Tuesday, November 4, 2008

Pregnancy is Not a Medical Condition

Okay, so there’s a lot to discuss concerning this topic but to start off, we would like to share the thoughts of a friend who is a Certified Nurse Midwife. Her main topic here is homebirth which is something that too many people do not understand. But, she also gives some great insight on C-sections which is a pretty hot topic right now. Whether you are interested in having a homebirth yourself or not, Jamie addresses some really important and misunderstood issues concerning childbirth in general so please read...

By Jamie Glenn, CNM
Butte, Montana

Home birth is an excellent and safe method of childbirth for a woman with an essentially normal pregnancy and few to no risk factors. I think most people's concerns with home birth are that complications cannot be dealt with in as timely a manner as they might in hospitals. Here are my arguments to the contrary.

1. Any well-planned home birth includes a plan for timely transfer to the hospital should the need for surgery arise. I don't advocate home births that occur out in the boondocks, a 4-hour drive from emergency services. I understand that there are some people who opt for this, but that is a risk they are willing to take. It comes down to weighing risk vs. benefit and that is a personal choice for each pregnant woman/couple.

2. The notion of "emergency C-section" is misunderstood in a lot of instances. A woman in labor is often in such a state of concentration/anxiety/pain/distraction that her memories of birth can be quite skewed as compared to the "outsider" point of view of the health care provider. Similarly, a woman's support person, boyfriend, or husband can be in a heightened state of anxiety/worry/concern during the birth and the events leading up to it. It's a phenomenon that happens quite often that a mother or father will make a statement about something that happened during a birth that is quite inaccurate, or they will ask questions that make it obvious that they were not aware of what was happening in the moment. And that's perfectly understandable! It's a high-stress time for many people. Things happen quickly in certain instances. Birth is not something that happens every day in a typical person's experience. We as providers, who are around this sort of thing regularly, have a clearer outlook than many of the birth parents. That's why I like to sit down with my patients after births and debrief them. I give them a chance to ask questions and I review the events, interventions, and indications for interventions. It helps clear up any misunderstanding, and gives us a chance to discuss at length the things that may have happened too quickly to adequately discuss at the time of birth.

One of the most common reasons for "emergency" C-section is fetal distress. This is manifest to providers in the form of fetal heart rate decelerations on a monitor strip.

[Quick lesson for those unfamiliar: It is a sign of good fetal neurologic health when the fetal heart rate shows beat-to-beat variability as well as periodic accelerations in the heart rate. It means that the fetus's autonomic nervous system (the one that works without thinking about it) is functioning properly. Decelerations in the fetal heart rate can occur normally as reflex responses to head compression or cord compression during contractions, or if the fetus is in a position that is pinching its umbilical cord. It's hard for me to talk about fetal heart monitoring without getting too detailed, so I'll just stop there. Just know that there are 500+ page books about interpreting fetal heart monitoring strips.]

A normal baseline heart rate for fetuses is 120-160 bpm. When decelerations are repetitive, prolonged (lasting greater than 3 minutes), or especially deep (the heart rate drops below 90 bpm), these are indicative of "fetal distress". It is a strong sign that the fetus's nervous system is no longer coping well with the stress of labor, and that the fetus is being deprived of needed oxygen. If this continues for too long, the fetus can sustain brain damage because of the lack of oxygen and/or the acidotic state it enters (blood pH becomes lower than it should be).

In a hospital setting, it is most often the labor nurses that are continually watching the fetal heart monitor, looking for non-reassuring signs like decelerations. When decelerations are first noted, the labor nurse will usually ask the mother to change positions or roll to her other side if she is in bed. This resolves a large number of decelerations. Other things that might be done in a hospital: starting an IV and giving extra fluid to the mother, putting an oxygen mask on the mother, or placing an internal monitor on the baby's head to more accurately read the heart rate. If the decelerations continue after all of these interventions have been done, the decision may be made to deliver by Cesarean. The point is that in many, if not most cases of "emergency C-section" for fetal distress, there has been a period (sometimes hours long) of warning before the decision is made to do a C-section. If a woman is laboring at home, her midwife or birth attendant is well trained in monitoring labor progress as well as ausculatation of the fetal heart. S/he will recognize early warning sign and his/her threshold for tolerating non-reassuring signs is much lower than it would be at a hospital. At the slightest sign of concern, the woman could be transferred to a hospital for closer monitoring, and to be closer to an operating room should the need arise.

I think a lot of women who have delivered by "emergency" C-section are told that she and/or her baby would have died if the decision had been made as little as five minutes later. This makes the mother/parents feel very grateful and relieved, as they are given the impression that they narrowly escaped death. And now there is a healthy mother and a healthy baby, and that's all that matters. I agree that a good outcome is always something to celebrate. I also feel that people are not informed of the several minutes (sometimes hours) leading up to the decision to do a Cesarean, during which a low-risk woman laboring at home would have plenty of time to be transferred to a hospital.

There are reasons for Cesarean section that are truly emergencies and are life-threatening with little advance warning. Some of these are placental abruption (the placenta separates before the baby is born), uterine rupture (the uterus gets a hole in it), or umbilical cord prolapse (the umbilical cord comes through the birth canal before the baby does). In the instance of home birth, these risks are miniscule because of the screening that occurs to qualify a woman for safe home birth. Abruptions happen most frequently when labor is induced. Inductions do not happen at home deliveries; labor begins on its own. Uterine rupture most often occurs when an old C-section scar is reopened by the force of labor. VBACs (vaginal birth after Cesarean) are most commonly done in hospitals with an in-house surgical team ready in case of this complication, and even then, rupture is extremely rare when labor begins on its own. And a baby with umbilical cord prolapse can be kept safe during transfer from home to a hospital. These are also most likely to happen when the water breaks and the fetal head is not well-applied to the cervix, or the head is not the presenting part, and is a rare complication.

[Whew! I could write forever... Take a minute to go get a snack or use the bathroom if desired.]

In general, over the past 50 years or so, our society has completely medicalized birth. No matter that women have been successfully giving birth and populating the earth since the beginning of time. Sure, we can save more of the premature babies and we can do surgery for women whose babies don't tolerate labor or are in a position that is not conducive to vaginal delivery. I think that's wonderful. But we still have a CRAPPY infant mortality rate. People probably feel that they are getting the best labor and delivery care here in the U.S., but the truth is that even though we spend more money than anyone else in the world on pregnant women and babies, we are not getting the best outcomes. In fact, we are second to last among developed countries! There are European countries that have dramatically more home births than ours (or consider home birth the norm) and have much better birth statistics than we do. Just because we have technology for women whose births are medically complicated, doesn't mean that it should be used for even the normal, uncomplicated births. In fact, the widespread use of continuous fetal heart monitoring has only increased the rate of vacuum- and forcep-assisted vaginal births and Cesareans, and has not improved maternal/fetal outcomes compared with intermittent auscultation.

About 1/3 of births in this country are by Cesarean. And a LARGE number of these are unnecessary. Don't even get me started on C-sections. Midwives have anywhere from a 5-10% C-section rate as opposed to the national statistics. Our birth statistics and outcomes are better than those of obstetricians even after taking into account the differences in patient population. Shouldn't midwives' wonderful statistics reassure our society about the safety of low-intervention hospital, home or birth center births? Most midwives actually do deliveries in hospitals, but our philosophy is to intervene with normal labor and birth as little as possible. Low-risk women have much smaller chances of developing life-threatening complications during labor, and those who choose to give birth at home are actually saving tremendous health care dollars! If we get out of the mindset that all births must happen at a hospital, and encourage the low-risk, healthy mothers to deliver at home or in birth centers, imagine the money we could save, and how our birth statistics would actually improve!

There are so many good research articles out there. I think it's so important to try to educate ourselves and our daughters about the options for childbirth and start reversing the medicalized view of childbirth, and start revering childbirth as a normal part of a woman's life again. Pregnancy is not a condition that needs to be treated.

We welcome your comments and questions!


Jamie said...

I'm excited to follow your blog and tell my friends to read it too! Good work. I think this is so important for women to discuss.

Thanks for your willingness to do this!

Judy Olson said...

I would like to have some 'talking points' so I can discuss home birth with my doctor who not in favor of it. Thanks, Judy

Valerie said...

I am excited for this blog! Way to go guys! I will definately be following it and adding to it! This is a topic that is misunderstood and I encourage all women to educate themselves!