|June 20, 2001|
Volume 3, Issue 25
|Midwifery Today E-News|
“Vaginal vs. Cesarean Birth - Part 2”
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Quote of the Week:
"Life is not always fair, nor is it totally in our control. Forces in life--call them God, nature, or fate--are bigger than we are and sometimes have an agenda different from our own."
- Nina Chaya Sabghir
The Art of Midwifery
CONGRATULATIONS TO OUR CONTEST WINNER, Susan Skinner of Rochester, Minnesota USA. She will receive a free one-year subscription to Midwifery Today magazine for having sent in the following tip. Her name was drawn from all contestants who entered. Thanks so much, Susan!
At a recent ACNM convention, Kelly Lott, massage therapist, taught us the art of a "scooping massage" around the gravid abdomen to relieve constipation: If you go around the abdomen using hand after hand massage in a clockwise fashion, it follows the path of the ascending-->to transverse-->to descending colon. Do for about 30 seconds. It works!
- Susan Skinner Rochester, MN
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TRICKS OF THE TRADE VOLUME III: Coming soon!
Based on a meta-analysis of available literature, chorioamnionitis appears to be associated with an increased rate of cerebral palsy in premature infants and, to a lesser degree, in full-term infants. A growing body of evidence supports the notion that inflammation of the fetal membranes caused by maternal infection contributes to neonatal brain injury. As much as 12% of cerebral palsy in term infants and 28% in premature infants might be attributed to infection of the fetal membranes, the chorion and amnion.
- Journal of the American Medical Society, Sept. 20, 2000
Midwifery Today Issue 58 Now Available!
Theme: Mamatoto ("motherbaby")
What Do You Think?
Editor's note: In this issue we are continuing to publish responses to a news item [Issue 3:23] about an American obstetrician who believes vaginal birth creates "needless" pelvic floor disorders later in a woman's life. The news story appeared to favor cesarean section as an acceptable alternative.
From a lecture by Marsden Wagner M.D. in New York City, April 2001
"Women will only agree to cesarean section (CS) if they are convinced it is safe for them and their baby. One of the first efforts of obstetricians promoting CS has been to take the scientific evidence on risks of CS and torture the data until it confesses to what they want it to say. One example: Obstetric hype in popular and professional magazines says research shows 60% of women who have vaginal birth have urinary and fecal incontinence. But a careful reading of the research papers they refer to reveals something very different. The hype lumps all women with vaginal birth together instead of doing what the researchers did---dividing them into risk groups. When analysis of risk was done, they found that women at high risk for urinary and fecal incontinence have had large numbers of births; have had babies weighing over ten pounds at birth; and most importantly, have been the victims of unnecessary, aggressive obstetric interventions during their labor and birth.
What are these aggressive, invasive obstetric interventions that have been proven scientifically to cause permanent damage to the pelvic floor and urinary tract and also lead to more otherwise unnecessary CS? One example is the use of powerful and dangerous drugs to start or accelerate labor, a practice that has doubled during the past 10 years. These drugs make labor abnormal with violent contractions that can damage the uterus and pelvic floor. The only reason women agree to such induction is because they are not told the truth about the drugs, for example that Pitocin (oxytocin), a drug used for decades to induce labor, doubles the chance the woman will have urinary incontinence in the future. By withholding such facts doctors seduce to induce.
Induction with drugs is not the only aggressive, invasive intervention that is frequently used in vaginal birth and is associated with damage to the urinary system, pelvic floor and rectal areas. Episiotomy has been scientifically shown to result in more pelvic floor damage than a natural tear. When an effort was made in the 1980s to reduce CS in the United States, the rate of using forceps or vacuum extractor to pull the baby out went up--some doctors just can't stop doing invasive interventions. And there is good data that using forceps or vacuum to pull the baby out has more risk of pelvic floor damage than any other form of birth.
Obstetricians have turned birth into a surgical procedure and done damage to women's bodies and now suggest the solution is to promote yet even more radical and aggressive surgery, CS. The solution is less unnecessary invasive surgical procedures during birth, not more."
[Re: the E-News article, Issue 3:23]: The two obstetricians tried to say that vaginal birth can damage a woman, but they never pointed out the ways in which CS can do harm not only to the woman but to the baby as well. The following excerpt from my article "Choosing Cesarean Section" in The Lancet of November 11, 2000 reviews some of the dangers associated with CS, the alternative to vaginal birth that some doctors are trying to promote:
"In addition to the increased risk the woman will die with an elective CS, there are other risks for the woman including the usual morbidity associated with any major abdominal surgical procedure--anesthesia accidents, damage to blood vessels, accidental extension of the uterine incision, damage to the urinary bladder and other abdominal organs. (1) Some of these risks are common: 20% of women develop fever after CS, most due to iatrogenic infections requiring diagnostic fever evaluation for both woman and baby. (1)
There are also risks women carry to subsequent pregnancies due to scarring of the uterus including decreased fertility, increased miscarriage, increased ectopic pregnancy, increased placenta abruptio, increased placenta previa (1,2,3). Recently in the United States the widespread use of the unapproved drug misoprostol (Cytotec) for labor induction has created a new risk of CS in subsequent pregnancies. Women attempting VBAC who are given misoprostol have a rate of uterine rupture of 5.6% compared with a rupture rate of 0.2% for women attempting VBAC not given misoprostol, a 28-fold increase in risk of uterine rupture. (4) For women choosing CS, all of these risks exist in all of their subsequent pregnancies even if the original CS was not an emergency. The increased risks of ectopic pregnancy, abruptio placenta, placenta previa and ruptured uterus are all life-threatening to both woman and baby.
For whatever reasons women choose CS, very few are clearly informed about fetal risks. In an emergency CS where the baby has developed a problem during the labor, the risks to the baby of doing the CS will likely be outweighed by the risks to the baby of not doing it. In an elective CS where the baby is not in trouble, the risks to the baby from doing a CS still exist, meaning the woman who chooses CS puts her baby in unnecessary danger. That some women are choosing CS strongly suggests women are not told this scientific facts.
The first danger to the baby during CS is the 1.9% chance the surgeon's knife will accidentally lacerate the fetus (6.0% when there is a non-vertex fetal position). (5) Obstetricians may be less aware of this risk--in one study only one of the 17 documented fetal lacerations was recorded by the obstetrician doing the surgery. (5)
A much more serious risk to babies born by CS is respiratory distress. Many reports in the scientific literature document the CS procedure per se is a potent risk factor for respiratory distress syndrome (RDS) in preterm infants and for other forms of respiratory distress in mature infants. (1) RDS is a major cause of neonatal mortality. The risk of newborn RDS is greatly reduced if the woman is allowed to go into labor prior to the CS.
Another serious risk to the baby born by CS is iatrogenic prematurity (the baby is premature because the CS was performed too early). Even with repeated ultrasound scans, the standard deviation for estimating gestational age is large, creating errors in judging when to do an elective CS. Doing the elective CS after the woman goes into spontaneous labor would markedly reduce this risk as well. A vast literature documents the increased mortality and morbidity, including neurological disability, associated with premature birth."
1. Wagner M, 1994. Pursuing the Birth Machine: The Search for Appropriate Birth Technology, Sydney, Australia: ACE Graphics.
2. Enkin M, Keirse M, Renfrew M, Neilson J, 1995. A Guide to Effective Care in Pregnancy and Childbirth , 2nd ed, Oxford University Press.
3. Goer, H, 1999. The Thinking Woman's Guide to a Better Birth. Putnam, New York: Penguin.
4.Plaut M, Schwartz M, Lubarsky S, 1999. "Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section," Am J Obstet Gyn 180:1535-42.
5. Smith J, Hernandez C, Wax J, 1997. "Fetal laceration injury at cesarean delivery," Obstet & Gynecol 90:344-6.
So beware. Surgeons try to sell surgery. Never forget that obstetricians are, after all, surgeons. Women must be extremely cautious in the face of this hard sell and get the facts from those who do not have a vested interest in surgery.
- Marsden Wagner, M.D., M.S.P.H.
To read full-length articles by Dr. Marsden Wagner, go to Midwifery Today's web site!
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Question of the Week
Q: I am currently supporting a close friend in the beginning stages of her first pregnancy. She has a history of severe childhood physical and sexual abuse and finds it very difficult) to be touched, massaged, or otherwise physically cared for. This is totally understandable. However, I am having a hard time figuring out what to offer when the usual physical comforts provide no comfort. Midwives and doulas, do you have advice in terms of what I can try or other avenues to take?
- Allison Campbell
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Question of the Week Responses
Q: While listening to fetal heart tones late in labor (when heard right above the pubic bone) it seems at times I hear cord sounds. This usually happens when the baby comes with a nuchal cord. I now prepare myself for a nuchal cord when I hear a cord pulsing at a woman's pubic bone, and I must say, it is nice to anticipate this fairly unexpected event. Have any other midwives found this to be true?
A: I noticed the same pulsations that you describe. I was at a particularly long VBAC with an anterior placenta and a single sutured uterine scar. (This was homebirth number 32 for me. Previously all deliveries were in the hospital with fetal monitoring, not Dopplers, so I never noticed this phenomenon before. I've been RN to at least 1000 if not 2000 laboring women). At this birth, as labor progressed I began to hear the pulsation over the uterine scar. The ultrasound report only said "anterior placenta." I assumed it was up high. When I heard the pulsation below the FHTs and over the scar, I began to worry the placenta was attached at the scar and there might possibly be an acreta. I wondered also if it could be a nuchal cord? In fact, given the two situations, I was hoping it was nuchal cord so that I would not have to transport mom for placenta acreta post-delivery. Upon birth, there were two nuchal cords, and the placenta disattached itself easily. My worry was for nothing. However, I was made aware of this phenomenon with that birth and have since found it to be true, and it is nice to anticipate a nuchal cord!
As a side note, I find it interesting that I never noticed this occurrence in the hospital--nuchal cord was always a surprise. Variable decels were often not related to a nuchal cord, and many times the monitoring strip looked beautiful, yet there was a nuchal cord or two!
Oregon School of Midwifery
Question of the Quarter for Midwifery Today Magazine
Theme for Issue No. 59: Prenatal
Question(s) of the Quarter: What are the essential elements of good prenatal care? How does prenatal care create better birth? As a midwife/doula, what do you hope to accomplish in the prenatal period with a pregnant woman?
Please submit your response by June 30, 2001 to email@example.com
Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
EDITOR'S NOTE: Only letters sent to the E-News official email address, firstname.lastname@example.org, will be considered for inclusion. Letters sent to ANY OTHER email addresses will not be considered.
In response to planned VBAC with expected dilation rate [Issue 3:24]:
I had a very long slow labor with my first beginning at about 4:00 am on a Thursday morning when my waters broke after being up most of the night with gentle contractions. I continued to have gentle contractions until 5:00 pm that evening when I finally got to 5 cm. At that point labor settled and by midnight I was at 8 cm, by 4:00 am fully dilated and I delivered my son (8 lbs 6 oz. without episotomy, anesthetics etc., in the position of my choice) by myself at 5:12 am. By the rules your doctor is using I would have required a c-section. My doctor measured my progress by things like how far the baby had descended toward the birth canal and how much my cervix had thinned. These are much more accurate measures than the stupid centimeters-dilated measure.
My doctor told me he had a rule for moms like me. Whenever he felt like interfering he would go outside and have a smoke instead and then he would ask himself the following:
1) Is the baby all right?
2) Is the mother all right?
3) Have we made any progress at all since the last time I checked even if it is something as simple as the head a little lower or the cervix a bit thinner?
If he could answer yes to all these questions, he would remind himself that 98% of the time nature knows best and he would wait a little longer. In his experience 98% of the time, no intervention would be needed later either.
He was a British doctor who had trained under midwives delivering babies at home in England during WWII. He had the lowest c-section rates (2%) of any doctor in the hospital and was very proud of it. He also had the lowest rates of complications of moms and babies, intra- and postpartum, which he kept very careful track of so it could be trotted out for comparison whenever his colleagues complained about his methods, which at least one did every year.
My suggestion is to find a good midwife and leave the decision about when to bring in an ob-gyn to her/him. A good one will know if s/he's in trouble and needs a ob/gyn to take over. But otherwise avoid ob/gyns like the plague.
- Natalie Bjorklund
In response to Caroline's comments about oil of oregano [Issue 3:24]: Yes, some oils are not to be used internally but many can be used without any harm to tissues (see "Essential Oils Desk Reference" by Essential Science Publishing--espublishing.com for specifics). North American Herb & Spice's oregano is backed up with a whole host of uses spelled out in "The Cure is in the Cupboard" and how to use it internally and externally. They agree that it should not be used in pregnancy as very little research has been done. I did not suggest use in pregnancy but in breastfeeding when there is a yeast/thrush infection. The only other alternative to treat the deep-seated systemic infections is Diflucan which has serious liver implications. It was designed to be given in one dose and yet most have to be treated every day for two weeks to be effective. I think women should be told that there is an alternative that has not had any serious side effects--the worst being pizza breath.
- PJ Jacobsen, IBCLC
Regarding the episiotomy query, the only "new" method I know is never
to do one (unless there is foetal distress right at the end).
There are many homeopathic remedies for hemorrhoids. Old farmers used to carry horse chestnuts in their pockets to keep hemorrhoids away. Homeopaths use Aesculus--homeopathic horse chestnut to treat them when they feel as if sticks were in them--sharp shooting pains, purple painful, and worse standing and walking. Witch hazel can be applied externally as well as taken internally homeopathically. Hamamelis is for hemorrhoids that bleed profusely with soreness and a pulsation in the rectum. Homeopathic sulphur is indicated specifically for hemorrhoids during pregnancy that burn, are sore and may itch. Check out a homeopathic repertory (I like Robin Murphy's) for more specific symptoms and remedies. Combination homeopathic creams can give quick relief when you aren't sure which remedy to try.
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