Interventions

Read Aryn’s post “Labor Induction: The Reasons for Caution are Many”

Click on an intervention to jump to informational reading:

Epidural regional anesthesia resulting from injection of an anesthetic into the epidural space of the spinal cord; sensation is lost in the abdominal and genital and pelvic areas

Induction a method of artificially or prematurely stimulating childbirth

Electronic Fetal Monitoring (EFM) Internal or external monitoring of the baby’s heart beat, often carried out during labour.

Cesarean sectionthe delivery of a fetus by surgical incision through the abdominal wall and uterus

Episiotomy surgical incision of the perineum to enlarge the vagina and so facilitate delivery during childbirth

Quotes taken from the following books and abbreviated as follows:
(Birth) “Birth: The Surprising History of How We are Born” by Tina Cassidy
(Pushed) “Pushed” by Jennifer Block
(GMO) “Get Me Out: A History of childbirth from the Garden of Eden to the sperm bank” by Randi Hutter Epstein
(BYW) “Birth Your Way” by Sheila Kitzinger
(OLG) The Official Lamaze Guide
(CBPC) “The Complete Book of Pregnancy and Childbirth” by Sheila Kitzinger
(ID2) “Immaculate Deception II” by Suzanne Arms


Epidural

“God’s gift to women? Perhaps. But once again, there are drawbacks. Women hooked up to epidurals are more likely to need artificial stimulation, such as Pitocin, to keep contractions strong. They are also more likely to have their blood pressure drop; develop a fever; and have difficulty passing urine, and so are regularly catheterized. Being unable to feel from the waist down makes pushing difficult, and there is a greater risk of needing forceps or a vacuum to complete the job. Though research has shown that epidurals do not raise the likelihood of a cesarean, there is controversy surrounding the issue. One study has shown that epidurals increase the likelihood of the baby presenting in the posterior position-in other words, not fully rotated. Such a presentation does lead to higher cesarean rates.” Birth pg. 100-101

“Research clearly links epidurals with fewer normal vaginal deliveries, more instrument deliveries, and longer labors, particularly for first time mothers. Women with epidurals are more likely to have fever during labor, and as a result, their babies are more likely to be evaluated and treated for infection. This means mother and baby get separated. There’s some evidence (though less conclusive) that epidural use-especially by first time mothers- increases the risk of cesarean…You may be told that epidural medication does not reach the baby. This isn’t true: Baby gets it within seconds of administration.”  OLG pg. 119

“But when women are routinely not able to feel the pain and respond to it- to move their bodies- they are more vulnerable to injury…When we’ve got a baby that rams through because its mother doesn’t feel anything, we’re increasing the risk of damage to her pelvis, to her vagina, and to her pelvic floor. And we don’t know whether we’re increasing risk to this baby. We’ve taken a hugely protective part of physiology and gotten rid of it.” Pushed pg. 173-174

Medicating the pain away disrupts labor. If you can’t feel the pain of contractions or the pressure of your baby’s descent, you can’t respond to it. Your body doesn’t know to release more oxytocin, and your birth canal is more vulnerable to damage. Removing labor pain also prevents endorphin release, depriving you the natural high of childbirth. Remove the pain at any point in the journey, and you remove the signals your body needs to keep labor progressing and to protect itself and your baby. OLG pg. 101

“In 1953, after rating more than a thousand newborns at the hospital, Apgar found that babies in the best condition were natural (not anesthetized) vaginal deliveries.” Birth pg. 160

“It is true that an epidural can provide blessed relief when a women is in uncontrollable pain. But often the pain is actually caused by the way she is being treated. The hospital environment, with its rules, tests, and the constant threat of obstetric intervention, is pushing up both the mother’s catecholamine levels and those of her baby. (When catecholamine levels rise abnormally in a woman in labor, her uterus contracts less efficiently, contractions become weaker or spasmodic, dilation of the cervix is slower, and labor longer.” BYW pg. 20-22

“For the mother the most common direct complications resulting from epidural anesthesia, other than increased risk of cesarean, are the lowering of her blood pressure. an increase in her temperature, and the inability to push her baby out. In addition, there are rare but life threatening complications that include convulsions, breathing paralysis, cardiac problems, allergic shock reaction, nerve injury and spinal headache. For the baby there are two direct risks. The first occurs when the mother’s blood pressure drops-to the baby through the placenta. The second is the tendency for the baby’s heart rate to change. In one recent study 11 percent of all the babies whose mothers had epidurals showed “profound” and “prolonged” heart rate changes…epidural anesthesia given to the mother results in an indirect but serious complication for some infants. These are babies whose mothers get a fever as a side effect of the epidural. Because infection is a serious threat to a newborn, it is generally hospital policy to put these babies in a high-risk nursery for three days. During this time they undergo painful procedures and are put on strong antibiotics.” ID2 pg. 82

“But it (the epidural) may have side effects for the mother and baby. Fifteen percent of mother’s and babies develop a fever during labor…Another thing that may happen is that the mother’s blood pressure drops suddenly when the epidural is given. This reduces the oxygen passing to the baby. The vaginal surgical delivery rate is four times higher than when a woman does not have an epidural, and the cesarean rate is twice as high. BYW pg. 30

Induction (Pitocin)

“In particular, the baby gives a signal when its lungs are mature. For a baby to born implies that the lungs are ready, because to be born is to breathe. When you induce labor, or when you do an elective cesarean section with no labor, the baby has not given the signal. The baby has not said, “I am ready, I am mature.” In other words, induced labor is preterm labor. Pushed pg. 140

“The midwide Gail Hart notes, “We can make a woman have contractions, but we don’t always succeed in forcing her body to release the baby and give birth. If we start a labor with chemicals, we may very well have to finish it with a surgeon’s scalpel. Pitocin also summons contractions that are stronger and more frequent than those produced by the body, which, if they are not monitored properly, can lead to hyperstimulation of the uterus-contractions that come too hard and too fast- which can cause fetal hypoxia, or oxygen deprivation.” Pushed pg. 14

“The reasons for caution are many. An induced labor is riskier than one that begins on its own. Not only is it more painful-Pitocin causes fierce contractions-induction is more likely to lead to fetal distress, more likely to require pain relief, more likely to end up in Cesarean, and more likely to cause a previous uterine scar to rupture. Some parents and researchers have even suggested that there is a link between the Pitocin epidemic and the higher incidence of autism since the mid-1980s.” Birth pg. 178

“The risks of induction: 1) Induction does not always work. Failed induction leads to cesarean section. 2) If the baby’s head is not down and membranes are ruptured artificially the first rush of amniotic fluid may bring the cord down and deprive the baby of oxygen. 3) Rupture of membranes can cause infection. 4) And induced labor is often fast and furious, so it is more painful than one that starts naturally. 5) Being immobilized makes it more likely that dilation is slow, and so the drip is turned up and more artificial oxytocin is fed into a woman’s bloodstream…6) Occasionally the uterus becomes hypertonic. That is, it clamps down on the baby with strong contractions lasting two minutes or longer, and this reduces the flow of blood. 7) Hyperstimulation of the uterus sometimes results in uterine rupture…8) There is increased risk of amniotic fluid embolism…At home or in a birthing center labor is not induced. This is because it is recognized that induction brings risks and may entail other forms of intervention.” BYW pg.23-24

“As (unmedicated) labor progresses, the contractions become stronger and more frequent, culminating in the “ejection reflex”…Pitocin has no such intelligence. And with an epidural deadening the bodies natural pain threshold, staff cam keep upping the dose, which can lead to contractions that fire like a machine gun or that last for minutes, during which time the fetus is oxygen deprived. This is called hyperstimulation. It is not uncommon and would be considered a trauma-beyond what is normal. In half of the cases of hyperstimulation, a fetal heart rate drops below normal (this is called a “nonreassuring” heart-tone. If it stays there, it’s fetal distress…Clinicians and women have the impression that its harmless.” Pushed pg. 137

“Some say scheduling births is all doctors can do to maintain their level of income while larger and larger portions of it are earmarked for malpractice insurance premiums. If a doctor misses a birth, he loses revenue. Even if an induction doesn’t work, a cesarean is waiting. And from incision to sutures, a cesarean takes less than an hour.” Pushed pg. 42

“Many women are told that elective induction has no downside. This is not true. Elective induction carries many risks and disadvantages. The important events of late pregnancy and early labor do not have a chance to unfold. Your cervix may not be sufficiently soft. Your uterus may not be highly sensitive to oxytocin. Your baby may not be mature enough. A baby who’s even slightly early is more likely than a full term baby to have problems adjusting to life outside the womb. Your baby may have trouble breastfeeding and is three times more likely to die in the first year of life than a full term baby. Labor is usually induced with intravenous (IV) Pitocin, a synthetic oxytocin. Pitcoin contractions feel stronger and peak more quickly than natural contractions. Also, you uterus never totally relaxes between contractions, which puts more stress on both your uterus and your baby. Pitocin doesn’t cross the blood-brain barrier, so your brain doesn’t get the message (as it would with natural oxytocin) to release endorphins. Without endorphins, you have no natural pain relief and thus have a greater need for pain medication. When your labor is induced, you also require IV fluids, continuous electronic fetal monitoring (EFM) and sometime a bladder catheter…Labor induction alters not only the process of labor and birth, but also postpartum events. Pitocin short circuits your natural hormone release, so neither you nor your baby experience the catecholamine surge necessary for energy and alertness after birth. Your baby is less likely to crawl to your breast and latch on and is less likely to make the head and hand movements on your chest that stimulate continued oxytocin release, which controls bleeding and helps your milk let down…Suspecting a very large baby (macrosomia) is not a good reason for induction. Research shows that inducing for “overdue” babies (before forty-two weeks) increases labor complication and cesareans without improving neo-natal outcomes. Unless you or your baby has a health problem that necessitates induction, it makes sense to wait patiently for labor to start on its own.” OLG pg 107-108

There’s strong evidence that breaking your water (manually rupturing your amniotic sac) will shorten you labor if your labor is prolonged of contractions are very slow, but it carries risks too. When your membranes are broken manually, both you and your baby are exposed to greater risk of pressure injury as well as greater risk of infection. Research also shows an increase in cesareans with early rupture of membranes…A systematic review of the research suggests that only women with truly abnormal labor progress should have their water broken, and that only women with truly prolonged labors and sluggish uterine activity should receive Pitocin. Neither intervention should be used routinely. OLG pg.118

Electronic Fetal Monitoring

“Another typical cause for an unexpected cesarean is because a “nonreassuring” fetal heart rate is detected by the electronic fetal monitor (EFM)…Many critics, studies, and even obstetricians marvel at the machine’s inaccuracy in, on the one hand, detecting trouble; on the other, signaling that the baby is having difficulty when in fact the child is fine. About 15% of all laboring women end up with an emergency or “stat” C-section because of the fetal heart monitor’s nonreassuring signals. A 1993 report in the American Journal of Obstetrics & Gynecology looked at ten major studies of the monitors and found that a fast or slow fetal heart pattern could not accurately predict how a baby was doing. Konrad Hammacher, a primary inventor of the Hewlett-Packard monitor…has said doctors shouldn’t use an EFM as the focus of care or the basis for a cesarean.” Birth pg. 121

“Risks of EFM 1) Sometimes the monitor picks up the mother’s heartbeat rather than the baby’s….it then appears as if there is fetal bradycardia. Unnecessary intervention takes place…2) Sometimes the opposite happens: caregivers are lulled into false security when a woman is wired up to a monitor and no one bothers to check regularly or looks at the whole pattern of her labor…3) The use of most monitors means that she (the mother) must stay in one place…this immobilization causes unnecessary pain and may slow down contractions and make them weaker so that dilation is slower….4) Attention turns to the electronic equipment rather than being focused on the woman’s needs, and she loses emotional support…5) In most hospitals the introduction of electronic fetal monitoring immediately pushes the cesarean section rate up at least threefold…6) Information that the fetal monitor provides bears little to no relation to the baby’s condition at birth…7) Many monitors don’t work well all the time.” BYW pg. 27-29

“A great deal of research done well after EFM was introduced compares fetoscope and Doppler use with continuous EFM. Evidence shows no difference in outcomes for babies and a higher rate of cesareans and operative vaginal deliveries for mothers with continuous EFM. Why? Its difficult to interpret EFM printouts. Misread printouts lead to mistaken conclusions, and caregivers often intervene unnecessarily when labor is actually progressing normally and baby is doing fine. In other words: for most labors, more intensive monitoring increases obstetric intervention (and risk) with no clear benefits for babies. OLG pg. 117

Cesarean (C) sections

“Labor, and the descent through the birth canal, prepares babies for their life outside the womb in a way that nothing else can duplicate. It is this action that stimulates the baby’s adrenal glands to produce the hormone that allows the baby’s body to do on its own all the things that were up until now done for it in the womb. This stimulation does not occur in the event of cesarean surgery.” ID2 pg. 20

“The frustration for Friedman…is that doctors have used his averages…as rigid benchmarks for monitoring labor’s progress, without considering how many women fall on either side of his asymmetrical bell curve. There is a wide range of “normal,” Friedman says, admitting he’s distressed and disappointed by how the curve is misused to diagnose a woman’s failure to progress, the most common reason American doctors list on charts for justifying a C-section. This is not how is was supposed to be. He had intended the curve to be a simple visual tool to help obstetricians, midwives and patients determine if and when labor might be deviating widely…from the normal range.” Birth pg. 158

“No matter how you slice the data, it is hard to believe that one in three women are unfit for vaginal deliveries. Cesarean section rates have increased by 46% in the past ten years without a comparable drop in maternal mortality. Are we saving lives?…No matter how much technology we add to the delivery room, it does not seem to take out the guesswork. It only leads to more operations.” GMO pg. 167

“Epidurals have been a boon to cesarean surgery because they make it possible for women to undergo a cesarean, yet be awake to see their baby born, and be able to hold it in the first minutes of life…Unfortunately, women have the impression today that a cesarean surgery is not a serious or risky procedure, and that is partly due to epidural anesthesia.” ID2 pg. 80

“A study in the British Journal of Obstetrics and Gynecology reveals that nearly half of all women who have a baby by Cesarean section do not go on to have other children-almost one in three because of infertility problems, and one in five because the Cesarean experience was so awful they could not face another birth by this method.” CBPC pg. 350

“Studies suggest that when fetal monitoring first came into use, C-sections skyrocketed…Once a women is attached to a machine, she is confined to a bed and on her back, which is thought to slow labor. The slow labor encourages doctors to use drugs to induce labor. Sometimes drugs-if used too soon in high doses- can cause strong contractions too early, another reason for surgery.” GMO pg. 165

“Consider the fact that one out of every four births in the United States since 1988 has been a cesarean surgery. Moreover, consider the overwhelming majority of cesarean births do not occur among those women who might be considered medically at high risk. Cesareans are much more often performed on healthy, well-educated, middle-class women who go to private physicians and give birth in private hospitals. Among the same population of women who have midwives at their births, the cesarean rate is well below 10 percent.” ID2 pg. 60

“The baby born vaginally has less mucus in her respiratory tract than one delivered by Cesarean section. (especially an elective Cesarean)…the baby can also maintain her own body temperature better after a vaginal birth.” CBPC pg. 359

Episiotomy

“In fact, recent scientific trials have shown that this procedure, except in cases of fetal distress or other rare situations, has no advantage and causes unnecessary damage to the perineum.” CBPC pg. 155

“Trials conducted…revealed that women with an intact perineum, or only a superficial tear, experience less pain after childbirth than those who have undergone an episiotomy. Women are also more likely to suffer severe tears into the anus with an episiotomy than when they have not had one…if done too early-it can cause unnecessary bleeding…and often the stitches get infected and antibiotics are necessary.” CBPC pg. 332-333

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