Pregnancy and Birth: The Cascade of Interventions (Part 1)

This post is a continuation of a series of pregnancy and birth posts. (Here is the first one.)

Over the next few weeks, I'm going to do several posts on pregnancy and birth. I hope to share a few things that were helpful to me; I hope they will help other parents as well.

Thoughtful, respectful discussion is strongly encouraged. My general disclaimer is this: I am not writing to condemn parents who do things differently. I only wish to share information that has influenced the way we live and parent. Perhaps it will give others something new to consider, perhaps not. I welcome your input, because I am always learning too. The important thing is that we are all doing our best to raise our children in safe, loving environments.

100 Years of Childbirth in America

At the turn of the twentieth century, childbirth in America took place almost exclusively in the home. The first maternity wards were connected with teaching hospitals, and only poor mothers gave birth in them. Physicians soon realized the value of all pregnant women as "teaching material," and they began a crusade to end home births. (1)

The doctors' campaign succeeded. By 1920, hospital birth was the new norm, and the standard of care included anesthetizing all laboring mothers. These drugged mothers were unable to care for their newborns, and so babies became secondary patients. Approximately 80% of mothers had hospital births by the end of WWII, and hospitals had to build large nurseries to house infants for the now mandatory post-birth observation period. Babies were further isolated by strict medical procedures put in place to keep the newborns safe from the infections that are ever-present in a hospital environment. (2)

It wasn't until the 1970's that women started to take back control of their bodies and birth experiences en masse. Many mothers refused anesthesia, opting instead for natural childbirth (or at least for pain relief that didn't render them unconscious). Babies were still taken from their mothers and admitted to the nursery to be weighed, bathed, and declared healthy by hospital staff, but mothers were given more time to bond with their newborns in the first 24 hours. (3)

Even with the surge of interest in natural birth in the 70's, the medicalization of childbirth has reached new levels over the last twenty years. Today, almost one-third of women receive a cesarean section ("c-section") - that number has gone up more than 50% since 1996. (4) More than one-third of labors are medically induced, and almost half of labors are medically stimulated. 76% of women are restrained in bed, most women are denied food, fluids, or both, and 86% of women are given drugs for pain relief. (5)

With the advanced technology and ease of access to modern medicine available to pregnant women in the United States, it would be easy to imagine that childbirth has become safer for mothers and babies. That is not the case.

The Cascade of Interventions (Part 1)

Without going into a discourse on every possible intervention practiced in medicalized childbirth, I'd like to briefly visit a few of the more common practices and list some of the reasons Tom and I decided to avoid them (I realize that emergencies do happen in a minority of cases, making interventions necessary).

     1. Induction

One of the most common reasons for induction is fear that the baby is "too big." Doctors scare parents with horror stories of shoulder dystocia (where the baby's shoulders get stuck during birth) and emergency c-sections in order to get the parents to agree to schedule induction. But the facts do not support the fear tactics. First, ultrasounds are notoriously inaccurate at predicting birth weight, so doctors cannot say with any confidence that a woman is carrying a big baby. (6) Second, shoulder dystocia is not tied to weight, and studies have shown that there is no greater chance of it occurring in a natural birth as it is in an induced birth. Finally, women who have inductions have a greater chance of undergoing a c-section than women who allow labor to occur naturally. (7)

Another common excuse to induce is that the baby is "overdue." There are several flaws with this argument. First, due dates are arbitrary. Due date calculations are based on the mother's last period, and the doctor assumes that the mother has a 28 day period with ovulation at day 14. If your cycle is different, your projected due date will be off. Second, the average pregnancy is actually longer than 40 weeks; nothing magical happens at week 40 that requires the baby be born at that moment. Finally, in the vast majority of cases, it is simply safer to let our bodies manage when labor begins. (8)

Studies have shown that induction increases your chances of many other interventions, including:

• vacuum or forceps-assisted vaginal birth;
• cesarean surgery;
• problems during labor, such as fever, changes in fetal heart rate, and shoulder dystocia;
• the laboring woman's use of an epidural or other drugs for pain relief;
• low birth weight;
• admission to the NICU;
• jaundice . . . that requires treatment for the newborn; and
• increased length of hospital stay for the mother and/or the baby. (10)
  

        Letting Labor Begin Spontaneously Is Ideal

Your body is miraculously designed to labor unassisted by artificial stimulation. In the last month of pregnancy, your cervix softens. Your uterus contracts to stretch and open your cervix and to help your baby move lower toward the birth canal. Your baby's lungs mature in the last few weeks, and his brain continues critical development through week 41. Some researchers have found evidence that it is the baby who releases a chemical that signals she is ready for labor. (9) When that happens, your body releases a surge of hormones to start labor. These hormones are present for two reasons: 1) to help you labor properly and 2) to help your "baby prepare for the transition from life inside the womb to outside and, especially, for breathing with his lungs for the first time." (11)

Experiencing contractions naturally allows you to labor in the most effective way for your body. Spontaneous labor is also healthier for the baby and allows him to be born when he is fully developed, while the chemicals introduced in an induction may have adverse effects on mother and/or baby. (12) If there is a valid reason for induction, there are many natural ways mothers can try to jump-start labor without resorting to chemicals. (13)

If your doctor is pressuring you to induce, ask her for evidence to back up what she is claiming. If she can give you any evidence, share your own research and let her know you wish to start labor without drugs. You have a right to refuse medical interventions, including induction. (14)

     2. Electronic Fetal Monitoring

Regardless of where you give birth, your provider will check the baby's heartbeat intermittently throughout labor and delivery to ensure the baby is not under too much stress. This can be done in several ways: with a stethoscope; a Doppler (a handheld device with a speaker); electronic fetal monitoring ("EFM") (an electronic ultrasound device strapped onto the mother's stomach); an internal monitor; or with telemetry monitoring (like EFM, but mother can remain mobile). (15) EFM has become a routine part of any hospital birth, regardless of whether the mother/baby are high or low risk. Unfortunately, continuous monitoring of the fetal heartbeat may have negative consequences.

"When EFM was first introduced, the initial goal was to identify fetal distress during labor and, subsequently, allow timely intervention that would improve birth outcomes." However, the use of early EFM does not lead to increased positive birth outcomes. (16) In fact, research suggests that the use of electronic monitoring actually increases the risk of cesarean sections, instrumental delivery, augmentation of labor, and epidurals. (17) And while expert panels in both the United States and Canada have recommended against the use of EFM for low-risk mothers, hospitals continue to routinely employ electronic monitoring for all laboring women. (18) And it is not only low-risk mothers that may be harmed by routine EFM. The U.S. Preventive Services Task Force states that "[t]here is insufficient evidence to recommend for or against EFM" even for high-risk mothers. (19)

"The routine use of [EFM] 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." (20) Not only does research show that EFM (either at admission and/or continuously during labor) may lead to more interventions, but one thing is also clear: babies born after continuous EFM are no more healthy than those born to mothers who were monitored intermittently. (21)

If you do not wish to be monitored continuously during labor, talk to your midwife or OB. Let her know that you would like to be monitored intermittently or even with Doppler. Show her the research that continuous (and admission) EFM increases the risk of further medical interventions.

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(1) http://www.collegeofmidwives.org/legal_legislative01/HxMfryIndex01/abriefhx.htm ("A Brief History of Hospital Nurseries")

(2) A Brief History of Hospital Nurseries

(3) A Brief History of Hospital Nurseries

(4) http://cfmidwifery.org/pdf/StateMatCare2005CfM.pdf ("State of American Childbirth") (citing Hamilton, BE, et al. “Births: Preliminary Data for 2006” National Vital Statistics Reports, Vol. 56, No. 7, December 5, 2007. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_07.pdf)

(5) State of American Childbirth (citing Declercq, ER, et al. Listening to Mothers II: Report of the Second National US Survey of Women’s Childbearing Experiences. New York: Childbirth Connection, 2006. Available at http://www.childbirthconnection.org/listeningtomothers/)
(6) http://www.nzma.org.nz/journal/119-1241/2146/ ("As the reliability of ultrasound estimation of fetal weight to detect larger babies was poor, the use of such an objective measurement in the management of suspected macrosomia in term singleton pregnancies should be avoided.")
(7) Goer, Henci, The Thinking Woman's Guide to a Better Birth at 51-52 (1999) ("Thinking Woman's Guide"); see also http://www.hencigoer.com/articles/elective_induction/ ("Elective Induction"); http://www.truebirth.com/2008/02/induction-to-avoid-cesarean-for-large-babies/ ("Induction to Avoid")

(8) http://www.givingbirthnaturally.com/reasons-to-induce-labor.html

(9) http://www.lamaze.org/ChildbirthEducators/ResourcesforEducators/CarePracticePapers/LaborBeginsOnItsOwn/tabid/487/Default.aspx ("Let Labor Begin on its Own") (citing Condon, J. C., Pancharatnam, J., Faust, J. M., & Mendelson, C. R. (2004). Surfactant protein secreted by the maturing mouse fetal lung acts as a hormone that signals the initiation of parturition. Proceedings of the National Academy of Sciences of the United States of America, 101(14), 4978–4983); see also http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595040/
(10) Let Labor Begin on its Own (citing Goer, H., Leslie, M. S., & Romano, A. (2007). The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 6: Does not routinely employ practices, procedures unsupported by scientific evidence. The Journal of Perinatal Education, 16(Suppl. 1), 32S–64S)
(11) Let Labor Begin on its Own (citing Jain, L., & Eaton, D. C. (2006). Physiology of fetal lung fluid clearance and the effect of labor. Seminars in Perinatology, 30(1), 34–43)
(12) Let Labor Begin on its Own
(13) http://www.givingbirthnaturally.com/natural-ways-to-induce-labor.html
(14) Induction to Avoid
(15) http://www.childbirth.org/articles/efmfaq.html ("Monitoring FAQ")
(16) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595164/; see also http://onyx-ii.com/birthsong/page.cfm?efm ("Why Are We Using EFM")
(17) http://www.changesurfer.com/Hlth/EFM.html; see also http://sanantoniomidwife.org/Revisiting%20the%20use%20of%20the%20electronic%20fetal%20monitor.pdf ("Revisiting the Use of EFM")
(18) Revisiting the Use of EFM
(19) Why Are We Using EFM
(20) http://www.lamaze.org/ChildbirthEducators/ResourcesforEducators/CarePracticePapers/NoRoutineInterventions/tabid/483/Default.aspx ("Avoid Interventions That Are Not Medically Necessary")
(21) Avoid Interventions That Are Not Medically Necessary