Thursday, May 1, 2014

Inductions help avoid C-sections? Really?!

My wanderings around the web led me to this website, run by a doctor (and Jewish mother) who basically takes a stance that is entirely against home births. I will admit that some of her writings have a point, even to someone like me. You might know that I previously had two completely natural births (in a hospital). The experience of my hospital stay wasn't wholly pleasant, but I am no longer sorry that I didn't have a home birth. 

Quite apart from the fact that I could not afford it - in Israel, hospital births are government-funded and 100% free, while home births with a midwife cost quite a bit of money - I've re-thought my entire attitude towards the matter ever since a family that lives near us tragically lost their baby. It is true that in their particular case, the tragedy was probably unavoidable - so, at the very least, they are not burdened with guilt for not going to the hospital earlier - but it made me aware of the fact that bad things happen. Well, of course we all know bad things happen, but it's different when it's happening to someone you know. And should anything go wrong, I want to have doctors and all the necessary medical equipment down the hall -not always hovering near me. Not if I don't need it. But 30 seconds away, if something should happen. Not a 10-minute car ride away, because the difference between 30 seconds and 10 minutes can be the difference between life and death. 

Having said that, I do find myself raising an eyebrow while reading the following post, based on a study that claims inductions actually lower the risk of C-sections (contrary to other studies). I can imagine a scenario when an induction is medically necessary, but the mother refuses to have one, or wants to wait, until there is fetal distress and a C-section is needed. However, isn't it a bit too much to say, "So it seems that if you want to reduce your risk of C-section, one of the most effective things that you can do is to have an induction of labor"? I don't know about you, but to me this sort of implies you shouldn't even try to birth naturally! 

Medical intervention without clear-cut indication is simply unethical. When I showed up at the hospital, only 1.5 cm dilated, only 5 days past my due date, with my amniotic fluid intact and fetal heart rate and all parameters absolutely normal, and was told I "need" an induction because "you can't be here indefinitely", that was unethical. True, if I had been induced, we would probably have, by and large, the same outcome (vaginal birth, healthy mom, healthy baby). True, perhaps in the large scheme of things my natural birth plan wasn't that important. I'm sure my friend, the one who lost her baby, would much rather have a C-section and a live baby. But in my case it wasn't a clash between natural birth and the baby's safety. It was a clash between natural birth and the hospital staff's convenience.  

By the way, I consider excessive cervical examinations, or any other procedure that is potentially distressing to the mother, and can be avoided (like having too many people in the room), an unnecessary intervention, because stress can (and did, for me) make the process of labor stop, especially in the beginning. Why would a mother in a normal birth process need 2 cervical examinations in an hour?! 

I remember at Tehilla's birth, the midwife walked in to check on us, smiled and said, "oooh, I see this baby is coming really soon!" - and I was flabbergasted. I mean, how could she know just by looking at me? I thought she was kidding. It wasn't like I was on all fours, rocking my pelvis and grunting. My husband and I were lounging around, and I was nibbling on some fruit dipped in honey (it was Rosh Ha-Shana night). I actually thought I'm having a break between contractions and that there's still time. Turns out many women have this "quiet spell" just before transition. The midwife didn't need to poke and prode; she had seen enough births to know we were progressing well. 

I'm very glad we live in an age of advanced medical technology. I'm glad we have options. I'm very, very happy mothers in developed countries no longer bleed to death because of placenta previa. But I still maintain that all interventions should be left as a stand-by, to be used when necessary


Deanna said...

The article about induction of labor doesn't seem to have a survey on how this procedure affects the momma. For the sake of convenience, my doctor broke the water when I went to the hospital for my first planned delivery. He was going to be out of town when my due date was. I was young, not experienced at having a baby, scared and way too trusting. Completely trusting my doctor, I thought he knew what he was doing. The baby was not in trouble, it was by suggestion of the doctor to do this procedure and who was I to question this well seasoned doctor. My due date wasn't for two more weeks. The doctor had difficulty breaking the water and struggled to puncture the bag. Hum. I went into labor quickly and would vomit. A few years later, this same doctor would induce labor for my sister causing her baby to be born a month early. Again the baby was not in trouble.

Mrs. Anna T said...

Deanna, breaking the waters prematurely seems to me not only unnecessary, but downright dangerous, placing the mother at risk of infection.

Anonymous said...

I am so sorry your neighbor has had to go through this. Yes, babies do die when born at home sometimes. What we are not told is that they also die when born in hospitals. Actually, they die more often in hospitals, but no one wants to talk about that.

One of the biggest killers of mom and baby is infection. There are germs that don't exist anywhere on earth but in hospitals. Mom is already immune to the germs in her own home, and has passed that immunity down to her baby. There are babies and moms who would not have died had they just stayed home, but who lost the battle because they went to the hospital.

Honestly, more than 90% of the time birth is not a medical event, but a simple biological event. A large % of the remaining births can be handled easily by an experience midwife, without risking infection. The tiny number that actually do need doctors almost always give plenty of warning (hours).

Sometimes the safest thing a mom can do is to stay in her own home.

Mrs. Anna T said...

BettySue, the way I see it, births are divided into three categories:

1) Safe for Mom and baby and can be handled both at home and at the hospital. This category comprises the vast majority of births. Problem is, you can only know in hindsight what your birth will be like.

2) Ending in tragic death of Mom or baby that could not have been prevented. This is what happened to my neighbour. Even if she had gone to the hospital with the first contraction she felt, and you know even doctors don't usually advise to do so, her baby was already dead. It was horrible but unavoidable.

3) The third group is births where medical intervention is needed for the sake of Mom or baby, during or after birth. If I ended up in this category - and remember, you can never know for sure - would I like to be "near" the hospital, as in a 10-minute drive away, or IN the hospital? Certainly in the hospital.

Can I think of situations where quick intervention is needed? Hypoxia, shoulder dystocia and postpartum hemorrhage are just a few situations where I'd rather be in the hospital to begin with than transfer to a hospital.

Of course the majority of perinatal and neonatal deaths happen in hospitals. That is because hospitals handle all (hopefully all!!) the high risk cases, such as preemies or babies with congential defects.

The risk of infection is real. That's why I don't rush myself and my children to the doctor for every trivial little cold: I know that there are usually far worse bacteria and viruses in the waiting room.

However, as you rightly noted, most of birthing mothers are not sick. Since (at least in the hospital where I gave birth), I entered through the L&D ward, passed straight to the maternity ward, and only met mothers like myself (not one looked sick) and staff which only worked in the L&D or maternity wards, I would say that my risk of catching infection wasn't much higher than, say, if I went to a mall.

You are right that statistically, odds are that you can give birth at home and probably be fine. But as what's at stake is so, so precious - your baby! - I personally wouldn't take even a small risk.

Anonymous said...

Hi Anna,
I just became a mom 5 weeks ago, and rven before I was pregnant, I used to read the articles on your blog about childbirth and found them to be very helpful. The c-section insanity is so real these days with one of three births being c-sections in my area. I planned a home birth but ended up having to go to the hospital after 24 hrs laboring at home. I was exhausted and not able to keep down fluids or food and the labor went another 10ish hours once I went there and so I really think that if I had not had an epidural and been able to sleep a little bit before transition and pushing that baby and I would have died. My baby had to be vaccum assisted. I think homebirths are great and wish I could have had one. But I think there is another factor why there are so many c-sections and complications like mine these days- on average people are simply weaker than they used to be. Maybe because of junk food or just the modern stressful lifestyle. I think its important to know yourself when planning a home birth. I probably should have admitted that I was more a frail sort of person who was already kind of weak from lots of morning sickness. Anyway that was my experience.

Mrs. Anna T said...

Anon, I'm so sorry your birth experience was a difficult one, but at least it ended well (not to be taken for granted). I don't think morning sickness has much to do with having a difficult labor (unless you're having it right to the end of pregnancy and it prevents you from eating and drinking properly). However, it is a very logical possibility, in my eyes, that some mothers have birth complications because our pelvic bone structure doesn't develop properly since our nutrition isn't up to scratch. The findings of Dr. Weston Price on this matter are indeed striking. However, you must not forget that in the past, too, many women had complicated births (and far fewer than today lived to tell the tale).

I don't think anyone is "weak" for getting an epidural. I would have gotten one if labor had been unbearable, or if it had lasted much longer than it had. I actually asked to be checked for dilation, with the thought that if I hadn't progressed much, I'd ask for the epidural. I was exhausted, but then I was told I'm already 9 cm, which put fresh heart in me. I had a nice nap before transition too!

Also, though I had two uncomplicated natural births, it is no guarantee to what I might have in the future. The baby might be in odd position. Or I might have twins. Or placenta previa. You just do what is best and right for you and the baby in your individual situation... though, I must admit, I am now rather pre-disposed against home births as a rule, just because I'd like a safety net and you never know when you're going to need it.

Lady Anne said...

Our youngest daughter is a tiny thing - less than five feet tall and under 100 pounds. When she was pregnant with her first baby, her doctor let her go two weeks past her due date, and then spend over 12 hours in hard labor before he *finally* decided to do a C-section. The doctors know how big the baby is; there was no excuse for him to allow her to get to such an awful situation. An induction when the baby was full-term - not two weeks late! - might have allowed her to deliver naturally, and to make her go so long when it was obvious the baby was too large was simply inexcusable. We could have lost her.

She had another doctor for her second child, and when she told him what had happened the first time around, he was aghast, and told her exactly what date her baby would be born - by C-section.

Mrs. Anna T said...

Lady Anne, it does sound like a tale of appalling negligence, and the opposite of what most doctors would do. Sometimes, though, the doctors do *not* know how big a baby is until he's out. A friend of mine was told her son would be around 3.5 kg (just a little above average). He was born at 4.1 kg (9 lbs)! Thankfully the birth went well. If it hadn't, no doubt there would be a malpractice lawsuit.

Also, a little about due dates. It is so, so important to, first, estimate the due date correctly (and not automatically based on date of last menstrual period), and second, remember that there's variation.

I should know. I was supposedly 43 weeks and 3 days (!) when I finally gave birth to Tehilla. But I *knew* I was not really that much overdue. How? I knew I had ovulated not 14 days, but more like a month after my LMP (I was nursing and my cycles were off). Which means I went into labor at around 41 weeks, which was consistent with my previous delivery (also 41 weeks).

However, did the doctors listen when I told them I can't be that far along? Nope. All throughout my pregnancy, I was told my baby is "really tiny", even though I kept saying the approximation of gestational age is way, way off. I was diagnosed with IUGR. They wanted to hospitalize me for observation (I cried. I had a toddler and home to take care of, I was feeling great, and my baby was a vigorous kicker and WAS growing - according to the REAL pregnancy dates).

When I finally went into labor, I lied to the hospital staff. Yes, I lied, but I also told the truth. I told them I was 41 weeks along. It was mathematically incorrect but biologically right.

She was born at 3.5 kg, a beautiful weight, no sign of being "postdates", and the placenta was fine, too.

This taught me an important lesson: if I'm ever pregnant again, and I know I ovulate late, I'll tell the doctor that my LMP was exactly 14 days before my ovulation day. Otherwise, I'll get a lot of grief.

harper said...

My midwife for my third child once spent a year practicing midwifery in a remote village in Ghana. The clinic there has few resources (which have to be rationed), and a trip to the helicopter pad that can take you to the nearest hospital takes two hours under the best circumstances. How do they deal with placenta previa there?

It is not fatal. They break the woman's water and start her on a slow pitocin drip to induce labor. By breaking the woman's water, the pressure on the placenta is relieved, allowing it to reposition itself (possibly with help), and no hemorrhage occurs. Once labor has started, the pitocin drip is turned off, and labor continues as normal.

When informed that placenta previa is considered a catastrophic complication in Western countries, the local midwife/nurse was shocked that we were so backwards. It had never occurred to her that this would be a necessarily life-threatening situation.

Mrs. Anna T said...

Harper, yes, there are non-surgical methods to deal with placenta previa. I have read about such procedures, especially from times when C-sections weren't as safe as today. However, today, statistically, the risks of a C-section are less than those of dealing with placenta previa in another way.

It doesn't mean that a mother with placenta previa who refuses a C-section will always bleed to death. But her chances of a good outcome for her and for the baby will be better with a C-section.