Be a Savvy Birth Consumer Part 2

City Pages March 2014 Article 
http://issuu.com/citypageskuwait/docs/cp_april_2014_online
* see page 32

Do you want to get the most out of your birth experience? Be savvy. Understand the language used during birth and make informed decisions.

While birth is a normal process and research shows that many of the routines at hospitals today are not necessarily beneficial and may even be harmful[1], the fact remains that birth today has become intervention-intensive and the majority of moms in Kuwait will likely experience one or more intervention during their birth. Most of the statistics for these interventions are not publicly available in Kuwait, so I will use the most recent statistics for women in America. The most recent Listening to Mothers Survey[2] showed that the majority of women surveyed experienced one or more of the following interventions during labor:

•   Continuous electronic fetal monitoring (EFM)(93 percent)

•   Restrictions on eating (87 percent)

•   IV fluids (86 percent)

•   Restrictions on drinking (66 percent)

•   Episiotomy (35 percent)

•   Epidural anesthesia (63 percent)

•   Artificially ruptured membranes (55 percent)

•   Artificial oxytocin augmentation (53 percent)

•   Cesarean surgery (24 percent)

What would those numbers look like in Kuwait? Perhaps some would be higher and some would be lower. The point is that you should be familiar with some technical medical terminology before you give birth. This is the second of two articles designed to empower moms to make informed decisions during birth. The previous article discussed Continuous Electronic Fetal Monitoring (EFM), Restrictions on Eating and IV Fluids, and Episiotomies. In this article we will discuss Artificial Induction or Augmentation (Syntocin), Epidurals, and Cesarean Surgery.

Artificial Induction or Augmentation (Syntocin):

Oxytocin is the central hormone that orchestrates a normal birth. It is nicknamed the hormone of “love” and is essential to bonding, creating feelings of euphoria, and produces uterine contractions. More than 50% of moms give birth using synthetic oxytocin (Syntocin or Pitocin), either to induce the beginning of the labor or to augment their labor once it has already begun.

While synthetic oxytocin and natural oxytocin are chemically identical, their affect on the body has significant differences. For example, natural oxytocin that is produced in the brain circulates in the cerebral-spinal fluid, whereas synthetic oxytocin is pumped into the veins and never crosses the blood-brain barrier. In addition, the body only produces enough oxytocin to meet its needs, where as synthetic oxytocin is pumped by steadily increasing amounts over a short period of time to much higher levels than what the body would naturally produce. Furthermore, while naturally produced oxytocin is responsible for creating the mothers powerful and rhythmic contractions that eventually birth her baby, it also has a softer side: oxcytocin floods a mothers body, reaching its highest peaks during the most intense part of labor, and helping the mother move into an alternative state of mind ((elation) in order to cope with labor and filling her body with love and affection for her baby and partner. A whole series of feedback hormones are also triggered with the natural production of oxytocin, including endorphins (euphoria) and prolactin (for milk production) to prepare her for the final moments of birth and her initial encounters with her baby. This feedback process does not accompany artificial oxytocin.

Synthetic oxytocin, on the other hand, produces more intense contractions over a shorter period of time, without the softening effects of natural oxytocin or the benefits of endorphins. This does more than just change the quality of the contractions- making them more intense and painful for the poor mother. It also increases the mother and baby’s risks for harm, necessitating continuous fetal monitoring. These risks include postpartum hemorrhage through what is called uterine atony: essentially, synthetic oxytocin has a diminishing return of effectiveness by the end of labor, leaving the uterus soft and weak, unable to contract to stop postpartum bleeding; and fetal distress: the sudden-hard and fast-squeezing contractions produced by synthetic oxytocin induced contractions diminishes the baby’s placental oxygen supply more often and for longer periods of time than natural contractions creating disturbing fetal heart rate patterns and necessitating continuous fetal monitoring, vaccum/forceps assisted deliver, and cesarean surgery.

The best way to avoid the use of synthetic oxytocin in your labor is to wait for your labor to begin on it’s own and to use movement throughout your labor to keep your labor progressing, and use a doula or other support person throughout your labor.

Epidurals:

I’m just going to skip other pain medication options and speak directly to the most commonly used pain medication: Epidurals. Epidurals are popular because they allow women to be awake and aware yet free from pain during labor and birth. They permit an exhausted woman to rest or sleep. And while their usual effect is to slow labor, the profound relaxation they offer can sometimes put a stalled labor back on track. They can be very effective.

But like all medical interventions, epidurals also have potential harms, including an increased risk of

·         a vacuum or forceps delivery

·         a drop in blood pressure, which may pose a risk to the baby

·         nausea and itching attributed to the narcotics in epidurals

·         difficulty with breastfeeding, linked to fentanyl, a common narcotic component in most epidurals

·         developing a life-threatening complication

·         breathing problems or difficulty swallowing

·         a baby who experiences a prolonged episode of abnormally slow fetal heart rate

Still, labor is unpredictable, and you want to keep all your options available. Just be sure that you make your decision freely, not because you feel pressure or lack an alternative. Here are some ways to do that as well as minimize potential harms:

Choose a care provider with a cesarean surgery rate of 15% or less. Studies show that in the hands of care providers with low rates, epidurals do not increase cesarean odds. 

Choose a mother-friendly birth environment. In most hospitals, confinement to bed, continuous fetal monitoring, and restricting labor support companions such as doulas, along with lack of amenities such as showers, deep tubs, and birth balls make it difficult to cope with labor without an epidural. Where epidurals are the norm, nurses may not know how to support a laboring woman without one, and staff may actively promote their use. And finally, delay an epidural until active, progressive labor (6-7 cm dilation) to reduce your risk of complications arising from epidurals.

Cesarean Surgery:

When the cesarean rate is between 10-15%, maternal mortality goes down and lives are saved. However, when a cesarean rate goes above 15%, there are no overall improvements for maternal or infant health outcomes. The risks of harm increase for both mother and baby, future pregnancies can be endangered, and health care resources are squandered on interventions that do not provide a positive net gain in health outcomes. The World Health Organization states that cesareans should only be performed for medically indicated reasons. These include placenta previa, malformed or injured pelvis, severe pre-eclampsia, active genital herpes, advanced HIV, transverse (side-lying) baby, twins if the first baby is breech and triplets, certain birth defects, medical problems with the baby or mother (emergency or chronic), placental abruption, prolapsed cord, or uterine rupture.

The following are NOT necessarily a medically indicated reason for a cesarean: prior cesarean, breech presentation, failure to progress, CPD (Cephalo-pelvic disproportion, or your baby's head is too big), twins if the first baby is presenting head down, large baby, fear, convenience, or wanting to give birth on a particular day.

Risks to the mother include:

•   4xs higher risk of death than vaginal birth

•   20%-40% mothers after cesareans have post-operative complications - uterine, wound or urinary tract infections are the most common.

•   increased risk of serious infections such as pelvic abcess, septic shock and pelvic thromboembolism.

•   up to 1 in 10 have a surgical laceration in their uterus.

•   6xs increase in postpartum depressions three months after surgery.

•   reduced fertility

•   increased risk of ectopic (outside of uterus) pregnancy

•   increased risk of unexplained still birth

•   increased risk of rupture of the uterus before or during labor, 2-4xs higher when subsequent labors are induced or augmented with pitocin.

•   risk of placental problems (placenta praevia or low-lying placenta; placental abruption where placenta separates early; placenta accreta, where placenta won't separate) increased by 2-4xs.

•   7-15xs increased risk of emergency hystorectomy after birth for the above reasons

•   increased risk of bleeding after birth, severe anaemia, blood transfusion, repeat cesarean, and infection, for all the reasons mentioned.

Risks to the baby include (for non-emergency cesareans):

•   5xs increased risk of needing intensive care treatment after birth

•   increased risk of prematurity; even with ultrasound scans, around 10% of babies are born more than two weeks early

•   increased risk of breathing difficulties after birth: minor problems around 6% compared to 3% vaginal delivery, even when born at term.

•   with ceasareans, 1.6% of babies require a machine for severe breathing difficulties compared to .3% of vaginal births.

•   Persistent pulmonary hypertension. of which 40%-60% of affected babies die, can affect up to 4 per 1,000  cesarean babies, compared to .8 per 1,000 vaginal babies.

•   1-2% risk of laceration (surgical cut) during the operation

•   all future pregnancies have an increased risk of prematurity, low birth weight, poor condition at birth, and death, for the reasons mentioned above.

To decrease your risk of having an unnecessary cesarean surgery, find a care provider with a low cesarean rate, let your labor begin on it’s own, move around and stay active during labor, work with a doula or other labor support, avoid unnecessary medical interventions, and push your baby out in an upright position.

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