Tag Archive | birth

Overused & Underused Procedures

My previous post about a good experience and a healthy baby as well as reading a relevant section in the wonderful new Our Bodies, Ourselves: Pregnancy & Birth book I’m reviewing made me want to post about this topic. There are a multitude of common procedures that are overused in hospitals and that when used routinely actually harm mothers and babies. I also thought about the multitude of evidence based, helpful procedures that are underused in many birth environments despite research indicating that they contribute to better outcomes for both mother and baby. (The use of the terms “overused” and “underused” and the examples below are taken from the OBOS book.)

Overused Procedures–these techniques are often used routinely (instead of appropriately based on true level of need in which case they can be truly helpful and sometimes even save lives) despite clear evidence that overuse is harmful:

Induction of labor
Episiotomy
Epidurals
Cesarean sections

Underused Procedures that have been shown to improve birth outcomes as well as to improve women’s satisfaction with their birth experiences include:

Continuous one-on-one support from a skilled caregiver during labor (a doula is a professional labor support provider who offers this one-to-one support).
Changing positions during labor (especially positions using gravity).
Laboring out of bed.
Walking during labor.
Comfort measures such as water, massage, and birth balls.

To increase your likelihood of satisfaction with your birth experience and of having a normal birth as well as a healthy mother and baby, choose a birth setting and care provider that supports and USES these underused procedures and only rarely, and appropriately, uses the overused procedures listed above.

Birth Experience or Healthy Baby?

Feb20

As you may have read in many blogs in the birth world, ACOG issued a press release this month opposing the choice of homebirth for women. One of the quotes towards the end of the release, “Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby,” is a sentiment that I see expressed fairly frequently and I’d like to explore it a little. I do not think these two things are mutually exclusive by any means. I say, why not BOTH? A “good experience”/process of giving birth AND healthy baby–these two things can, should, and do go together. Many of the elements that make up a good experience are also things that are best for the baby–as I said, the two concepts are not mutually exclusive, instead they reinforce and contribute to each other! Most of the time, taking good care of a mother in birth (i.e. contributing to her “good birth experience”) is the very best thing you can do to take care of her baby. Babies do not need to be “rescued” from their mother’s bodies–healthy mothers help lead to healthy babies! Women and babies BOTH deserve a good birth experience.

I also question whether ANY mother actually considers this a choice, or makes this choice. Erica Lyon, quoted in the book Pushed, speaks eloquently on this topic:

“…The goal is to have a healthy baby. ‘This phrase is used over and over and over to shut down women’s requests,’ she [Erica Lyon] says. ‘The context needs to be that the goal is a healthy mom. Because mothers never make decisions without thinking about that healthy baby. And to suggest otherwise is insulting and degrading and disrespectful’…What’s best for women is best for babies. and what’s best for women and babies is minimally invasive births that are physically, emotionally, and socially supported. This is not the kind of experience that most women have. In the age of evidence based medicine, women need to know that standard American maternity care is not primarily driven by their health and well-being or by the health and well-being of their babies. Care is constrained and determined by liability and financial considerations, by a provider’s licensing regulations and malpractice insurer. The evidence often has nothing to do with it.” (emphasis mine)

Satisfaction with Your Birth Experience

Feb16

There are four factors that research have found to make the greatest contribution to your degree of satisfaction with your birth experience (experience or not of pain isn’t one of them!):

Having good support from caregivers.
Having a high quality relationship with caregivers.
Being involved with decision making about care.
Having better than expected experiences (or having high expectations).

According to additional research, pain relief only becomes important in relationship to level of satisfaction when expectations are NOT met (so, if you planned for a epidural and didn’t have time to get one, or you expected to cope differently with pain than you did, and so forth).

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When reflecting on these things based on my personal experiences, they seem completely appropriate (including the experience or not of pain–my sense of satisfaction with my own birth experiences has nothing to do with how much or how little pain I experienced or how I interpreted my sensations as painful or not. With both my babies, I had a high level of satisfaction with my birth experiences and in both I had a high quality relationship with my caregivers (family practice physician with the first baby and midwife with the second). During both labors I had very excellent support from my husband (the professional caregivers had little involvement with either of my births). He was so present for me and so able to provide what I needed that I had a sense of us being like one person during labor. Decision making about care also came into play with my satisfaction level. with my second baby particularly, I was completely in control. No one else made decisions about my care. So, it was much more than “involvement in” decision making, but for me, an important component of satisfaction was total control of decision making.

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Finally, I totally identify with the “better than expected experiences.” With my first baby, I was stunned and very pleasantly surprised to arrive at the birth center fully dilated. I had expected to labor for an additional 10 hours or so at the birth center (I was in labor for about 11 when we got there). With my second baby, I was again stunned and also pleasantly surprised to be in labor for a total of 2 hours. While I felt a bit “run over by a truck” by the speed and the intensity of the second labor, I was delighted to have such a quick birth. It was great.

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I also started thinking about what else, personally, would be on my list of things contributing to satisfaction with my birth experiences and I think location is a big one for me. Being in an environment of my choosing and in which I felt safe, comfortable, and respected was very important to my feelings of satisfaction. My second baby was born at home and that was very satisfying to me. I’m sure there are other things that were important, but I can’t think of anything specific right now.

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How about you? What contributed to your feelings of satisfaction (or not) with your birth experience(s)?

Waiting before pushing…

Feb16

Your uterus is a powerful muscle and will actually push your baby out without conscious or forced effort from you–at some point following complete dilation your body will begin involuntarily pushing the baby out. Many women experience the unmistakable urge to push as an “uncontrollable urge”–but, in order to feel that uncontrollable urge, you often have to wait a little while! Though some care providers and nurses encourage you to begin pushing as soon as you are fully dilated there is often a natural lull in labor before your body’s own pushing urge begins. Some people refer to this lull as the “rest and be thankful” stage. It gives your body a chance to relax and prepare to do a different type of work (in labor the muscles of your uterus are working to draw your cervix up and open. During pushing, the muscles of your uterus change functions and begin to push down instead of pull up). If you wait to push until you really need to, you will often find that your pushing stage is shorter and progresses more smoothly that pushing before you feel the urge.

I’m reviewing a copy of the wonderful new pregnancy book from Our Bodies, Ourselves and they shared the following about this issue:

“Research suggests that the length of time before the baby is born is the same if you allow one hour of ‘passive descent’ of the baby (when you relax and don’t consciously try to push) or you start pushing immediately after you are fully dilated.”

Will I need an episiotomy?

Feb5

The short answer is no, you do not “need” an episiotomy. Women rarely (if EVER) actually “need” an episiotomy. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening as the baby’s head is being born. This procedure is rarely necessary and you should ask your care provider how often they perform episiotomies. A good answer is, “almost never” or “I’ve done 3 or 4 in my career.” Answers that are NOT good and that should encourage you to question further are, “only if you need it” or, “many first time moms need one” or, “a clean cut is easier to repair than a nasty, jagged tear!” or, “don’t worry about it. I’ll make the decision when the time comes.” These are not good answers, because there has no study has ever shown any benefit to routine use of episiotomy! There is no scientific evidence supporting the practice.

A commonly used analogy to explain why a cut is NOT better than a tear is to imagine a piece of fabric–when you try to tear it, it resists. But, when you make a small cut in the top of the fabric and then then try to tear it, it easily rips all the way down. The same is true of your skin! (and your muscles–an episiotomy cuts through your muscle as well as your skin. Many naturally occurring tears are very small and occur only on the surface of your skin).

Here is some more explanation from an issue of Midwifery Today e-news issue number 8:23:

“Ironically, one of the biggest contributors to perineal tearing is episiotomy, which has long been heralded as the great preventer of tearing. One recent study, which only assessed the effects of episiotomy on third and fourth degree tearing, found a definite correlation between episiotomy and tearing. The risk of severe tearing was found to be nearly four times higher with episiotomy than without. Another study involving thousands of women found that the number one risk factor for perineal tearing was episiotomy.”

Though it often is presented as a choice–i.e. “would you rather tear or be cut?” I offer that there is a third option….Neither! A perineal wound is NOT an inevitable part of giving birth (even with your first baby). Though it is not abnormal to tear, it is also perfectly possible to not tear or need stitches. One way to work with your body to avoid tearing is to give birth on your hands and knees, kneeling, or squatting. Another way is to stop pushing when you feel a burning sensation or “ring of fire” and let the baby’s head naturally ease out. Your uterus will push the baby out without sustained, breath holding, high exertion pushing from you–you can rest and let your uterus do the work! When you are doing forceful or directed pushing you are more likely to tear than if you follow your own body’s pushing urges and signals. Some people also advocate perineal massage prior to birth to help the tissues stretch. While it does not hurt to become more familiar with this part of your body and how your muscles feel when they are relaxed or tense, perineal massage has not been shown to have very much effect on your chance of tearing during birth.

Care in Normal Birth

Feb4

I recently discovered there is a free pdf book available from the World Health Organization called Care in Normal Birth: A Practical Guide. The booklet is very research oriented, so while it is great for finding evidence based information, it is not “light” reading for every day use! It is directed towards birth professionals.

Evidence Based Care Fact Sheet (& Mother Friendly Care)

Jan22

In Sept. 2007, Citizens for Midwifery published a useful new fact sheet summarizing the evidence basis for the 10 Steps for Mother-Friendly Care. The fact sheet is two sided and packed with information. The Coalition for Improving Maternity Services (CIMS) has a mission “to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs.” To this end, they created the evidence based
Mother-Friendly Childbirth Initiative (MFCI). This Initiative “provides guidelines for identifying and designating “mother-friendly” birth sites including hospitals, birth centers and home-birth services.” There are ten steps for mother-friendly care and ample evidence supporting each step.

CIMS also has a very useful consumer handout–“Having a Baby: 10 Questions to Ask“–that helps expectant couples ask questions of their health care providers to determine if the care they are receiving is the evidence based, mother friendly care all pregnant women deserve.

The 10 Steps are:

“A mother-friendly hospital, birth center, or home birth service:

Offers all birthing mothers:
- Unrestricted access to the birth companions of her choice, including fathers, partners, children, family members, and friends;
- Unrestricted access to continuous emotional and physical support from a skilled woman-for example, a doula or labor-support professional:
- Access to professional midwifery care.
Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.
Provides culturally competent care — that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.
Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position.
Has clearly defined policies and procedures for:
- collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary;
- linking the mother and baby to appropriate community resources, including prenatal and post-discharge follow-up and breastfeeding support.
Does not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following:
- shaving;
- enemas;
- IVs (intravenous drip);
- withholding nourishment;
- early rupture of membranes;
- electronic fetal monitoring;
Other interventions are limited as follows:
- Has an induction rate of 10% or less;
- Has an episiotomy rate of 20% or less, with a goal of 5% or less;
- Has a total cesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals;
- Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.
Educates staff in non-drug methods of pain relief and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.
Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.
Discourages non-religious circumcision of the newborn.
Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding…”

Why “Woman-Centered” Childbirth?

Jan15

I refer to my approach to childbirth education as “woman-centered.” Why? I believe woman-centered birth supports normal birth. The two are inextricably linked. According to the Association of Labor Assistants and Childbirth Educators, “woman-centered childbirth recognizes the primary role of the mother, and allows labor to progress according to the mother’s natural rhythms.” As an ALACE trained educator, I stress the importance of respecting the mother’s instincts and choices about how to give birth, including positions for labor and birth, comfort measures, and choice of caregivers and support. My goal is to help women reclaim trust in their bodies inherent abilities to give birth in a safe and unhindered manner.

This does not mean there is not a role for the father in birth or that I do not value the role of fathers. A father most definitely goes through a “birth” of his own–into fatherhood–and the psychological growth he experiences is significant. He also experiences fears and changes as he prepares to meet his baby and is of significant importance during labor and birth in his irreplaceable role of loving and supporting the mother of his baby. My beliefs about birth are underscored by the feeling that the mother is of central importance in the process of birth and that respecting birth as a woman-centered and woman-directed passage is the healthiest, safest, and best way for babies (and therefore, families!) to be born.

Pushing the issue of pushing in labor…

Jan14

Coping with the second stage (pushing) of labor can involve several different approaches. There are many benefits to pushing according to your own body’s urging and natural rhythms. Your uterus will actually push the baby out for you without any straining from you if you are in a gravity utilizing position–upright–and following your body’s spontaneous pushing urges! Some care providers and nurses instead encourage “purple pushing”–this is often the kind of pushing you see on television portrayals of birth, prolonged breath holding and bearing down, red straining face, and directed efforts (often with loud counting to 10).

The benefits of spontaneous bearing down instead of controlled, prolonged, directed pushing, and straining include:

less strain on your perineum and consequently less chance of tearing
less incontinence later
better oxygenation for your baby (less breath holding–>more breathing–>more oxygen for baby)
less wasted effort since you are working in harmony with your uterus

If you have an epidural, delaying pushing until you feel an urge or the baby’s head is visible on your perineum is preferred as well and reduces your chance of tearing and of trying to push out a malpositioned baby.

How can your labor support person “push the issue of pushing” during labor? (i.e. support you in spontaneous pushing instead of the controlled, directed pushing common on labor & delivery units). Your labor support person–husband, partner, friend, mother, sister, doula, or other person offering you their nonmedical companionship during labor–can remind provider and nurses of your birth plan (which should specify spontaneous pushing). If directed pushing is being used anyway–i.e. loud counting–your labor support can try the counting as well once or twice and then ask you in an audible voice: “does it help you when I count like that while you push?” You can then say, “no”–this is not directly offensive to nurses, but clearly states what is helping and what isn’t and getting pushing back into your “court” which is absolutely where it belongs!

Thanks to the fabulous publication International Doula for getting me thinking about this topic (and for the catchy title)!