and newborns in the United States are healthy and at low risk for complications, national surveys reveal that essentially all women who give birth in U.S. hospitals experience high rates of interventions with risks of adverse effects. Optimal care avoids when possible interventions with increased risk for harm. This can be accomplished by supporting physiologic childbirth and the innate, hormonally driven processes that developed through human evolution to facilitate the period from the onset of labor through birth of the baby, the establishment of breastfeeding, and the development of attachment. With appropriate support and protection from interference, for example, laboring women can experience high levels of the endogenous pain-relieving opiate beta-endorphin and of endogenous oxytocin, which facilitates labor progress, initiates a pushing reflex, inhibits postpartum hemorrhage, and confers loving feelings. Large national prospective studies report that women receiving this type of care are much less likely to rely on pain medications, labor augmentation, forceps/vacuum extraction, episiotomy, cesarean section, and other interventions than similar women receiving usual care. Such physiologic care is also much less costly and thus provides outstanding value for those who pay for it. Burgeoning research on the developmental origins of health and disease clarifies that some early environmental and medical exposures are associated with adverse effects in childhood and in adulthood. Recognition of known harms and the possibility that many harms have not yet been clarified further underscores the importance of fostering optimal physiologic effects and limiting use of interventions whenever possible.
Overused Maternity Practices
Many maternity practices that were originally developed to address specific problems have come to be used liberally and even routinely in healthy women. Examples include labor induction, epidural analgesia, and cesarean section. These interventions are experienced by a large and growing proportion of childbearing women; are often used without consideration of alternatives; involve numerous co-interventions to monitor, prevent, or treat side effects; are associated with risk of maternal and newborn harm; and greatly increase costs. Mothers, babies, and purchasers would benefit from giving priority to effective, safer care paths and using risky interventions for well-supported indications only or when other measures are inadequate. The following practices would instead be consistent with the framework of this report: avoiding induction for convenience; using labor support, tubs, and other validated nonpharmacologic pain relief measures and stepping up to epidurals only if needed; and applying the many available measures for promoting labor progress before carrying out cesarean section for “failure to progress.” Such protocols would require considerable change in many settings, but would lead to a notable reduction in the use of more consequential procedures and an increase in cost savings. Available systematic reviews also do not support the routine use of other common maternity practices, including numerous prenatal tests and treatments, continuous electronic fetal monitoring, rupturing membranes during labor, and episiotomy.
