Healthy Birth Blog Carnival: Avoiding Unnecessary Interventions

February 1st, 2010 by Dionna | 15 Comments
Posted in Pregnancy and Birth

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This post is part of the Lamaze Healthy Birth Blog Carnival. The topic of this month’s carnival is “avoiding interventions that are not medically necessary.”

A Birth Story

I was 37 ½ weeks pregnant when my water started leaking around 12:00p.m. What a cacophony of feelings that brought! The two strongest were fear that I was having our baby too early and excitement that we would finally get to meet him or her. I called my doctor and she advised me to come to her office to make sure everything was ok. After checking dilation (2) and vital signs (everything was fine), she told me to go home and get a bag packed – we were going to have this baby within the next 24 hours! My doctor pointed out that once my water had broken, I was on a 24 hour timer. She wanted me to come in sooner rather than later so that they could monitor me and baby.

Nervous, I drove home and ate lunch with my husband before we packed and headed to the hospital. Even though I wasn’t having strong or regular contractions, the nurses started their standard procedure: I was hooked up to a monitor, an IV, and told not to eat anything but ice chips. Good thing I just had lunch!

Forty-five minutes later, they let me off of the monitor to walk around. And walk we did – for hours! Around 10:00p.m., my contractions were mildly uncomfortable and regular, but they would die down every hour or two when the nurses would hook me back up to the monitor.

And I was hungry. Walking had worn me out, but all I had to sustain me was the IV drip of sugar water.

5:00a.m. rolled around and I hadn’t slept a wink. My contractions were strong and extremely painful – it was full blown back labor. After another dilation check, my doctor confirmed my suspicions: the baby was sunny side up and I was still not fully dilated.

The doctor started me on pitocin and made sure my bag of waters was broken. Holy night. They aren’t kidding when they say that pitocin amplifies contractions, they were a nightmare!

I was beyond exhausted, and around 7:00a.m. I begged for an epidural. So much for my natural birth! The epidural eased my contractions, but now I couldn’t move – there was no way this baby was going to flip over.

Disappointed, we consented to a cesarean section around 10:00a.m. My doctor said I was close enough to the 24 hour deadline that it just made sense.

How and Why to Avoid Unnecessary Interventions

Does that story sound familiar? It is a perfect example of the “cascade of interventions” that is likely to begin the moment a laboring woman is hooked up to unnecessary medical equipment at the hospital.

And it was almost my story. Thankfully, I found a midwife who believed in the power of my body and did not push unnecessary medical interventions. Instead of the above scenario, my birth story included fewer interventions and ended in a vaginal delivery (sunny side up!).

I know firsthand the value of refusing unnecessary medical interventions. But my birth story was only possible because I took time to educate myself and enlist a wonderful support team. Women need to learn why unnecessary interventions can be dangerous and how to avoid them. Below is information and resources on the seven interventions Lamaze addresses in their Healthy Birth Practice Paper: intravenous lines, restrictions on food and drink, continuous electronic fetal monitoring, artificial rupture of the membranes, pharmacologic augmentation of labor, epidural analgesia, and episiotomy.

If you know of other great resources on these topics, please leave a comment so I can add the link to the list.

1. Intravenous Lines

Doctors have traditionally required laboring women to submit to an IV “to compensate for the food and drink she is denied during her four- to thirty-hour labor, to correct or prevent the occurrence of ketosis, to facilitate the administration of analgesics and pitocin, and to prepare for epidural analgesia.” (1) IV’s can hamper labor in a number of ways. The IV needle and the cold fluid drip can be painful, the pole limits movement, excess fluid can cause the mother to urinate frequently (at best) or her lungs to fill with fluid (at worst). IV fluids can also disrupt the balance of the baby’s blood, causing severe hypoglycemia. (2)

Women should discuss their desire to avoid an IV before they go into labor. Most doctors and midwives will agree to either wait on an IV unless it is needed or to use a hep-lock instead of the full IV. (3) Be prepared to share information with your medical profession that explains why IV’s do not provide balanced nutrition for laboring women, the dangers of water intoxication, and the evidence that IV’s slow labor and increase the occurrence of more medical interventions. (4)

IV’s (Excerpt from Birth as an American Rite of Passage)

Labor and Birth Interventions

2. Restrictions on Food and Drink

Laboring women are often denied food and drink due to a mistaken belief that they may later vomit and choke during an anesthetized cesarean section. But this practice became routine decades ago when laboring women were regularly heavily medicated “and often gave birth under general anesthesia without their airway protected.” Research has shown that the chance of aspiration today is rare – 1 in every 200,000 women – and can be avoided by using regional rather than general anesthesia. (5)

The best practice is to encourage laboring mothers to eat healthy foods to keep their strength and energy up, much like if they were running a marathon. If your doctor or midwife is hesitant to allow food during labor, show her the evidence that eating and drinking during labor is safe: “food intake in labor [does] not increase the incidence of vomiting, medical interventions during labor, or adverse birth outcomes . . . .” (6)

Birthing at a non-hospital setting (a birth center or at home) is another way to avoid the first two interventions. Most midwives have no problem with a mother refusing an IV and eating and drinking at will. If you choose to birth in a hospital, try to stay home as long as possible after you go into labor. You will labor more comfortably and efficiently in familiar, safe surroundings, and there will be no one there to hook you up to machines or feed you ice chips.

Eating During Labor

Eating During Labor Has No Effect on Delivery

Fasting (Excerpt from Birth as an American Rite of Passage)

3. Continuous Electronic Fetal Monitoring

“When EFM was first introduced, the initial goal was to identify fetal distress during labor and, subsequently, allow timely intervention that would improve birth outcomes.” However, the use of early EFM does not lead to increased positive birth outcomes. (7) In fact, research suggests that the use of electronic monitoring actually increases the risk of cesarean sections, instrumental delivery, augmentation of labor, and epidurals. (8) And while expert panels in both the United States and Canada have recommended against the use of EFM for low-risk mothers, hospitals continue to routinely employ electronic monitoring for all laboring women. (9) And it is not only low-risk mothers that may be harmed by routine EFM. The U.S. Preventive Services Task Force states that “[t]here is insufficient evidence to recommend for or against EFM” even for high-risk mothers. (10)

If you do not wish to be monitored continuously during labor, talk to your midwife or OB. Let her know that you would like to be monitored intermittently or even with Doppler (a handheld device with a speaker). Show her the research that continuous and admission EFM increases the risk of further medical interventions. Tell her that you do not want to have your movement restricted, that you wish to avoid the anxiety that comes from being tethered to a piece of medical equipment, and that there is no evidence that your baby will be born healthier by being monitored electronically. (11)

External Electronic Fetal Monitor (Excerpt from Birth as an American Rite of Passage)

Internal Electronic Fetal Monitor

Understanding Fetal Monitoring

4. Artificial Rupture of the Membranes

When a medical attendant artificially ruptures the membranes, he inserts an instrument that resembles “a crochet hook through the cervix, [then] snags and breaks the amniotic sac.” This procedure “increases the danger of fetal infection from vaginal exams and/or inserted instruments” and invokes the 24 hour rule (which again will result in a cascade of more interventions). Worse still, “without the protective cushion of the amniotic fluid the baby’s head is subject to greater pressure during contractions, and the umbilical cord is more likely to become compressed, resulting in oxygen deprivation and consequent respiratory distress.” (12)

Make sure your care provider knows that the most recent research demonstrates that artificially rupturing the membranes does not speed up labor, as was once thought. Instead, the procedure only increases the chance of infection in both mother and baby and ultimately the risk of cesarean section. (13)

Amniotomy and PROM

Artificial Rupture of the Membranes (Amniotomy) (Excerpt from Birth as an American Rite of Passage)

5. Pharmacologic Augmentation of Labor

When labor is allowed to occur naturally, the mother’s brain produces oxytocin, a hormone that stimulates uterine contractions. Pitocin is a drug that is a synthetic version of oxytocin. (14) While pitocin is only indicated in cases of “hypotonic uterine dysfunction” (a rare “condition in which the contractions become ineffective at producing cervical dilation”), pitocin is actually the most common drug given in hospital births: 81% of women who birth in hospitals receive pitocin. (15)

Pitocin shortens labor, but it does so at significant risk. Pitocin-induced contractions are considerably longer and stronger than naturally occurring contractions with less of a break in between contractions. The result of this increased intensity is more pressure on the baby, which often leads to a compressed umbilical cord, decreased oxygen supply, stressed fetal heart rate, and ultimately a higher percentage of cesarean sections and even uterine rupture. (16)

To avoid pharmacologic augmentation of labor, it is vital to select a caregiver who allows women to labor in their own time – even if that means they go several weeks past their “due date.” Once you are in labor, nipple stimulation helps your body release oxytocin.

Labor Induction

Pitocin (Excerpt from Birth as an American Rite of Passage)

Pitocin Induction and Augmentation

6. Epidural Analgesia

Epidurals carry significant risks to both mothers and newborns. Epidurals interfere with the natural progression of labor and can lead to many more medical interventions.

For mothers, “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.” Finally, epidurals are associated with an increased risk of cesarean section. (17)

There can also be detrimental consequences for babies. 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).” Painful and often risky septic workups include multiple blood draws and spinal taps. (18)

Finally, epidurals can negatively affect the breastfeeding relationship for hours, days, even weeks. 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. (19)

To avoid an epidural, educate yourself and trust your body. Look into methods of finding peace and managing your reaction to the process of labor:  the Bradley Method, Hypnobabies, and Lamaze are all popular choices. Having a professional doula present will also reduce your chances of unnecessary medical interventions.

Epidural/Caudal Analgesia/Anesthesia (Excerpt from Birth as an American Rite of Passage)

Epidurals: Risks and Concerns for Mother and Baby

Why Won’t this Newborn Be Breastfed?

7. Episiotomy

An episiotomy is the process wherein a doctor uses “scissors [to] snip the stretching skin of the perineum downward toward the anus (median episiotomy) or downward and sideways (mediolateral episiotomy) to enlarge the vaginal opening and make it easier for the head to emerge.” The danger of an episiotomy may not be intuitive: an episiotomy makes the chance of severe (third and fourth degree) perineal tears nine times as likely as a birth without the procedure. (20)

To avoid an episiotomy, make sure that your caregiver knows that “[t]here is no evidence that an episiotomy reduces the risk of perineal injury, improves perineal healing, prevents birth injury in babies, or reduces the risk of future incontinence (involuntary loss of urine or feces)—all reasons that were given for the routine use of episiotomy in the United States.” (21)

Episiotomy (Excerpt from Birth as an American Rite of Passage)

Routine Episiotomy Harms and Offers No Benefits to Women

Avoiding Unnecessary Medical Interventions

Education is key to avoid routine interventions. Take charge of your birth – become knowledgeable, surround yourself with caregivers and a support team who make you comfortable, and trust your body.

Here are a few more sites that can help you in your journey to prepare for a safe, natural childbirth:

Avoiding Interventions

Child Birth Preparation

Preparation for Birth

Preparing for Natural Childbirth

On Code Name: Mama, I share information, resources, and my thoughts on natural parenting and life with a toddler. Please take a moment to subscribe to my RSS feed for free updates.

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All of these interventions are addressed by Judith A. Lothian, RN, PhD, LCCE, FACCE in “Lamaze’s Care Practice #4: No Routine Interventions,” http://www.lamaze.org/ChildbirthEducators/ResourcesforEducators/CarePracticePapers/NoRoutineInterventions/tabid/483/Default.aspx

I have written on several of these topics previously and have used excerpts from those posts here. Please click on the following links to read more about induction and EFM, epidurals, and avoiding unnecessary interventions.

(1) “IV’s,” http://www.birthingnaturally.net/barp/iv.html (Excerpt from Birth as an American Rite of Passage)
(2) IV’s; “Labor and Birth Interventions,” http://www.naturalbirthandbabycare.com/birth-interventions.html
(3) “Heplock or IV?,” http://www.naturalchildbirth.org/natural/resources/interventions/interventions14.htm
(4) “Lamaze’s Care Practice #4: No Routine Interventions” and citations therein
(5) Lamaze’s Care Practice #4: No Routine Interventions; “Fasting,” http://www.birthingnaturally.net/barp/fasting.html (Excerpt from Birth as an American Rite of Passage)
(6) Lamaze’s Care Practice #4: No Routine Interventions and citations therein
(7) Moore, Mary Lou, “Recent Research Questions the Values of Routine Intervention,” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595164/; see also Kripke, Clarissa, M.D., “Why Are We Using EFM?,” http://onyx-ii.com/birthsong/page.cfm?efm
(8) McCusker, J. et. al, “Association of electronic fetal monitoring during labor with cesarean section rate and with neonatal morbidity and mortality,” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1349387/;”Electronic Fetal Monitoring,” http://www.changesurfer.com/Hlth/EFM.html; see also Thacker, Stephen & Stroup, Donna, “Revisiting the Use of EFM,” http://sanantoniomidwife.org/Revisiting%20the%20use%20of%20the%20electronic%20fetal%20monitor.pdf (“Revisiting the Use of EFM”)
(9) Revisiting the Use of EFM
(10) Why Are We Using EFM?
(11) Lamaze’s Care Practice #4: No Routine Interventions and citations therein
(12) “Artificial Rupture of the Membranes (Amniotomy),” http://www.birthingnaturally.net/barp/membranes.html (excerpt from Birth as an American Rite of Passage)
(13) Lamaze’s Care Practice #4: No Routine Interventions
(14) Lamaze’s Care Practice #4: No Routine Interventions; “Pitocin Induction and Augmentation,” http://www.natural-pregnancy-mentor.com/pitocin-induction.html
(15) “Pitocin,” http://www.birthingnaturally.net/barp/pitocin.html (excerpt from Birth as an American Rite of Passage); Pitocin Induction and Augmentation
(16) Lamaze’s Care Practice #4: No Routine Interventions and citations therein; Pitocin
(17) Lamaze’s Care Practice #4: No Routine Interventions and citations therein
(18) Buckley, Sarah, M.D., “Epidurals: Risks and Concerns for Mother and Baby,” http://www.sarahjbuckley.com/articles/epidural-risks.htm; see also 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
(19) 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; Lamaze’s Care Practice #4: No Routine Interventions
(20) “Episiotomy,” http://www.birthingnaturally.net/barp/episiotomy.html (excerpt from Birth as an American Rite of Passage)
(21) Lamaze’s Care Practice #4: No Routine Interventions and citations therein

15 Responses to:
"Healthy Birth Blog Carnival: Avoiding Unnecessary Interventions"

  1. Wow. What a comprehensive article. Thankfully I was hyper-prepared in terms of avoiding intervention, but this could be of real value to any pregnant ladies considering their plans for birth.

  2. DT

    I kept reading the birth story and thought, “I don’t remember that, I don’t remember that either.” You tricked me.

    • Dionna   CodeNameMama

      Ha! Can you believe I actually choked up while reading the fake birth story out loud to Tom? I am such a sissy.

  3. Amber   AmberStrocel

    Having a supportive team really is SO important. My daughter was born at 34 weeks and I know her birth would have been much different if not for my midwife. As it was I did have to consent to interventions that I wouldn’t otherwise, having a high-risk birth changes things. But I was able to labour mostly in the shower, avoid pain medications and deliver vaginally.

    The other thing I wanted to note is that Canadian hospitals, or at least the ones in my region, do not have the restrictions on food and drink. They encourage you to stick to ‘lighter’ choices – yogurt, juice, and so on, but they delivered me a full lunch during my first labour. There are no restrictions, but most people don’t really feel like having a roast beef dinner while they’re in labour anyway.

    • Dionna   CodeNameMama

      It is wonderful that you were able to have a natural birth with a premie! I know in the States a lot of doctors would make a premature birth an automatic cesarean.

      My sister just gave birth with a midwife. She was in active labor when we got there, so maybe things would be different if she had been at the hospital for hours, but they didn’t want her to have anything but ice chips.
      I told her if she wanted something, I would sneak it to her ;)

  4. Mom

    I think the secret to avoiding interventions is to do what Shawna did…wait till the last minute to let em at you!!! lol

  5. Meghan

    Concerning EFM, talk to your provider about the variance and standard deviation of the instrument (the error of the instrument basically). Years ago, while an undergrad, I read an interview with the developer of the HP EFM machine. He stated that the current use was outside the scope of the design due to the high error of the machine. If your provider is unfamiliar with instrument error (all instruments have error, your provider should be aware of it). Also, if you ask detailed questions about the natural variance of fetal heart rates, you won’t get a good answer. There is too much variation within humans to develop limits other than “normal” and “low.”

    I cannot find the article now. I emailed my former professor in hopes that he may still be using it for the scientific ethics course.

  6. Hello Dionna,
    Thank-you for your comment on my blog. I am delighted to see your post. It is thorough and provides great references.

    • Dionna   CodeNameMama

      Thank you Carol! I’m excited about participating in the next Healthy Birth Carnival. It’s a great way to get out good information!

  7. Well done!!!! Well said!!!

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