First Do No Harm

Why do I feel I have to justify myself when I say that doctors and hospitals are damaging women and babies? I have a little bird on my shoulder that says "Oh, but you don't want to seem like you are against saving lives".

We have some fantastic tools at our disposal now in the field of medical care. We have antibiotics. We have surgery. We have anaesthetics. We have ultrasound. But these tools are being overused and mismanaged.  Women are being hurt and babies are suffering because of our indiscriminate and irresponsible use of methods and materials that should be reserved for special situations.

What are the effects on mothers who want a vaginal birth and come out of the hospital with a scarred uterus? What are the long term effects on her mothering instincts and choices? What are the long term effects of cesarean section birth on newborns? What are the long term effects of epidural medication on newborns? Artificial oxytocin?

What happens when a mother in full labor suddenly becomes quiet and calm because of the pharmaceuticals coursing through her system? How does the baby feel when that happens? Is there a correlation between epidural medication and later drug use? What happens to the part of the brain that responds to addictive substances and behaviours, when the birth process is augmented with artificial oxytocin and opiates?

What happens to a marriage when a man witnesses his wife being treated like an animal? How does that compare to the bonding that takes place when a man sees his wife in full triumphant labor and birth?

What happens to little girls who are born by cesarean section? Are they more likely to birth that way? Is there a cellular memory of the movement through the birth tunnel? What are the long term effects of cesarean section on sexuality throughout a woman's life? Is she more or less likely to be fully orgasmic later into menopause?

Is there a correlation between asthma in children and induction of labor? Is there a correlation between autism and epidurals? What health problems are we seeing that may be connected to our new way of giving birth?

The average cesarean section rate in Canada is conservatively reckoned to be about 20%; higher in some places and lower in others. One in five children are now born surgically. This is a huge scientific experiment that is not controlled, or monitored, or even admitted.

Over 90% of first time mothers in hospitals in Montreal are taking epidural medication.

In spite of recent studies that show the contrary, the majority of women carrying breech babies are delivering by cesarean section.

Forty one weeks is considered standard for induction, Bishop's Score be damned! And if a woman is over forty, she is likely to be induced at 39 weeks.

We need to get these figures down and we need to start examining the effects of our modern tools, methods and materials on the mothers and babies who place their trust in us.

Induction Epidemic

"Unless conception occurred via in vitro fertilization, techniques used for obstetric dating are accurate to 3 to 5 days if applied in the first trimester, and only to 1 to 2 weeks subsequently. Estimates of fetal weight are accurate only to 15% to 20%. Even small discrepancies of 1 or 2 weeks between estimated and actual gestational age or 100 to 200g difference in birth weight may have implications for survival and long-term morbidity. Also, fetal weight can be misleading if there has been intrauterine growth restriction, and outcomes may be less predictable. These uncertainties underscore the importance of not making firm commitments about withholding or providing resuscitation until you have the opportunity to examine the baby after birth."
Textbook of Neonatal Resuscitation, 6th Edition, Ed J. Kattwinkel, American Academy of Pediatrics and American Heart Association (2011), p. 288

We cannot know when a person is supposed to die; neither can we predict exactly when a baby is to be born.

We have some numbers to play with and we do our best under the circumstances. Everyone knows that babies take nine months to grow in their mothers’ wombs. In the Jewish Talmud, it is stated that pregnancy should last 270 days from conception to birth. Modern Western medicine counts 40 weeks from the date of the last normal menstrual period, which gives a baby 38 weeks to mature, if his mother conceived fourteen days after her period. Many midwives will look carefully at a woman’s menstrual cycle, and will try to calculate together with the woman when she may have conceived. Based on these dates, she will give an estimate of a two or three week period during which the woman is likely to give birth. Some women give birth before their due dates, a few exactly on the day, and many give birth up to two or even three weeks after the date has passed. The tendency to carry a baby for over 41 weeks appears to run in families and can sometimes be predicted if a woman has carried her first child “post dates”.

One thing is for sure, babies do come out eventually. However, it is possible that certain risks increase the longer a baby stays in the womb. The placenta may diminish in optimal function after about 42 weeks, putting the fetus at risk for hypoxia. Babies born after 41 weeks often have a higher incidence of meconium in the amniotic fluid, which puts them at higher risk of meconium aspiration. Babies keep growing, so a 42-week baby may have a slightly larger head than she did at 38 weeks, thus making it a little harder for her mother to push her out.  Modern medicine tries to diminish these risks by making sure a baby is born on or around the estimated date of delivery, or the due date. There is a lot of controversy about this reasoning, and rightly so. The due date is rather arbitrary. No one really knows when the baby was conceived, and even if they do analyze various ultrasounds, we can still never predict which babies will want to stay in the womb for longer. Occasionally there is a real problem with a baby which prevents the labor from starting spontaneously. This is very rare and does not justify the high induction rates we are seeing.

On

Why are we concerned about chemical inductions? Our main concern is that because chemical labor induction creates very strong, painful and frequent contractions whose character is different from the contractions produced by the woman’s own body, there is an increase in epidural requests. Once she has requested an epidural, the risk of an instrumental or surgical birth increases. Our next concern is whether the woman’s body is ready for a chemical induction. If it is not, then all the chemical and natural assistance in the world will not convince her cervix to open and she may labor for days and end up in surgery. 

 

Let us first have a look at some statistics, remembering that these numbers can be stretched and manipulated just like the perineum during birth. A recent study examined the correlation between labor induction and cesarean section. It looked at a reasonably small group of women (just over 1200) who were at 41 weeks of pregnancy. About half of these women went into labor spontaneously, and the other half was induced. The half who went into labor on their own had a 14% c-section rate, while the rate for the other half was 19%. The increased rate was due to an increase in c-sections performed for “failure to progress”, which was “diagnosed and cesarean delivery performed when cervical dilatation or fetal descent ceased for 2 to 4 hours despite adequate uterine activity”. However, the researchers concluded that the increase was not due to the labor induction “per se”, but rather due to “nulliparity, advanced gestational age, undilated cervix prior to labor, and epidural analgesia”.[i]

It seems to me that if we look at these figures with open eyes we can see that, in fact, induction is definitely an important player in the rise in c-section rates, even if we split hairs and suggest that it is not the main cause. Nulliparity certainly has an effect, and every doula knows that a first-time mother is going to be more of a challenge than a mother who has already gone through the experience. When a first-time mother experiences the contractions produced by synthetic oxytocin, she is much more likely to request an epidural than an experienced mother who knows that labor will, in fact, end and her child will be in her arms soon enough.

A woman with a closed, hard and posterior cervix is not an acceptable candidate for chemical induction. The rates of surgical delivery increase with a lower Bishop’s score. The following chart shows how we calculate this important score.

       

Score	Dilatation	Effacement	Station	Position	Consistency
0	0	<40%	-3	posterior	firm
1	1-2 cm	40-50%	-2	mid	moderately firm
2	3-4 cm	60-70%	-1,0	anterior	soft
3	5+ cm	80%+	+1,+2	anterior	soft

A point is added to the score for each of the following:
   1. Preeclampsia
   2. Each prior vaginal delivery

A point is subtracted from the score for:
   1. Postdates pregnancy
   2. Nulliparity
   3. Premature or prolonged rupture of membranes

The scoring is done according to the physician’s or midwife’s estimation of the cervix, and extra points are added or subtracted. Any score under 6 usually means that the cervix is not ready for induction and cervical “ripening” is initiated using prostaglandins. A score above 6 is encouraging and often means that a woman will be successfully induced and has more chance of a vaginal delivery. Induction leads to a higher epidural rate; epidurals lead to higher c-section rates: it is undeniable that labor induction can increase the risk of a c-section.

How can the doula help? We do not want to alienate the women we are working with. If she is happy with an induction and understands the possible implications, then it is the doula’s job to support her. We do not want to turn a woman against her doctor. If a woman has chosen a doctor and is convinced she has made the right choice, then the doula must not interfere with that relationship. It is a woman’s right to ask questions of her doctor, and she can say no to the doctor’s suggestions, but it is not the doula’s responsibility to do so. We do not want a woman to feel guilty about listening to her doctor. We often find ourselves in the following situation: the client is reasonably happy with her doctor, who has said that she almost never induces before 41 weeks. The woman has just passed forty-one weeks and the doctor is not working on the upcoming weekend. She has offered an induction on the Thursday, so that she can be at the birth. Both the baby and the mother are fine on the one hand, but on the other hand, the mother is getting very tired of being pregnant and her in-laws are calling every five minutes. The client calls her doula in tears. What can happen during this call is what we call a “learning moment”. That is, the doula and her client discuss all the issues and go over all the options and implications: The doctor has confirmed that the baby is doing well. This is an opportunity for the woman to take the process into her own hands and refuse a medically unnecessary induction. She can wait until after the weekend, when she and her doctor can make a decision. Often, in this type of situation, a woman will spontaneously go into labor.

More serious is the situation where there is a perceived risk to the baby. In this situation, it is up to the doula to support her client and refrain from bringing doubts, research and opinions into the equation. If a doctor is convinced that, for example, the fluid is dangerously low, it is not the right time for a doula to suggest that perhaps this is physiologically normal or that the ultrasound technician could not see behind the fetus. This is the time for the doula to support her client wholeheartedly.

This is an example of the fine art of being a doula. We are not midwives, working from a rooted trust in the healthy efficiency of the female body. We are not physicians, sensitive to flaws and malfunctions in the labor process. We are there to support a woman through the labor process, as she sees fit, without judging, without voicing our opinion. Here is a story about an induction where the doula was very active in the whole process. This woman’s first labor had been chemically induced and she was hoping to avoid it the second time around.

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[i] Obstet Gynecol 2001;97:911-915

 

Induction Epidemic

As I mention in my book, we still don't know exactly how long a human baby needs to gestate. We don't usually know the exact date of conception, and we have no real understanding of why or how labor starts. Statistics are wonderful tools for proving a point, so I am going to shy away from using them for now. I have read endless discussions on medical professionals' lists about the benefits and risks of 41 week inductions, and I am not at all convinced.

My father is very ill. His body is getting weaker and weaker, and when I was caring for him over New Year's he seemed as frail as a preemie, and weighed about as much. But his mental state is still as sharp as it ever was, his sense of humor as dry, and he had a wonderful New Year's toast with all of us, wishing us all a Happy New Year.

I don't know when he is going to go. It could be in two weeks, it could be in two years. But none of us would think to hasten his departure by giving him some meds that would call on the Angel of Death. Of course, if he were already half gone, we have been ordered by him to let him go. But as it is, we are waiting, trying to stay in touch as much as we can. My mother is there, cooking his favorite food and listening to his favorite music with him, reading him detective stories and generally fussing over him.

As it is at the end of life, so should it be at the beginning. If a woman and her baby are doing well, and all the medical tests show that everything is fine, then there is absolutely no reason that the baby and his mother should be "stimulated" to start labor. I am not arguing that once a woman reaches forty weeks she should be abandoned by her medical caregiver. Certainly, she can have a weekly Non-Stress Test or a Biophysical Profile. But if these tests show that all is well, why are we relying on numbers and averages to make medical decisions?

We had a holiday season recently. The hospitals in our city were packed during the week before Christmas. It wasn't because everyone had been having wild sex at the end of March last year. It was because women, their partners, and their medical caregivers wanted those babies to be born before the holiday, so they decided upon induction rather than waiting and suffering the inconveniences that would result.

A doula is a very useful resource in this situation. She can and should help the parents-to-be understand the advantages and disadvantages of induction, and help them to ask the medical caregivers the right questions. Informed choice is not just a buzzword, it actually means that the patient is informed and can make a choice. The patient should be informed, not just by the doctor who has to go away for Christmas, but also by someone who can inform her that if her cervix is long, closed, and high, and she is a first time mother, and her mother and sisters all carried their babies to 42 weeks, then  she may have a higher risk of ending up in surgery than if she waits a few days and trusts her doctor's backup.

There is an induction epidemic going on. Induction can and does lead to further interventions. If a prostaglandin induction does not stimulate labor, then oxytocin is initiated. Prostaglandin gel, IV oxytocin, and epidural medication can have a bad effect on the fetus, and may lead to emergency cesarean birth. All of these interventions are miracle workers when they are used to save a mother's or a  baby's life. To use them for social reasons is not only bad medicine, it is a sad reflection on our culture and our way of life.