Pregnancy and Birth: Interventions (Part 2)

November 12th, 2009 by Dionna | 3 Comments
Posted in Feed with Love and Respect, natural parenting, Pregnancy and Birth

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This post is a continuation of a series of pregnancy and birth posts. (Here is the first one and the second.)

Over the next few weeks, I’m going to do several posts on pregnancy and birth. I hope to share a few things that were helpful to me; I hope they will help other parents as well.

Thoughtful, respectful discussion is strongly encouraged. My general disclaimer is this: I am not writing to condemn parents who do things differently. I only wish to share information that has influenced the way we live and parent. Perhaps it will give others something new to consider, perhaps not. I welcome your input, because I am always learning too. The important thing is that we are all doing our best to raise our children in safe, loving environments.

The Cascade of Interventions (Part 2)

Without going into a discourse on every possible intervention practiced in medicalized childbirth, I’d like to briefly visit a few of the more common practices and list some of the reasons Tom and I decided to avoid them (I realize that emergencies do happen in a minority of cases, making interventions necessary). I discussed induction and electronic fetal monitoring in Part 1 of this topic, today I have information to share about internal exams and epidurals.

3. Internal Exams

In order to give birth vaginally, your cervix must open to allow the baby passage. I often hear women discuss cervical dilation in the context of late pregnancy and childbirth.

“I was stuck at a 6 for eight hours.”
“That’s nothing, I was at a 3 during two weeks of nearly constant false labor!”
“I’m glad that wasn’t me, I was a 2 when I was admitted to the hospital and was already at a 10 forty-five minutes later.”

Doctors frequently check cervical dilation in the last few weeks of pregnancy. These internal exams can be uncomfortable, if not downright painful. But even though internal exams have become a fairly routine part of doctors’ check-ups both before and during labor, putting any significance on dilation can lead to false expectations about when labor will begin or how long labor will take.

“[T]he degree of cervical dilation prior to the onset of labor is not the best predictor of when true labor will begin.” Nor is it the best predictor of how long labor will last. “You can make oodles of progress and then just sit there for weeks or go from zero-to-baby in no time.” (1)

Internal exams can cause harm. Multiple painful exams during an already emotional time can make a laboring woman anxious, fearful, and hopeless. (2) They can increase the risk of infection, especially if the woman’s water has already broken. (3) Each time a nurse or doctor checks for “progress,” bacteria are pushed into the birth canal. Vaginal exams can also “cause the amniotic sac to break prematurely.” (4)

You are free to ask your medical professional NOT to perform internal exams on you before you go into labor, and you are free to request that internal exams be kept to a minimum during labor. There are times when an internal exam might be helpful to give a medical professional certain information (for example, to ascertain the position of the baby’s head), but there is no reason to interrupt labor unnecessarily to check dilation.

4. Epidurals

“In a recent survey of childbearing women in the United States, 76% of the women who had a vaginal birth reported having an epidural.” (5) Shockingly, another survey revealed that 41% of women who received an epidural “were unaware of the procedure’s possible side effects.” (6)

Epidural Risks to Mothers

I intended to write on the risks and harms of epidurals, but the doctors who wrote the following several paragraphs have said everything so much more succinctly than I could have. To summarize, epidurals interfere with the natural progression of labor and can lead to many more medical interventions, including cesarean section. “Epidurals significantly interfere with some of the major hormones of labor and birth, which may explain their negative effect on the processes of labor.” (7)

“With an epidural, because the pelvic muscles relax, it may take longer for the baby to rotate and descend through the birth canal, and the baby is more likely to get stuck in a position (called “posterior”) that makes cesarean surgery much more likely. The absence of pain can interfere with your natural release of oxytocin and may lead to the need for Pitocin. Epidural medication can cause a drop in your blood pressure, so you will need IV fluids both before and during the epidural. Lower blood pressure can cause a drop in blood (and oxygen) flow to your baby, so you will need continuous EFM if you have an epidural. Some women with epidurals do not feel when they need to urinate, so you may need a catheter to empty your bladder.

The changes in the way labor and birth unfold and the interventions needed to watch for, prevent, and manage side effects during an epidural set the stage for a number of possible problems. Studies show that epidurals are associated with a lower rate of spontaneous vaginal birth, a higher rate of instrumental birth (vacuum or forceps), and longer labors, particularly for women having their first babies. Studies also show that women with epidurals have a higher rate of fever during labor and, as a result, their babies may need to be tested and treated for possible infections, necessitating separation of mothers from their babies after birth. There is some evidence that the use of an epidural, especially for first-time mothers, may increase the likelihood of cesarean surgery.” (8)

Epidural Risks to Newborns

If the previous information had not convinced me to refuse an epidural, the fact that epidurals carry risks of harming new babies would have made it an easy decision. The effects of an epidural on the mother carry over to the newborn.

As noted previously, epidurals often cause laboring mothers to have a fever. Babies are affected by these epidural-induced fevers. “In one large study of first-time mothers, babies born to febrile mothers, 97 percent of whom had received epidurals, were more likely at birth to be in poor condition . . .; to have poor tone; to require resuscitation . . .; and to have seizures in the newborn period, compared to babies born to” mothers without fevers. One researcher has noted a tenfold increase in risk of newborn encephalopathy (signs of brain damage) in babies born to febrile mothers.” “Babies born to febrile mothers are almost always evaluated for infections (sepsis).” (9)

“Sepsis evaluation involves prolonged separation from the mother, admission to special care, invasive tests, and, most likely, administration of antibiotics until tests results are available. In one study of first-time mothers, 34 percent of epidural babies were given a sepsis evaluation compared to 9.8 percent of nonepidural babies.” (10)

“The ‘septic work-up’ done on such newborns is not only painful but also risky.” The newborn is subjected to blood draws every few hours as well as one or more spinal taps. These aggressive and often unnecessary interventions are stressful to the new baby’s body. Moreover, “placing a baby in an ICU strain the beginning parent-child bond [and] results in” a lower breastfeeding success rate. (11)

Research has shown that epidurals can negatively affect the breastfeeding relationship for hours, days, even weeks. (12) This may be due to the fact that every drug the mother is exposed to during labor crosses over the placenta to the baby “who is more vulnerable to toxic effects.” The drugs present in epidurals have been shown to cause breathing problems, neurobehavioral abnormalities, and weight loss – all of which can be detrimental to a successful latch and breastfeeding relationship. (13)

The bottom line is that there are significant risks to both mother and newborn from the use of an epidural. Mothers are far too often uninformed about these risks. Every woman should educate herself on the medical interventions she is considering before she goes into labor.

Stay tuned for Part 3.

__________________________________________________________
(1) “Is Cervix Dilation an Early Sign of Labor?,” http://www.givingbirthnaturally.com/cervix-dilation.html

(2) “Labor and Birth Interventions,” http://www.naturalbirthandbabycare.com/birth-interventions.html

(3) Labor and Birth Interventions; see also “The Vaginal Exam During Labor: Is It Necessary?,” http://www.dare-to-give-birth-naturally.com/vaginal-exam.html

(4) The Vaginal Exam During Labor: Is It Necessary?

(5) “Care Practice #4: No Routine Interventions,” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1948093/ (citing Declercq E. R, Sakala C, Corry M. P, Applebaum S. Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. 2006 New York: Childbirth Connection)

(6) Care Practice #4: No Routine Interventions (citing Declercq E, Sakala C, Corry M, Applebaum S, Risher P. Listening to mothers: Report of the first national U.S. survey of women’s childbearing experiences. 2002 New York: Maternity Center Association (now, Childbirth Connection))

(7) “Epidurals: Risks and Concerns for Mother and Baby,” http://www.sarahjbuckley.com/articles/epidural-risks.htm

(8) Care Practice #4: No Routine Interventions (citations in article)

(9) Epidurals: Risks and Concerns for Mother and Baby (citations in article)

(10) Epidurals: Risks and Concerns for Mother and Baby (citations in article)

(11) Arms, Suzanne, Immaculate Deception II: Myth, Magic and Birth at 98-99, available at http://books.google.com/books?id=r0CvyFZuVxYC&printsec=frontcover&source=gbs_v2_summary_r&cad=0#v=onepage&q=&f=false

(12) Care Practice #4: No Routine Interventions (citations in article)

(13) Epidurals: Risks and Concerns for Mother and Baby (citations in article); see also “Why Won’t This Newborn Be Breastfed?,”  http://www.nursingcenter.com/pdf.asp?AID=810926

3 Responses to:
"Pregnancy and Birth: Interventions (Part 2)"

  1. Heather   xakana

    Awesome! I’m glad you included internals in there, so few people know they have options on it or how little they mean. And victims of sexual assault can find unbearable (feeling just like the assault, all over again, especially since they are often forced on women despite their preferences not to have any). You can refuse all internal exams, period, if you so choose. The hospital can try to refuse to admit you, but if they do, then they’re violating one of the biggest laws regarding hospitals.

    On epidurals, again a great job, but you left out the damage to the bond that mothers with epidurals can experience. All the rest can be overcome, but there’s nothing to put that bond in place and that’s far more common than fevers, seizure, etc. I’ve actually not known a mom with those problems who had an epidural, but I know SO many who had bonding and breastfeeding problems.

    Even when it’s necessary, the risks need to be known so mom isn’t blindsided like so many are. Even being prepared, it’s hard as hell dealing with those issues. Which is why your blogs are such awesomeness–hopefully, they will help someone avoid some unnecessary procedures or at least think about them and be prepared for potential side effects.

  2. Tara

    I’m also glad you mentioned internals. They are such a routine part of OB care that women forget that they are an intervention too–sometimes a very painful intervention! Lying on my back through contractions so the nurse or doctor could check me felt like torture! And then if progress is not being made in the “right” way a woman often feels like her body is letting her down–there is no acknowledgment of all the other awesome work those contractions can be doing.

    Since then I’ve had two births where my midwife never touched my vagina until I either felt pushy or until the baby was actually coming out, and those births were so much less fearful and more empowering. I would like every woman to have that type of experience. :)

  3. Dionna   CodeNameMama

    Heather – thanks for recommending that I include internal exams!

    As for bonding, I started to do something on bonding in the very first post of this series. If you ever took psych classes, you’ll probably remember the famous studies back in the 80’s that said there was a “critical period” for bonding after birth. The authors of those studies have since retracted their statements and said that there is no critical period – I mean, look at parents who have babies in the NICU for weeks or months. They still end up having just as good of a chance at a healthy, loving parent/child relationship as a baby who was born at home. So no, I didn’t find any credible research on a detrimental interruption of the bond.

    Tara – I agree. My midwife checked me no earlier than 12-14 hours into my labor (I ended up laboring for about 29 hours), and I vaguely recall her checking me a couple of hours before I gave birth (but at that point they were worried and discussing a hospital transfer). It was painful and violating, even though I trusted my midwife.

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