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Thursday, September 11, 2014
Truth About Medical Interventions – C-Sections, Inductions, Epidurals
Truth About Medical Interventions – C-Sections, Inductions, Epidurals
C-Sections Instead of Breech Delivery
Routine cesarean section for breech presentation has been recommended over the last forty years. As a consequence, the rate of vaginal breech delivery has decreased sharply. In the United States, the rate of cesarean section for breech presentation rose from just 10 percent to nearly 80 percent in 15 years (1970-1985). On closer examination, however, it is clear that the association between breech presentation and perinatal mortality is due principally to the confounding variables of prematurity and congenital malformation. Traumatic injury and complications giving rise to birth asphyxia in a vaginal breech delivery are uncommon. The recommendations for routine cesarean section have therefore been made on the basis of imperfect data. The issue of vaginal delivery compared with abdominal delivery of the term breech pregnancy is currently being addressed in a worldwide multicenterrandomized controlled trial (“The Term Breech Trial”). -MIDIRS 9:1, March 1999
Reasons for present cesarean rate
1. Dystocia or failure of labor to progress (31% of cesareans): pelvic opening too small for the baby; birth canal too small for the baby; contractions irregular or not intense enough to dilate the cervix.
2. Breech presentation (12% of cesareans): baby emerging feet first.
3. Repeat cesarean (31% of cesareans): mother has previously given birth by cesarean.
4. Fetal distress (5% of cesareans): baby is shown to have abnormal heartbeat pattern with fetal monitoring, and diagnosis is confirmed by fetal scalp blood pH testing.
5. Other (21%) of cesareans): maternal illness such as diabetes or heart disease, active herpes, or medical emergencies such as placenta previa or prolapsed cord.
A study that looked at outcomes of pregnancies complicated by a multiple nuchal cord entanglement included 8,565 deliveries. A single loop of cord around the fetal neck at delivery was found in 2,191 deliveries, and more than one loop was found in 326 deliveries. Pregnancies with a multiple cord entanglement were more likely to have an abnormal cardiotocograph consisting of persistent variable deceleration in advanced labor. These infants were also more likely to have meconium, a low Apgar score at one minute, and a low umbilical artery pH of 7. There was no difference in the rate of cesarean sections, placental abruption and Apgar scores at five minutes between the two groups, and no stillbirths occurred in the cord entanglement group. The study concluded that with multiple nuchal cord entanglement there was no risk of adverse neonatal outcome, and that a multiple cord entanglement is not a contributing factor in intrapartum stillbirth, placental abruption or cesarean delivery. MIDIRS Dec. 1996
Prerequisites for a safe vaginal birth after a previous cesarean (VBAC):
Common management guidelines:
1. Parents have discussed all the pros and cons of a VBAC with their doctor.
2. The present pregnancy has no indications for recommending a cesarean section.
3. A low transverse incision was used in the previous cesarean section.
4. The mother is admitted to the hospital early in labor, so that her progress can be carefully monitored.
5.Backup facilities for an immediate cesarean section are available.
Controversial Management Guidelines:
1. Some doctors will not permit a trial labor is the mother has previously had a cesarean section because of too small a pelvis.
2. Some doctors won’t use drugs that stimulate labor if the mother has had a previous
3. Some doctors don’t recommend regional anesthesia during a vaginal delivery after a
cesarean because they believe it could mask rupture problems.
4. Some doctors recommend theroutine use of low forceps to shorten labor if the woman
has previously had a cesarean.
Patient choices suggested by the cesarean support groups:
• Allow the mother to forego any preoperative medication.
• Allow the mother to choose regional anesthesia so she can see the baby being born.
• Use epidural anesthesia if a qualified anesthesiologist is attending.
• Use a low transverse skin incision whenever possible for cosmetic reasons.
• Allow the father to remain with the mother in the delivery room.
• Allow the mother to have her arms free.
• Allow the mother to view the birth without a screen or with a mirror.
• Encourage the doctor to talk reassuringly with the parents during the operation.
• Allow the mother, if possible, or the father to hold the baby immediately after the birth.
• Have the initial routine pediatric exam done where the parents can watch.
• Delay weighing, measuring, and eye drops until after the initial bonding period.
• Allow for the mother, father and baby to remain together in the recovery room during first hour after birth.
• Allow the mother to nurse the baby as soon as the operation has been completed.
• Allow the mother to have full rooming in as soon as she wished.
• Allow mother to have a helper such as the husband or a friend to assist her in caring for the baby.
• Allow siblings to visit the mother and baby daily.
• With repeat cesareans, have preliminary laboratory test done on an outpatient basis so the mother does not have to be admitted until the day of the surgery.
In one day’s time I received two calls asking about the relationship between the administration of pitocin and neurologically compromised infants at birth and my intuitive antennas went off. Pitocin is a synthetic version of oxytocin the naturally produced hormone in the laboring woman. It is preferably administered through IV. As with all drugs, it does not come without its side effects, the most common being increased blood pressure in both the mother and child. Even the American Academy of Pediatrics agrees that no drug has been tested as safe for the baby in utero.
Pitocin is used for either labor induction or labor enhancement (what an inappropriate use of that term!) The use of pitocin does not, however, duplicate the natural progression of labor. Pit induced labors have longer, harder and more painful uterine contractions. Additional reported risks of induction are:
For the mother: higher rate of complicated labors and deliveries, greater need for analgesics and anesthetics, postpartum hemorrhage and a higher rate of placental rupture and separation life-threatening to both the mother and baby.
For the baby: induction causes fetal distress, a higher rate of jaundice, a greater chance of a prematurity, low apgar scores at 5 minutes, permanent central nervous system or brain damage and fetal death.
In either induced or enhanced use of pitocin, the blood supply (therefore the oxygen source) to the uterus is greatly reduced. With naturally paced contractions, there is a time interval between contractions allowing for the baby to be fully oxygenated before the next contraction. In induced or stimulated labor, the contractions are closer together and last for a longer time thus shortening the interval where the baby receives its oxygen supply. Reduced oxygen could have life-long consequences on the baby’s brain. 1
It is the belief (not necessarily the practice) in the medical profession that induction should occur when the risk of continuing pregnancy presents a threat to the life of the mother or baby. These situations include: some severe diabetics, kidney disease, severe preclampsia, severe high blood pressure, kidney disease, and an overdue pregnancy where a danger to the fetus has been proven. If induction were carried out only when these conditions were present, at most, an estimate of 3% of births would be induced. 2
In reality though, due date paranoia remains the most common reason for induction and the consequent use of pitocin. Surprisingly, studies on the due date calculations revealed frightening evidence. Firstly, the due date varies significantly between first time pregnancies and subsequent pregnancies. 3 Also, maternal race has been shown to be a determining factor in gestation time. 4
Another variable to the accuracy of the due date is the recent dependence of ultrasound as a reliable criteria for infant size and gestational age. First trimester measurements have an error bar of ± 5 days, increasing to ± 8 days in the second trimester and are as high as ± 25 days in the third trimester!
Bigger fetuses are assumed to be older and in studies where the ovulation date was known 70% of women who were classified as postdates were incorrectly dated. 6
Furthermore, studies on induction have shown that 30% of fetuses testing normal developed fetal distress when labor was electively induced and the cesarean rate was 15% versus 2% for spontaneous labor. 7
Using pitocin to enhance labor leads to an increase in epidurals, and therefore obstetric intervention during birth adding additional risks to both the mother and baby. (See ICPA Newsletter Jan/Feb, 1999). And finally, a controlled randomized study showed that the use of pitocin to stimulate labor was not as productive for the progression of labor as allowing mothers to change positions during labor by walking, sitting or standing. 8 Giving the mother back control of her body–what a novel idea and topic for a future newsletter.
As more and more interventions are added to the birth process, the cause of birth trauma is proportionately rising. It is our job as chiropractors to continue to educate mothers about the choices they have in birth and help reduce the devastating effects birth trauma is having on their babies’ delicate nervous systems. It is a huge job ahead of us, yet I know chiropractors have the passion and the means to make it happen!
Jeanne Ohm, D.C., F.I.C.P.A. – Originally Printed in: I.C.P.A. Newsletter January/February 20001. “A Good Birth, A Safe Birth” Diana Korte and Roberta Scaer2. Caldeyro-Barcia R. “Some consequences of obstetrical interference. Birth Spring 1975; 2(2)3. Mittendorf R, Williams MA, Berkey CS, Cotter PF. The Length of uncomplicated human gestation. Obstet Gynecol 1990; 75(6): 929-9324. ibid5. Otto C, Platt LD. Fetal growth and development. Obstet Gynecol Clin North Am 1991; 18(4) 907-9316. Nichols CW. Postdate pregnancy. Part I. A literature review. J Nurse Midwifery. 1985; 30(4):222-397. Devoe LD, Sholl JS. Postdates pregnancy. Assessment of fetal risk and obstetric management. J Reprod Med 1983; 28(9); 576-5808. Read JA, Miller FC, Paul RH. Randomized trial of ambulation versus oxytocin for labor enhancement: a preliminary report. Am J Obstet Gynecol. 1981;139 (6):669-72
Why Women Do Not Like The “Induction of Labor” Procedure• Induced labor causes contractions to become far more painful than nature ever intended.• Induced labor causes women who would not have chosen drugs for childbirth to ask for them.• Induced labor puts the baby at risk of possible brain damage through oxygen deprivation.• Induced labor puts the mother at risk of uterine rupture if she previously had a cesarean birth.• Induced labor dramatically increases the risk of emergency cesarean birth.• Induced labor causes a woman to lose control and confidence in the natural birth process.• Induced labor causes a woman to be monitored excessively during childbirth.• Induced labor increases a woman’s chance of hemorrhage, during the birth and afterwards.• Induced labor causes a woman to be unable to complete hormonal staging.• Induced labor forces a baby who is not ready and a body that is not ready to try to give birth.• Induced labor by rupturing the membranes may cause a woman’s umbilical cord to collapse thereby increasing the likelihood of death to the baby.• Induced labor by rupturing the membranes may encourage the baby to assume a position that may cause the mother more pain and a longer labor that would have been experienced otherwise.• Induced labor causes lasting side effects in the mother of complete loss of sexual desire, prolonged severe postnatal depression, and reduced immune function. The use of Prostin, which is pig semen, is most certainly a reason for the woman’s loss of sexual desire reported regularly after childbirth.• Drugs such as misoprostal, used for induction have not been proven safe.• Induced labor may cause the baby to have lowered immune function, leading to allergies, asthma and brain seizures due to the effects of the animal hormone used to induce or force the labor, caused by the long after-life of this drug and due to the fact that many babies have been induced prematurely and their immune system is not fully developed yet.• Induced birth may permanently damage the woman’s uterus causing her to be unable or unwilling to bear more children
Words with a Midwife
Q: How and why do you induce labor?
If and when the intrauterine environment becomes more hazardous for the baby than the outside, or to relieve maternal suffering–which on occasion the mother can only subjectively describe. -Phil Watters, OBGYN, Hobart, Tasmania Australia
I feel odd responding to this question because I don’t induce labor. I am a direct-entry midwife in Kentucky. I have only been practicing independently for a year; however, I was trained by Mary Ann Watson, CPM, QE, a direct-entry midwife with over 18 years’ experience in homebirth. Her philosophy/protocols regarding induction questions are:
1. What if I never go into labor?
Women were designed to give birth. Gestation for each mother with each baby will occur at its own pace, just as labor progresses at its own pace. Just because the baby inside feels large enough to survive, it may need more time inside to develop a crucial system? No woman has ever been pregnant forever. Mary Ann continues weekly prenatal visits until the birth. As long as no complications arise, she does not risk out or induce women just because they are overdue.
2. What if my baby is too big?
Normal, healthy women do not grow babies they cannot birth. The species would have destroyed itself if this were true. Induction may also contribute to malpresentation. If the baby is allowed time to find a good birthing position, it will adapt to the pelvic inlet. Arbitrary induction may cause labor to begin before the baby is in a good position.
3. Should VBACs be induced?
Mary Ann’s practice prior to coming to Kentucky was primarily VBAC births. She has an excellent record of successful VBAC births. Her VBAC moms are not induced and do not have a greater complication or transport rate than her other clients.
4. What if the placenta stops functioning?
Normal, healthy placentas do not just stop functioning 14 days past the due date. I myself have had one client go either 3 or 5 weeks overdue (she was unsure of her dates). Mary Ann has had clients confirmed at 30 days or more overdue. Those babies were fine, and those placentas were healthy.
Some women do try to induce themselves with herbal preparations, castor oil, or some other home preparation. She firmly discourages this, for all the reasons above. Many of these induction attempts are not successful. One mother who was successful in inducing labor later regretted it. She had three productive, relatively short labors. This fourth, induced labor was long, slowly productive, and exhausting. She now discourages other women from trying to induce labor.
Our philosophy that birth is a natural process and our desire to allow it to progress with no intervention that is not absolutely necessary begins with good prenatal care and with accepting that labor will begin when it is time. -Candy Hall, midwife
The Epidural Epidemic
Epidurals during birthing have become so routine, as mothers are being convinced that pain during labor is unnatural. Convinced that they should not endure pain during the birth process, mothers are set up to believe in a drug instead of their bodies’ own natural capabilities. Sixty four percent of certified nurse midwives reported concern over the increased number of their clients who desire epidural anesthesia, and a majority of certified nurse-midwives surveyed (53%) reported a negative attitude toward the increased use of epidurals. 1
We started including questions about births years ago on our children’s case history and 9 times out of 10, mothers will check off that they had a “natural childbirth” and in the next question, they check off that they had an epidural. In other words, if they delivered vaginally, and their eyes were open, they are being led to believe that they delivered naturally.
What is not being provided to the parents is the increased complications which are a result of epidural usage. The PDR2 cautions that “local anesthesia rapidly crosses the placenta…and when used for epidural blocks, anesthesia can cause varying degrees of maternal, fetal and neonatal toxicity.” It continues, “this toxicity can result in the following side effects: hypotension, urinary retention, fecal and urinary incontinence, paralysis of lower extremities, loss of feeling in the limbs headache, backache, septic meningitis, slowing of labor, increased need for forceps and vacuum deliveries, cranial nerve palsies, allergic reactions, respiratory depression, nausea, vomiting and seizures.” Many of these side effects result in multiple complications. For example, maternal hypotension causes bradycardia (decreased heart rate) in the fetus. This altered heart rate can lead to fetal distress and operative deliveries.3
This has led doctors to warn “a high concentration anesthetics and epinephrine should be avoided, as they may influence labor.”
Things to Know About Epidurals:
1. Causes longer labors with slower progress.5 6
2. Can cause fevers in mothers during childbirth. 7
3. Increase use of pitocin by as much as 3 ½ times, which causes slow and irregular contractions. 5 8
4. Increases use of antibiotics in your baby by as much as 4 times. 4
5. Increases use of forceps by as much 4½ – 20 times.5
6. Causes neonatal jaundice due to altered red blood cells. 9
7. Increases the incidence of birth trauma due to the use of mechanically assisted deliveries. 10 11
8. Causes adverse behavioral effects of the neonate. 12
In order to bring about a reversal in epidural usage, mothers must become educated not only on its potential side effects, but on their bodies’ own ability to give birth naturally. The overwhelming fear associated with birth has become a learned behavior in our culture. Fear causes additional muscular tension in the body, resulting in decreased blood supply to organs and therefore impaired uterine function. It is our privilege and obligation as Chiropractors to care for these women throughout their pregnancies, offering them encouragement and educating about choices for their upcoming experience. I have been told by many chiropractors (and have heard it in our own practice) how women look forward to their visit with us because we treat the process of pregnancy with respect, and we enhance the mothers confidence in her own innate abilities.
Jeanne Ohm, D.C., F.I.C.P.A. – Originally Printed in: I.C.P.A. Newsletter March/April 1999 By Randall Neustaedter OMD, LAc, CCH | Published 8/11/2004 | Diseases and Conditions: Prevention and Treating | Excerpt from Child Health Guide, North Atlantic Books, 2005
1. Graninger EM; McCool WP. Nurse-midwives’ use of and attitudes toward epidural analgesia. J Nurse Midwifery 1998; 43(4):250-612. 1996 Physicians Desk Reference3. Stavrou C; Hofmeyr GJ; Boezaart AP. Prolonged fetal bradycardia during epidural analgesia. Incidence, timing and significance. S Afr Med J 1990; 77(2):66-84. Thompson TT; Thorp JM Jr; Mayer D; Kuller JA; Bowes WA Jr . Does epidural analgesia cause dystocia? J Clin Anesth 1998; 10(1):58-655. Studd JW; Crawford JS; Duignan NM; Rowbotham CJ; Hughes AO. The effect of lumbar epidural analgesia on the rate of cervical dilatation and the outcome of labour of spontaneous onset. Br J Obstet Gynaecol 1980; 87(11): 1015-216. Alexander JM; Lucas MJ; Ramin SM; McIntire DD; Leveno KJ. The course of labor with and without epidural analgesia. Am J Obstet Gynecol 1998; 178(3):516-207. Lieberman E, Lang JM, Frigoletto F Jr, Richardson DK, Ringer SA, Cohen A, Epidural analgesia, intrapartum fever and neonatal sepsis evaluation. Pediatrics 1997; 99(3): 415-98. McRae-Bergeron CE; Andrews CM; Lupe PJ. The effect of epidural analgesia on the second stage of labor. AANA J 1998; 66(2):177-829. Clark DA; Landaw SA. Bupivacaine alters red blood cell properties: a possible explanation for neonatal jaundice associated with maternal anesthesia. Pediatr Res 1985; 19(4):341-310.Town A. Latent spinal cord and brain stem injuries in newborn infants Develop Ed Child Neural 1969, 11; 54-6811.Menticoglou SM; Perlman M; Manning FA; High cervical spinal cord injury in neonates delivered with forceps: report of 15 cases. Obstet Gynecol 1995; 86(4 Pt 1):589-9412.Murray AD; Dolby RM; Nation RL; Thomas DB. Effects of epidural anesthesia on newborns and their mothers. Child Dev1981; 52(1):71-82