Monday, January 7, 2013

What YOU Can Do To Have A Healthy (and Happy) Birth

A few of you read my post on how the medical community could lower rates of infant and maternal mortality. A couple of my friends very rightly pointed out that women need to educate themselves more  in order to have a birth that is both safe and happy. When I right my post on the medical community, I had a ton of ideas whirling around in my head, so I just started writing and what came out was that post. I decided to just focus on the medical community so that that particular post wouldn't stretch out into the world's longest birthing rights post, which this alone is in the running for. I have since been meaning to do a sequel on how parents can create a safer birth, but I've gotten side-tracked onto subjects such as birthing a baby with a birth defect, pants on LDS women at church, a ridiculous and preachy evangelical Christian movie on marriage, and Christmas candy. But I'm back now. On topic. (Wait! There went a squirrel...)

So in my extensive research, here are some things that you can do to lower your risks of problems cropping up during the birthing process:
  • Find a qualified attendant you feel comfortable with.  Whether you choose an OB-GYN or a midwife make sure that he/she is competent. Certification or med school alone doesn't mean someone can handle an emergency effectively. You can have a hospital birth with a doctor and your baby can end up severely brain damaged from a birth injury. (Before you scoff at this, please note that I have an uncle on my mom's side who is severely brain damaged from a birth injury. He was born at a hospital with a doctor. In the ward my husband grew up in, there was a boy his age who was severely brain damaged from a birth injury sustained at a hospital birth with a doctor in attendance.) On the other hand, I've seen Direct Entry Midwives who have been delivering babies for 30+ years who have seen it all: cord prolapse and malpresentation, meconium in the water, mother in shock, baby in respiratory distress, twins, breeches, VBAC's, etc. and have never lost a mother or baby and have c-section and transfer rates under 5%. Then there are midwives who mess up and cause birth injuries and OB-GYN's who are gung-ho for natural birth. It's a mixed bag. Questions you might consider asking a midwife:
    • What is your c-section and transport rate? Have you ever lost a mother or baby? Have any of your babies had a birth injury? Some midwives are very forthcoming with this information and even have it on their websites. If she has lost a baby, inquire about the circumstances. There are some midwives who have delivered babies who have terminal birth defects, for example, and I don't think that should be counted against them.
    • How would you handle a cord prolapse? Cord prolapse is rare, but is one of the most serious things that can happen in a home birth. Well, even in a hospital birth it can be very serious. Basically, this is when the cord is coming before the baby and the baby is lying in such a way as to compress the cord and cut off oxygen flow. It requires a c-section ASAP. If a cord prolapse happens, a competent midwife usually put the mother on all fours and hold the cord up to take the pressure off of the cord and provide oxygen flow to the baby and call the ER and have them set up the operating theater right away so that the mother goes into surgery as soon as she arrives at the hospital. The mother will stay in this position until she goes into surgery. A few babies have died from cord prolapse in transit. On the other hand, many others have born alive and healthy from a successful transport. If you are in the hospital, you may be able to get a c-section more quickly, but on the other hand the operating theater still may have to be set up or your doctor may be sleep deprived and moving slower. If you are on your back during the time it takes to set up the operating theater the risks to the baby increase. Nothing is for sure in birth, even in a hospital. But if an emergency arises at home and your midwife is prepared, it can save your baby's life and health.
    • What if I decide I want pain medication? Or I don't want to get in the hot tub? Or I want everyone out of the room? Your midwife is any good at delivering babies, she should be pretty accommodating. The birth suite I went to for Duckling's birth had a policy of "if mom wants to go to the hospital and get pain meds, we go". When I was in labor and starting to get too hot in the hot tub, it was the supervising midwife who asked me if I wanted to get out of the tub. I've heard of other midwives who have told moms that it's OK if they want to labor more by themselves and have the midwife just standing by in the next room to keep an eye on things. Labor, especially transition, does strange things to a woman sometimes and you really need someone who can flow with it.
    • Questions you might consider asking a doctor:
    • What is your c-section rate? Have you had a mother or baby die? Brain damage in a baby from a birth injury? Most OB's will probably be taken aback, but as a patient, you do have a right to know what an OB's history is, just as with a midwife. Inquire about circumstances if there has been a death.
    • What would you do if there is cord malpresentation? Cord malpresentation is relatively common, and actually pretty fixable if done properly. This is one where midwives often have better skills, as they usually handle it by unwrapping the cord from around the baby as he comes out so that oxygen flow isn't cut off. Doctors often have a practice of rushing in and cutting the cord immediately before the baby comes out, which cuts off oxygen flow and can cause the baby to go into distress.
    • What are your thoughts on induction with Cytotec? Cytotec (Misoprostol) is a drug for treating ulcers. Because it causes abnormally strong uterine contractions, it is also used to induce abortions for elective purposes or for missed miscarriage. It is commonly used by doctors to induce labor because it works faster than pitocin, though it has never been approved by the FDA for such use. When it first hit the market the label read that it was contraindicated for usage by pregnant women. After an alarming number of reports of uterine rupture and infant and maternal deaths where Cytotec was used to induce labor, Searle, the manufacturer of Cytotec, distributed a letter warning doctors not to use the drug for induction. The American College of Obstretrics and Gynecology there isn't enough evidence to conclude that Cytotec is unsafe and maintains that it is safe for induction. You can find the full text of Searle's letter of warning here, if you are interested. Obviously every woman must decide for herself if she is comfortable with the use of such a drug during labor.
    • How many unmedicated births have you attended? Many OB-GYN's have little experience with unmedicated birth, which means that they are very unfamiliar with a basic biological function of the female body. Since they don't know what natural birth even looks like, even normal occurrences in the birth process seem like emergencies and are treated as such.
  • Birth in a place you feel safe- Seriously, this is a big one, and you have to be really honest with yourself about where you are comfortable. In nature, if an animal feels threatened during labor, a stress hormone catecholamine will stop labor so that the mother can flee. We humans are the same way. If you feel threatened and overly stressed during labor, your body will start releasing increasing levels of catecholamine and stop labor. If you're at home or a birthing center, this may mean a transport to the hospital. If you are at the hospital and labor stalls, you will probably receive labor induction medication or a c-section. If you feel safest at a hospital, then without a doubt, you should choose a hospital birth. If you really don't feel comfortable in a hospital, then an out-of-hospital birth will probably be best unless you are especially high risk.
  • Don't rush off to the hospital too soon- Folks, I hate to be the bearer of bad news, but real life  labor and birth are not like what you see in the movies and on TV. (And just being a ship captain isn't enough to legally give you authority to marry people. Sorry.) In the movies and on TV, a woman's water breaks and everyone starts running around like mad to get her to the hospital right away. In real life, that's usually not the best course of action. Reasons why:
    • Policies on time to delivery- Hospitals have time limits on how long you can be at the hospital from check-in to delivery. Your body and baby haven't read those policies and will move at their own pace. It's also very common to have slower, irregular contractions, and even stalls during early labor, just as a natural part of the labor process. Early labor can often go on a while and the thing is, you don't need to be at the hospital until active labor hits and you are close to delivery. For all the talk from OB-GYN's and anesthesiologists about how "things can change very fast", when the body is left to do its thing unhindered, they usually don't. (Now if you put a laboring woman on her back, a position which reduces oxygen flow to the baby and decreases the size of the pelvis, use drugs, and deprive a woman of food and water for several hours, then yes, things can go wrong very fast.)
    • Policies on eating- Hospitals also have policies forbidding the laboring woman from eating or drinking until the baby is born so that if medication or surgery are administered there isn't any chance of a reaction. It sounds good in theory, but labor is very athletic and hard work, which increases the body's need for glycogen (glucose) and even a few hours without food or water can send the laboring woman's body into ketosis, which causes the muscles- including the uterus- to function less efficiently, slowing or even stalling labor. And this is one problem with inductions is that you have to be at the hospital from start to finish.
    • Continuous electric fetal monitoring- I talked about this in my post on the American medical community and the high infant and maternal mortality rates in this country. There is no evidence showing that continuous monitoring is safer or more effective than intermittent monitoring, and there are plenty of problems with it. The longer you are on your back during birth, the greater the chance that you will have difficulty pushing the baby out or that the baby will go into distress.
    • And if you do have a "Hollywood" labor where your water breaks- Your greatest risk is infection if your labor kicks off with your water breaking, however, as long as you don't put anything in the vagina, this is a very, very, very small risk. But if multiple dilation exams are being done on you, there is a greater risk of infection
    • Okay, so when am I supposed to go to the hospital? The general rule is, of course, when the contractions are about a minute long and five minutes apart. It is possible that you could "hang out" in that type of timing for a while and the baby could still be a ways off. The late Dr. Bradley talked about the emotional signs of active labor being crucial in knowing when to leave for the hospital. Indecisiveness, inability to focus or carry on a conversation, not being able to smile or laugh, not wanting to move around much, are all signs that it is time to go. If mom can smile, laugh, walk around the mall, or pay attention to a TV show, it's too early to leave for the hospital. A tastier litmus test is suggested by nurse midwife Pam England in her book Birthing From Within: when you are in labor, start baking chocolate chip cookies. When the cookies start to burn because you are getting lost in labor land, it's time to go to the hospital. (Just make sure to turn off the oven first.)
  • Know the circumstances under which you really do need a c-section- Let's just say that if you are a highly athletic woman who teaches fitness classes and your doctor tells you that your ab muscles are just too tight to push the baby out (I kid you not, I heard this one), you can be pretty sure he just doesn't want to stick around and wait...
    • Position of the baby- Though most doctors are saying all breeches should be c-sections, breeches of all kinds have been safely delivered vaginally in hospitals and even at home with experienced midwives. (And as one couple and Illinois state trooper found, even a footling breech previously scheduled for c-section can be delivered safely by the side of the road.) In the US, if you are lucky, you may be able to find a doctor who will do a vaginal birth for a frank breech. In Canada and Australia, complete breeches are also considered safe for vaginal delivery, provided the baby has no other risk factors such as prematurity. If you really want to avoid a c-section for a breech and you live in America, you may have to find a midwife with lots of breech experience. I find it really sad that so many women are losing options on how to birth their babies here in the US. It's not so much a matter of how you end up delivering, it's more a matter of being able to choose, from my perspective. Transverse lie of a singleton or Baby A twin require a c-section.  (Transverse lie is not uncommon for Baby B twins. They tend to go head down once their sibling comes out.) There are risks associated with a vaginal breech birth, but there are also risks associated with a c-section. It's up to every mom to decide what is best for her and her baby. If you find out that your baby is in breech or transverse, take heart! You have options. Spinning Babies.com has loads of information on how you can prevent and turn breeches and transverse lie. ICPA.org has info about using the Webster Technique to turn breeches. The American Pregnancy Association has stated that the Webster Technique is highly effective and turns about 82% of breeches into vertex.
    • Placenta previa- It's pretty common for the placenta to float around during the first trimester and cover the cervix, but if it persists into the second or third trimester and is accompanied by severe vaginal bleeding, an emergency c-section with a classical scar must be performed to save the mother and baby. Sometimes the bleeding starts pre-term and isn't severe and goes away with bed rest, and then the baby can be delivered full-term via c-section.
    • Pre-eclampsia, eclampsia, HELLP syndrome- These require an emergency c-section to save the baby and mother. Knowing the symptoms of pre-eclampsia and related syndromes could save your life or the life of someone you love. Women with access to great health care are still dying from this disease here in America because it often goes unnoticed by medical professionals. If you are having symptoms of pre-eclampsia, you may have to be your own advocate to get the care you need.
    • VBAC after 2+ cesareans- Think you're out of the running for a VBAC because you've had multiple c-sections? Not necessarily. Medical reports show that moms who have had two, three, and even a whopping four or five c-sections can still successfully VBAC.  (You'll have to scroll down to the VBAC section). Repeat c-sections may increase the likelihood of uterine rupture or a repeat c-section with a VBAC. On the other hand, repeat c-sections carry their own set of risks too. Classical (vertical scars) are a rather mysterious thing. What I know is that the general consensus among doctors and midwives is that a VBAC should not be attempted with a classical scar because they have a greater chance of rupturing than low incisions (10% as opposed to 0.3-0.7%). What I have heard are rumors that it can be done and has been done, especially since classical scars used to be the only types of scars used and were what the first VBAC advocates had. Again, every mother has to make the decision about what is best for her and her baby.
    • Multiples- Roughly half of all twins and about 99% of triplets are delivered via c-section in the U.S. If you start researching, you'll find that many moms have had perfectly safe, full term, vaginal deliveries of twins (and even triplets) in and out of hospital- even as VBAC's. Apparently there is a Dr. Tate in Atlanta who believes in VBAC's so much that he helped a mom deliver her triplet girls (two vertex, one footling breech) vaginally and spontaneously at 38 weeks gestation. This woman delivered triplets as a successful VBA2C. Another story to knock your socks off, one mom who had genital herpes did a successful VBAC of triplets at home at- are you sitting down?- 41 weeks. So yes, you can make it to full term with multiples and do a natural birth!
    • Cephalo-pelvic distortion- If you genuinely are too small and the baby is too big, then you will need a c-section. CPD was much more common when abnormal bone development from rickets was widespread. However, when you are lying down, your pelvis becomes much smaller and it makes it much more difficult to push even a normal sized baby out. A good article on CPD is here under the "Can I have a home birth if..." link.
So there it is. My advice on how to get the birth you want. In closing, from an evolutionary perspective,  if birth really were so dangerous that there was a likely chance of death for every mother and baby who gave birth without several high-tech interventions, the human race would have died out a long time ago.  From a religious perspective, I believe that God designed our bodies and that He knows far more about the birthing process than any doctor or scientist. Either way, I believe that obstetrics needs to work with and not against the biology of the female body.

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