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Archive for the ‘Medical Interventions’ Category

Is home birth safe?

Most doctors in the US will say no, absolutely not. But is that really true? Here are a couple studies so that you may decide for yourself.

1. 2009 study published in the Canadian Medical Association Journal (CMAJ)
Conclusion: “Planned homebirth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric intervention and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.”
 Details: This is a very good study because it looked at only women who were low-risk; even the women who gave birth in the hospital would have qualified for a home birth if they had desired. Therefore, the study is not biased in favor of homebirth, but is as fair as humanly possible. For a planned home birth, rates of perinatal (baby) death per 1000 births was 0.35. For the planned hospital births with a midwife, rates of perinatal death per 1000 births was 0.57. For planned hospital births with a physician, rates of perinatal death were 0.64. Notably, the study finds that women who had planned home births were significantly less likely to have bad maternal (mother) outcomes, such as severe tearing or hemorrhage.

2. 2005 study published in the British Medical Journal
Conclusion: “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”
Details: This study looked at all of the planned home births in 2000, attended by Certified Professional Midwives in the US and Canada, in locations where home birth is not integrated into the healthcare system or well-accepted by most medical providers in the area.

3. The Maternal Mortality Rate in the U.S. is atrocious, for how medically advanced we think we are. 
Instead of having fewer mothers die in childbirth now as opposed to 20 years ago, the US has actually seen an increase in maternal deaths since 1990. This means that a woman in her twenties is more likely to die in childbirth than her mother was. As an industrialized country, we fall dismally behind countries such as Canada, Japan, and the Netherlands, all of which have midwives attending the majority of births. We rank 39, which means that 38 countries have better maternity survival rates than we do…and most of them are substantially better.

So what have we done wrong? Why are women more likely to die in childbirth than they were only 20 years ago? Could it be  due to the skyrocketing unnecessary medical interventions such as induction and cesareans? Could it be that maybe, with all our medical advances in case of emergency, we’re so on edge that doctors actually create the very circumstances they were trying to avoid? Could it be that most births are not medical emergencies, and that most women will give birth safely to healthy babies if left to their own timing, with a midwife who will offer support and appropriate medical care throughout this phenomenal life change?

Maybe. Maybe we’ve had it all wrong.

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Induction is a term that describes the act of sending a woman’s body into labor. Technically, the word can be applied to both natural methods of induction, such as walking or sexual intercourse, and to unnatural methods, such as the administration of drugs or artificially breaking the bag of waters.

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Pitocin

Pitocin is a synthetic hormone that mimics oxytocin, the hormone that sends a woman into labor. It is administered via intravenous drip into the bloodstream, and causes contractions that are intended to either start labor or “jumpstart” a stalled labor. Since Pitocin is the most widely-used form of induction, I will dedicate a full post to it.

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Cytotec

Cytotec is a small pill that can either be taken orally, or is inserted in the vagina to induce labor. Once administered, it absorbs into the body and cannot be removed or its effects stopped.

Despite being quite popular among medical staff, this drug is not FDA approved for use on pregnant women since it frequently causes uterine rupture and can be fatal to both mother and baby. Uterine rupture means that the top of the uterus detaches from a woman’s body, often breaking open at the top and sending the placenta and unborn baby into her abdomen instead of through the birth canal. This occurs because the contractions created are too strong and hyperstimulate the uterus. Uterine rupture or danger of rupture is extremely serious and the baby must be born as quickly as possible, usually through cesarean, and the mother’s uterus must be repaired or removed.

Several years ago the manufacturing company sent out a warning to all medical practitioners against the use of Cytotec on any pregnant or laboring woman. Unfortunately, and extremely unethically, this pill is still used widely within the medical community.

Please read this article previously posted about Cytotec, and the serious dangers it represents to both mother and baby. If you decide to induce medically for any reason, please request Pitocin, and do not allow anyone to give you Cytotec, also called misoprostol.

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Prepidil and Cervidil

These two drugs, each a type of prostaglandin, work similarly to Cytotec in that they soften both the cervix and lower part of the uterus. They are frequently used in conjunction with Pitocin to enhance its effects. Prepidil is a gel applied directly to the cervix, and Cervidil looks like a tampon that is inserted into the vagina and releases the synthetic prostaglandin. Unlike Cytotec, these two drugs were FDA approved for labor induction in the mid-1990s. In case of hyperstimulation (overworking) of the uterus, the Prepidil can be wiped off and the Cervidil removed in order to halt the flow of prostaglandin. In this way the two are safer than Cytotec, which cannot be removed, but they can and do still cause uterine rupture occasionally.

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Breaking the Waters

For some women, labor begins by the bag of waters breaking. This happened to me with my first labor and it was pretty obvious to me when it broke. The break can cause harder contractions, but also greatly increases your chance of infection if the bag breaks before you are ready to be in labor. If labor doesn’t start soon after, most care providers will want to induce and administer antibiotics.

Breaking the waters refers to artificially rupturing the bag that holds the baby and amniotic fluid. This is a fairly common procedure and is considered safe because there is no danger of uterine rupture. If a woman’s body is ready for labor, breaking the waters effectively starts labor for 70-80% of women within 24 hours. The problem with this method of induction is that, for the other 20-30% who don’t go into labor quickly, danger of infection is high. In a hospital setting, this also places a time limit on how long labor is allowed to go. If breaking the waters does not start contractions within a specified period (usually 24 hours), then a hospital will begin other methods of induction, such as a Pitocin drip or the administration of one of the previously-mentioned interventions.

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One of the most common interventions requested by a laboring woman in the US is an epidural. Many cannot imagine going through labor without receiving one. However, not many women know what it is, why it started as a labor drug, and what the benefits and risks are in using an epidural. So, here we go! Let’s explore this intervention.

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What is an epidural and why is it used?

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The first epidural was administered in 1885, when a doctor in New York injected cocaine into the back of a suffering (not pregnant) patient. Much later, doctors decided to try it on laboring women, and since then the use has skyrocketed.

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The goal of an epidural is to provide pain relief for a laboring mother who feels that she cannot cope with the labor process. It is administered through a spinal block, meaning that the drugs are injected directly into the spinal column instead of orally or through the bloodstream. The woman sits on the bed and a large needle is placed into the small of her back. Some women say they feel pressure when the needle is inserted.

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The drugs in an epidural are local anesthetics, which are most often given in combination with analgesics. The anesthesia numbs the lower body. The analgesia reduces the perception of pain, similar to narcotics. They include drugs such as epinephrine and morphine.

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Does an epidural work?

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Well, it depends on who you ask. About 25% of epidurals are “perfect.” Meaning, they provide pain relief for as long as needed, there was no feeling on both sides of the body, and the needle was placed correctly without accidentally hitting a nerve or causing damage. The other 75% either wear off quickly so that more drugs need to be added, only numb one side of the body, or cause nerve damage.  10% of epidurals don’t work at all. However, so many women are terrified of birth thanks to the media, doctors, and horror stories from other mothers, that we continue to ask for epidurals because we think we cannot handle the excruciating pain we know it will be.

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How does it affect normal labor?

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Many studies have been performed on how an epidural affects normal labor for a healthy woman. One of the first noted is that the use of an epidural prolongs labor. This is most likely due to several factors that work together: a woman is limited in her movement, her uterine muscles are somewhat numbed by the drugs and are unable to contract properly, and the woman cannot feel when her body is ready to push, so has to rely on nurses to tell her when. All of these factors play into the lengthening of labor.

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Epidurals also increase the need for Pitocin to restart labor once it has stalled. Contractions caused by Pitocin are much harder and longer than normal contractions, so this also frequently leads to the need for more drugs via epidural.

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When a woman is in labor, her body releases endorphins that help her to transcend pain. They send her into an altered state that allows her to tune in to her body and her baby. The rest of the world fades away and she is in her own world throughout the labor. It is nature’s pain relief. An epidural reduces the release of these labor hormones and makes women more docile and silent during labor. Sarah J. Buckley, a leading Australian physician, mused that “perhaps the widespread use of epidurals reflects our difficulty with supporting women in this altered state, and our cultural preference for laboring women to be quiet and acquiescent.”

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In addition to these ways in which an epidural affects labor in general, there are several other ways in which epidurals negatively affect both the mother and baby. Now, I do not list these to frighten anyone unnecessarily, but I do believe that it is extremely important to fully know what you’re agreeing to before allowing someone to mess with your body.

Side effects

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Mother:

Close to a quarter of all women who receive an epidural experience complication. And they can be serious. A woman who has had an epidural is three times as likely to die as a woman who did not have one. One in five hundred women will experience short-term paralysis that can last days, and in half a million epidurals, one will be left permanently paralyzed.

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The most common side effect is a drop in blood pressure. Because it is so common, nurses generally administer fluids via IV before placing the epidural, although still roughly half of women experience low blood pressure. This leads from mild side effects such as feeling faint, to more serious problems such as maternal cardiac arrest and lowered blood supply for the unborn baby. Shivering, nausea, vomiting, and severe headaches are also common after an epidural. One major UK study found that a woman was twice as likely to hemorrhage after giving birth with an epidural than was one who did not have an epidural.

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Finally, epidurals increase the risk of other interventions, especially a cesarean, which is major abdominal surgery, presents it’s own set of risks to both mother and baby, and requires weeks of recovery.

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Baby:

Although I have heard both doctors and mothers say over and over again that epidural drugs do not reach or affect the baby, study after study shows otherwise.

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First, the placenta is not a barrier between the mother and baby. It is a conduit. What goes into the mother also reaches her unborn child. That is why, during pregnancy, women are cautioned to eat a healthy diet, and to avoid or limit over-the-counter-drugs, caffeine, alcohol, sugar, or exposure to chemicals and smoke. Why, then, do all of those rules go out the window during labor when there is no medical need to use any drugs except in women who truly do have medical complications?

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…regional anesthetic agents do not remain regional in their distribution. Measurable levels of these drugs appear in maternal blood from 1-7 minutes after instillation and measurable levels appear shortly thereafter in fetal blood regardless of the type of regional anesthesia or the agent employed.

~Dr. Howard Fox, University of Kansas Medical Center, Division of Neonatal Medicine

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If the drugs do enter the baby within 10-15 minutes after an epidural, what do they do?

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A lot, actually. Fetal distress is one of the most common side effects of epidurals in labor, and it is also the most common reason cited for emergency c-sections. Changes in the fetal heart rate are very common, which indicate that the baby does not have adequate oxygen or blood. Babies exposed to epidural drugs can also experience respiratory problems, and at birth have even higher drug levels in their systems than even their mothers do.

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I cannot tell you how many times I’ve heard and read women declare that they had to have an emergency c-section due to fetal distress, and that they were so thankful they were in a hospital so that the doctor could save their babies. What they don’t realize is that the drugs given to them by that doctor were the very things that caused the emergency in the first place.

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Is there any way to relieve pain without drugs?

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Absolutely! Pain relief in itself is not necessarily a bad thing. When drugs are not used, a woman, given freedom to labor how she chooses, will move into positions she finds most comfortable. Be that walking, sitting, resting in warm water, on hands and knees, or in one of the myriad other positions she will find a way to adjust herself that feels right. Her movement also helps her baby move down the birth canal into the correct position for birth. This is not possible with an epidural because women are confined to their backs on a bed, which by far the worst possible position for giving birth because it closes the pelvic opening, making it much more difficult for the baby to get through. Lying on her back also ensures that she is working against gravity, rather than with gravity.

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Many midwives and doulas use soothing herbal scents or tinctures to help soothe a laboring woman, as well as massage or acupressure. Laboring women also frequently find music and dim lighting to be calming as they work to bring new life into the world. Fear of labor and laboring in an unfamiliar place with unfamiliar people can increase both pain and length of labor. Seeing birth as a normal and natural part of your passage into motherhood helps tremendously.

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Additional side effects

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In order to be completely thorough, here are additional side effects for both mother and baby not mentioned above, in no particular order:

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Severe postpartum depression

Death of baby

Increased likelihood of: being induced, using forceps, and episiotomy

Feelings of emotional detachment

Decreased mother-infant bonding

Complications to baby

Chronic back pain

Fetal drowsiness

Chronic migraine headaches

Chronic “pins and needles”

Loss of consciousness

Convulsions

Septic or bacterial meningitis

Fecal and urinary incontinence

Seizures/Trauma

Inability to push out baby

Misplaced catheter

Accidental injection of anesthetic into bloodstream

Punctured dura

Allergic reaction

Fetal hyperthermia

Neonatal jaundice

Poor fetal muscle strength

Neurological complications

Permanent nerve damage

Loss of sensation and sexual function

Damage to spinal cord

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The decision whether or not to use an epidural is completely up to you. In some cases it is truly necessary, such as for a cesarean birth. Other times it is personal preference or because another intervention made contractions too much to handle. Just know the possible negative side effects so that your choice is fully informed. And also realize that introducing one intervention often leads to more interventions that you may not have planned on or wanted.

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References:

The American Pregnancy Association

Born in the USA by Marsden Wagner

“The Hidden Risks of Epidurals” by Sarah J. Buckley as reported in Mothering Magazine

“Effects of Maternal Analgesia on Neonatal Morbidity.” By Howard Fox, University of Kansas, Neonatal Division

The Bradley Method by Marjie Hathaway, et al.

Pregnancy in America, documentary 

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Cytotec (generic name Misoprostol) first hit the market as a prescription drug for the prevention of ulcers. It was supposed to counteract the unfortunate side effects of certain medications for arthritis and pain relief that cause a higher rate of ulcers (I think I’d rather have the arthritis, personally!). The FDA ran trials and approved it for this use only.

However, it was soon discovered that, given to a pregnant woman, a low dose of Cytotec will successfully start labor contractions at a fraction of the cost of pitocin. So, doctors began giving the drug “off-label” to millions of women.

So, what’s the big deal? you may ask. It works, doesn’t it? Well, I’ll tell you what the big deal is.

Cytotec kills women and babies.

That’s a pretty big deal, right?

I’ll say it again: using Cytotec for induction can kill or seriously injure both the mother and baby.

One unfortunate side effect of misoprostol is that it can cause uterine rupture, which is life-threatening because the uterus detaches from the mother’s body. It causes severe bleeding, fetal distress, and the baby or placenta can be delivered into the mother’s abdominal cavity, rather than through the birth canal. Mothers who experience uterine rupture need an immediate cesarean to get the baby out and to repair or remove the uterus. The mortality rate for women who have a uterine rupture is extremely high, and their babies either die or are left seriously disabled.

The deaths of healthy mothers and babies should be enough to keep doctors from giving the pill to anyone. However, it gets worse. The most shocking part of the use of Cytotec in this way is that the manufacturing company, Pfizer, clearly labels each bottle with a warning against using the drug on pregnant women. When doctors ignored it, they sent out an extra warning to all healthcare practitioners involved in prenatal care and childbirth:

The purpose of this letter is to remind you that Cytotec administration by any route is contraindicated in women who are pregnant because it can cause abortion…

Serious adverse events reported following off-label use of Cytotec in pregnant women include maternal or fetal death; uterine hyperstimulation, rupture or perforation requiring uterine surgical repair, hysterectomy, or salpingo-oophorectomy; amniotic fluid embolism; severe vaginal bleeding, retained placenta, shock, fetal bradycardia and pelvic pain.

(This excerpt was taken from the actual letter. If I knew how I would scan the whole letter and add it to the post, but I’m not quite that technologically adept yet).

With all the reasons not to give Cytotec to any pregnant woman, you would think that no doctor would ever do so. And yet, even with the warnings and evidence of danger, women are still given this drug to induce labor and the fatalities continue.

The biggest question is, of course, why?! If it causes so much damage, why on earth would doctors continue to prescribe it? There are only two reasons I can think of that Cytotec would be given for induction rather than pitocin: money and convenience. Cytotec is much cheaper than pitocin to induce labor, and it is also extremely easy to use: just pop a pill early in the morning, and the baby is out by evening. Or dead by evening.

To all mothers-to-be, please, please do not allow anyone to give you Cytotec! Remember, it is also called misoprostol. If you choose to be medically induced for any reason, make sure you are given pitocin via IV rather than a pill that is either taken orally or placed in the vaginal opening. It is not worth the risk to you or your baby.

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