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Epidural does NOT = no pain

Thursday, August 27th, 2009

Did you know the rate of drugged babies at birth in the U.S. is about 98%?  So that leaves 2% to natural births.  Definitely the minority.

A lot of pro epidural people think natural childbirth participants are crazy.  They think and feel that childbirth was painful enough with the medication, why would anyone want to do it without?

Well, maybe we should ask these questions first of the medicated delivery:

  • When were the drugs administered (after you’ve labored almost to 10cm)?
  • Was the administration of the medication painful (after all, it is injected with a very long needle into a very sensitive area)?
  • Did you feel the drugs decreased your ability to function (feel the urge for pushing, urination, no sensation in your legs, etc.)?
  • Did you feel out of it (the medication causes sleepiness)?
  • Were you conscious enough after delivery to breastfeed and bond with your baby (emotional disconnect causes pain as well)?
  • Did you take any classes or receive training for birth, whether it be natural or not (preparation reduces fear which reduces pain)?

So pain is really a subjective thing and perhaps in labor, more of the “pain” that epidural users report is due to some of the items mentioned above and not just to the act of childbirth.

I am not saying natural childbirth is for everyone as we all have our own pain tolerance but let’s at least investigate our options, explore why it is better for us and our babies and perhaps at least try to labor before signing up for the epidural at our first office visit.

Posted in Labor & Delivery, Medical Consumerism, Medical Procedures, Natural Childbirth, Pain Management | 2 Responses »
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EFM: hinderance or help?

Tuesday, August 18th, 2009

Fetal monitoring comes in all shapes and sizes these days.  From a simple stethoscope and kick counts to the ultrasound, doptone and electronic fetal monitoring; each has it’s own pros and cons in checking in on your little one’s vitals.

Throughout your pregnancy, your medical professional probably uses a stethoscope or doptone to listen for your baby’s heartbeat.  You will also keep track of how active your baby is by noticing the kicks and movements inside your belly.  During labor, however, the trend has been towards a more technical method of monitoring.

If you have a hospital birth, odds are they will use an external fetal monitor (EFM) to track the baby.  The EFM is composed of an electronic transducer that is strapped to your belly by means of an elastic belt that send an electronic reading of the fetal heart rate (FHR) and mother’s contractions to a base station in your birthing room.  Anytime there are any dips or raises outside of the normal range (120-160 bpm), indicating stress, an alarm beep sounds.  This also goes off if the disks slide around while you are busy laboring or if it gets wet from your water breaking, etc. which usually causes nurses to rush in to see what is happening.

An obvious benefit to fetal monitoring is in diagnosing early fetal distress and being able to closely assess a high risk mother/pregnancy.

But the risk of the rate of high false-positives are an important one to weigh when allowing EFM.  Of course, no one has good data to back this up but it is noted that out of 1000 births, an extra 30 cesarean sections and an extra 38 forceps extractions occur in continuous EFM versus intermittent auscultation.  If a alarm situation does arise, changing positions, relaxing and giving mother oxygen can all help to relieve any stressors to baby.

There is no recommendation of EFM in low-risk mothers and it does not show an improvement in maternal or fetal outcomes.  So why is it such a common occurance (about 75% of births)?  It then becomes an issue of staffing as it is recommended that it be a 1:1 ratio of nurse to patient when using intermittent monitoring but obviously if a machine is doing the work for the nurse, then they can divide their time between more patients.

Besides the risk of unnecessary medical interventions, including cesarean section, continuous EFM can be cumbersome and an annoyance, especially if you wish to labor or deliver in a tub.  It can be discussed previous to birth to perhaps have intermittent monitoring.  I do however feel that if the labor is induced, it can be a great benefit to use continuous EFM as intermittent monitoring may not pick up on all the ups and downs that baby is experiencing due to the manufactured, chemical contractions from the pitocin.

As with any medical procedure, just be informed and aware of all the benefits and risks.  Ask why do I need this?  What can happen if I don’t have it done?  Are there any other alternatives?

Posted in Complications, Labor & Delivery, Medical Consumerism, Medical Procedures | No Responses »
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Prods and pokes to the little folks

Monday, June 15th, 2009

So you’ve prepared for your natural birth and have been a good medical consumer researching all your care for the pregnancy and birth of your baby but there are still many more informed decisions to make after your baby is born in regards to his care.  Depending on what location you give birth at or in which state you live, there are a variety of procedures, tests and shots that may/will be given/offered.

Peggy O’Mara in Having a Baby, Naturally suggests the following before making a decision about newborn care:

  • Weigh the pros and cons of each procedure or test.  Gather information from both sides.  Do this as early as possible.
  • Involve your partner in the process.
  • Ask if there are alternatives to the accepted treatment.
  • Seek medical providers who are sympathetic to your needs and wishes.
  • Consider the implications of both sides of the decision.
  • Consider delaying procedures, if that is an option.
  • Do one procedure at a time.
  • Hold your baby during each procedure, if you can.
  • Make peace with your decision and live with it, knowing you’ve tried your best to safeguard your baby’s health.

The first assessment to baby will be the APGAR rating at one minute and five minutes after delivery.  Baby will be given 2 points for each category of: appearance or color, pulse, grimace or responsiveness, activity and respiration.  Most babies score higher than a 7 and higher on the second assessment.  This test can be done with baby right at your side.  Keep in mind it is subjective.

In the first few minutes of your baby’s birth, hospitals will want to administer vitamin K.  Vitamin K promotes blood-clotting since babies are born with very low levels.  You can deny (you have the right to refuse any medical procedure) this treatment that can prevent a rare hemorrhagic disease.  An eye treatment of erythromycin or tetracycline ointment is often times a state law which is an antibiotic used to prevent the effects (blindness) of gonorrhea to baby.  Delaying this for an hour or two will aid in allowing for some visual family bonding (the ointment does cause temporary blurred vision in baby).

In the first first hours through the first few days, baby will also be assessed for jaundice.  Doctors will note the skin and whites of the eyes for yellowing due to hyperbilirubinemia.  There are three types of jaundice: jaundice of early onset – might indicate a serious problem, normal physiologic jaundice – occurs around 3rd day and is normal and jaundice of late onset – peaks at 10 to 15 days and is caused my a hormone in women.  Most jaundice cases are normal and require no medical treatment.  Normal jaundice is “treated” with breastfeeding and exposure to sunshine.  Your doctor may do blood draws to monitor the rise in the bilirubin levels and baby’s treatment could go to phototherapy lights or blood transfusions depending on the severity.  The occurrence of jaundice may be increased if drugs were used during childbirth, if labor was induced, if mom took birth control pills or mega vitamins or if it’s a male or Asian child.

After 24 hours, most states require the PKU test.  It is a heel prick for blood samples to test for a group of genetic conditions including phenylketonuria (inborn error of metabolism to digest phenylalanine), galactosemia and genital hypothyroidism.  The state will notify you if there are any positive results.  If baby is left untreated, some degree of retardation will occur.

Two other newborn procedures that are very large topics to be covered in other posts are: circumcision and immunizations.  If baby is a boy, circumcision may be chosen to be performed.  This is a very personal choice as nothing medical supports the removal of the foreskin of the penis.  Immunizations are highly controversial and sometimes required by schools.  The concern over some of the additives of vaccines is still an issue even though they are not in the immunizations anymore.  Another of the big issues is the schedule of the vaccines and the quantity given to the child at one visit.

Posted in Complications, Medical Procedures, Newborn Care | No Responses »
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Did I pass?

Monday, June 8th, 2009

testWell the stick read positive didn’t it?  But your test taking doesn’t stop there, it may have just begun.  Depending on your medical support professional (primarily comparing doctor vs. midwife), the type of and frequency of prenatal tests can vary greatly.  Did you know since it is your body you have the right to refuse any medical procedure?  Although there are some tests that are good to take, there are also a lot that can give false or misleading information, can worry you for nothing and can “mark your file” negatively.  Let’s go over the most common prenatal tests in this post (go here for information on genetics testing).

At your basic visit (monthly or weekly depending on gestational duration) with your medical support professional, various things shouldbe checked.  Blood pressure for one.  This one is obviously non-invasive and is important especially in the last trimester to make sure you are not developing hypertension (high blood pressure) which can be an indicator of preeclampsia.  Growth is another thing to check.  Yours and the baby’s.  You will be weighed to check that you are gaining adequate weight for the health of your baby.  A fundal height (from the top of the pubic bone to the top of the uterus) using a measurement tape will also be taken.  This can help to indicate issues with the amniotic fluid or position of baby.  Urine may be tested regularly as well which monitors sugars and proteins in your body which can suggest diabetes, bladder infection or hypertension.  One other regularly checked item is fetal heart tones.  A fetoscope or doppler device can listen to the baby’s heartbeat.

Somewhere along the line, you will probably have your blood checked.  This could be to establish your blood type, screen for Rh factor (if mom has a -Rh factor and dad has a +Rh factor, baby will be +Rh and mom’s system may create antibodies to fight off baby) check for sexually transmitted diseases (some can be passed to your baby or cause complications during pregnancy and birth).

Near the 20 week gestation mark, it is common to have an ultrasound performed.  We will discuss ultrasound in a future post.

A glucose test is performed around 24 to 28 weeks gestation.  You ingest a sugar mixture and after an hour, you have your blood sampled.  If it is too high, there usually is another test performed and you wait four hours after drinking the sugar mixture.  If the glucose level is too high then, they will diagnose you with gestational diabetes.  That will be a post unto itself in the future as there is a lot of controversy of this test that can never be reproduced, asks your body to process a large volume of sugar that you would never typically eat and does not have back up statistics to the risks of mother or baby.

Group B Strep (GBS, beta strep) is a bacteria that commonly lives in humans and approximately 25% of women carry it.  It is of no harm to mother but it can be a risk (lung, spinal cord or brain infection, meningitis) to your baby at birth.  98-99% of babies born to mothers with group B strep will not contract it if treated (mother recieves antibiotics during labor) at the time of birth.  A vaginal and rectal swab is taken around 35-37 weeks gestation.

Cervical exams are invasive and do not provide much information.  They should not be a part of routine care as an increased risk of infection occurs with frequency of vaginal exams.  Checking effacement and dilation does not indicate when the baby will arrive and just causes anxiety to the mother.

As with any prenatal test/exam, Robin Elise Weiss, LCCE suggests these questions to ask beforehand:

  • Why should this test be performed? 
  • How will the test be done? 
  • What risks, if any, does the test pose to the baby or to me? 
  • How experienced are the people doing the tests, and how dependable are the results? 
  • When and from whom will I get results? 
  • What typically happens following good or bad results? 
  • How might the results change the management of my pregnancy? 
  • What could happen if the test is not done? 
  • Could we get the same information in another way? How? 
  • What is the cost, and will it be covered by my insurance?

    • Posted in Complications, Medical Procedures, Tests | No Responses »
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    Sometimes no news is good news

    Friday, June 5th, 2009

    needleBefore you consent to prenatal genetic screenings, you need to ask yourself what would you do with the results.  One test may spiral into another and realistically, these tests have an all too high rate of false positive which will cause worry for no reason.  The tests can also pose risks to the pregnancy.  If the results of testing for genetic abnormalities would not change the course of your pregnancy, then unless you feel you need to prepare mentally in advance, the test might not be worth taking.  It is a personal decision but should benefits should be weighed against the risks before you proceed.

    Chronic Villus Sampling is done around 10 to 12 weeks gestation and it looks for chromosomal abnormalities which could indicate birth defects.  Down’s syndrome, cystic fibrosis and sickle cell anemia can be determined from this test but CVS does have a risk of false positive and if it is positive, an amniocentesis is usually the next step.  Also, doing this invasive test (a needle is inserted into your abdomen or vagina to collect a sample) too early in pregnancy can cause developmental problems in the baby and miscarriage.

    Amniocentesis takes a small amount of fluid out of the amniotic sac to test for birth defects.  Many women over 35 are pressured into taking this invasive test which has risks to baby and mother (infection, bleeding, fluid leak, premature labor, fetal distress, miscarriage) where statistics indicate a higher chance of birth abnormalities.

    Maternal serum screening tests (Alpha-fetoprotein, triple screen) are done around 15 to 20 weeks gestation.  They check for proteins or hormones in your blood that may indicate a genetic or developmental problem in the baby.  Again, there is a high rate of false positives.

    The mental and emotional strain (and sometimes physical) that these tests have on the mother can “ruin” the pregnancy for her only to have a healthy, normal baby at the time of delivery.  Be a good consumer of the statistics and remember, you have the right to refuse any medical procedure.

    Posted in Medical Consumerism, Medical Procedures, Tests | No Responses »
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    Word of the day: Episiotomy

    Friday, May 29th, 2009

    Per Mosby’s Medical Dictionary, an episiotomy is a surgical procedure in which an incision is made in a woman’s perineum to enlarge her vaginal opening for delivery.  This is usually done in the last stages of delivery to prevent tearing.  It has been debated medically whether allowing a tear to happen naturally or to perform an episiotomy is the better scenario.  It used to be thought that a tear is harder to mend and harder to heal but it is recognized now that a natural tear heals just as well as a surgical incision (more TMI: I have a good testimony to that.  I had a 3rd degree tear on the last push due to my son’s shoulder dystocia, but at many checkups I had nurses comment – “oh your stitches look great” or even better, “your bum looks great!”).

    In the world of natural childbirth, an episiotomy can be performed without using drugs to numb the area.  What?!?!  Cut me open with scissors on purpose and without dulling the pain first?  Yes.  Again, a wonder of our Creator and how birthing works, you can have what is called a pressure episiotomy and it will not hurt.  If properly applied by your medical professional, all you will feel is perhaps a release of pressure.  To ensure this works correctly, your medical professional should wait until the baby’s head is crowning and cut only during a contraction when the stretched perineum is without circulation and sensation is naturally reduced.

    Prior to baby’s arrival, there are some things you can do to avoid a tear or episiotomy.  Having good nutrition means healthier skin.  Squatting improves elasticity to the perineum.  Kegels helps tone and tighten the pelvic muscles with helps baby to put chin on chest, encouraging the smaller part of the head to come first.  Avoid soap which is drying.  Lotion and massage can help.  Talk to your doctor to explain your wish to avoid this all to common procedure (35% of mothers with a vaginal birth experienced an episiotomy according to the Listening to Mothers survey conducted by Childbirth Connection).

    Additionally, during labor and delivery there are things you can do to avoid a tear or episiotomy.  Your birth supporters can apply warm compresses to your perineum and use massage to encourage stretching naturally.  Keep your elbows up and out and knees back when pushing.  Push with self-control, be patient with your pushing and ease your baby out.

    The advantages to an episiotomy are: a faster birth (but baby and mommy need that time), it prevents tearing towards the clitoris (ouch, very rare) and it allows for more room (for what, to get both of doc’s arms in there?).  The disadvantages are: generally unnecessary (typical to a lot of medical procedures these days), can cut through muscles (ouch to that), more blood loss (and it could be scary to see your newborn come out with your blood on it’s head), creates too fast of a birth (not allowing for baby and mommy to do their thang), more pain in recovery (it’s not fun to carry a blow-up, donut pillow around in case you do feel like sitting) and swelling (which makes healing harder).

    Posted in Medical Procedures, Terminology | 1 Response »
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    Word of the day: Amniotomy

    Tuesday, May 12th, 2009

    Per The American Heritage® Medical Dictionary, amniotomy is the “surgical rupture of the fetal membranes to induce or expedite labor”.  In layman’s terms, it is the breaking of the bag of waters.  It may also be done for the insertion of an internal fetal monitor and to check for meconium (the baby’s first stool).

    Amniotomy is performed with an amniohook amniohookclosewhich is a long, thin, crochet needle-looking tool that is inserted through the cervix and snags and breaks the amniotic sac.  When the bag of waters is ruptured, the amniotic fluid, which is full of the hormone prostaglandin, comes in contact with the cervix and may or may not produce stronger, more regular contractions.
     
    The average time of rupture of the bag of waters in a natural labor with no interventions is 8-9cm dilation and at times, a baby may deliver with the amniotic sac still intact.
     
    An amniotomy should only be performed if you are in active labor (4cm or more dilated), the baby is at full term, the head should be engaged and there should be an indication for the procedure.  Once the procedure is done, there really is no turning back.  Most medical care givers will not let a woman with a broken bag of waters go more than 24 hours without delivering the baby, which could lead to a cesarean section if you do not progress.
     
    Some potential side-effects, risks and complications are: cord prolapse, cord compression, infection, harder and more intense contractions during labor (the bag of waters equilizes the pressure and acts as a cushion for baby and mother), more tears to the perineum (the bag of waters allows for more gentle stretching), swelling to baby’s head from uneven pressure and as mentioned above, you will on a time clock for delivery.
     
    As with any medical procedure, there is a time and place for it.  Interventions have advantages and disadvantages and they may lead to further interventions and complications.  Always consider your options carefully and make informed decisions that are right for your baby, for you and for your birth and try not to make it out of rashness and a desire to have the labor be over with.

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