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Wednesday, 16 April 2014 10:04

A Healing C-Section

Can a C-section be healing? I believe so. Not because I have to believe, but because I experienced one just about two short months ago. Would you like to hear the tale? Let’s begin with the birth of my first child.

Well, it actually has to start about four weeks before he was born. It is September 2011 and I am just about 35 weeks pregnant with my first baby, a very exciting time indeed, when the scariest thing possible happens. I go into preterm labor. Or so I thought. The first thing, of course, that I did was call my provider at the time. I told them I felt cramps that spanned all the way around my abdomen just below my belly button. I was restless and cranky, but had no other signs. They listened to me on the phone and when one 'thingie' as I called it at the time hit, they told me I was having contractions and to come in immediately. So, I did. After spending an hour at the hospital it was concluded that, yes, I was having contractions; but, no, they were not doing anything. My response was SERIOUSLY?! 

I was told I was having prodromal labor (no text can do it justice). Prodromal labor is not, as some would tell you, Braxton Hicks contractions. Having had both, I know. Prodromal labor is all the fun of labor without any progress or baby. It sucks because it comes and goes and is as tiring as actual labor.

For four weeks I went through this. Contracting sometimes for six hours straight at a time and then nothing. Nine days into October I went into labor. I was in labor!! I was dilating and everything. Then we were crushed again. After 18 hours in labor I stalled out. Once again at home I would contract for eight or more hours. I was absolutely exhausted but nobody knew of anything that I could do. I was told to just 'tough it out'. Finally, that Friday I went into labor and stayed there. We went to the hospital and were released about six hours later with the doctor saying there just was not enough progression to warrant admission.

Here is where the story gets infuriating for my birth team with my second child.

When we were sent home, still in labor, our doula said she was going home and not to bug her until we were admitted to the hospital. When I told her the reason we hired her was to be with us during this time, while we were laboring alone, she said she was tired and her daughter had a game the next day she wanted to go to. We were horrified but what can you do? We went home and I labored Saturday and Sunday with the blurry help of my tired husband. Finally, with him facing a Monday of going to work as a zombie he forced me to go to the hospital to take them up on a morphine drip so I could get some rest and he could get to work. When we arrived at the hospital I was checked and was found to be four cms dilated. We called the horrible doula, mainly because my husband desperately needed relief, and progressed from four to seven fairly quickly. Then my body gave out. I did not know what to do so I was not moving or changing position. I was just breathing trying to will more strength into my body while sitting on a birth ball. My doula was checking her Facebook and email. My husband was passed out on the other side of the bed, sitting up, with a death grip on my hand. Never once was it suggested that I switch positions or even lie down in the bed.

Another hour later and I was sleeping through contractions. Yup. That was me. My doula took my exhausted husband aside and suggested I get an epidural to get some rest. By this time I had been laboring naturally for over 69 hours on top of the prodromal labor, I was exhausted. I got the epidural and sent my husband to the 'in-room' couch for a nap. My doula disappeared. I have no idea where she went.

The hospital staff did what they could and my doctor violated hospital policy by letting me labor two extra hours. You see when my waters broke there was meconium in them and this meant I had a 12 hour window in which to give birth. However, my baby was doing so well he let me go two extra hours. Finally, with a body that, on Pitocin, had made it to 9.5 cms, I began to shut down. I was swelling shut. Worst of all my baby was crashing. I was rushed into a C-section where my baby came out with an APGAR of 1.1! Warrior that he was he bounced back four minutes later to have an APGAR of eight.  At 11:30 pm I was wheeled into my maternity room and left alone to ponder what the hell had just happened.

Fast forward to Thanksgiving 2012, about 13 months later, I am staring at a stick not believing the little blue plus sign. I shake the darn thing like it is one of those old time mercury thermometers. The lines do not go away. Though I am not certified, I have taken all my doula training courses, researched, read and most importantly, located good resources outside the hospital. This time I get a midwife and go with an OB who is not only VBAC friendly and highly recommended by every midwife I interview, but is personal friends with my midwife and she has him on speed dial. I get a new doula, who just so happens to be my mother-in-law. I have prodromal labor, but this time am encouraged to take calcium-magnesium daily and Tylenol when it gets bad. With the exception of the stomach flu every month for seven months straight my pregnancy is about as eventful as watching paint dry.

The day before I hit 38 weeks, a Sunday, I am cranky, achy and generally pi**ed off. Hey, it is July and it is hot where I am. Plus, my husband refused to take me to the pool that day. He remarks on how agitated I am and I tell him I have been achy all day, standing up folding a ton of baby laundry and still have to get the nursery together. Did I mention we had not gotten anything ready with the exception of home birthing items, the crib in the correct location (which was already there because my first born was sleeping in it while we were fixing his room) and the co-sleeper ready? Everything else was in pieces. My hubby jokes that it is good that nothing is really happening. Only a man would call what I was going through nothing. Then at 3 am Monday morning I have show. I yell at my husband, take two Tylenol PM to sleep and think nothing of it. With my first I had a show at 36 weeks and he was born only two days before his due date.

Since work is 60 miles away (and my boss had been begging me for weeks to do this) I telecommute that Monday. I get about two hours of work when I just cannot sit still any longer. I walk. I lie down. I take calcium-magnesium. I tell my midwife I am having some bad Braxton-Hicks and ask suggestions. She is skeptical but contractions are about 20 minutes apart and 45 to 50 seconds long. To be fair to her I tell her they have no pattern. See, I have OCD so when people say they have to be consistent I naturally think they ALL have to be 45 seconds long. I labor the rest of the day away. When my husband comes home he immediately calls the midwife. I really do not believe this is labor at all so go to take a shower. When my midwife arrives she comments, as she is checking us, that she could hear me moaning from the front door. I was moaning? I am two cms dilated and not very effaced but definitely in labor and had been so since I saw the show that morning. Everything looks good and she wants us to get some sleep so I take Tylenol PM and she goes home, which is about a mile from my house.

I get no sleep. The contractions, which had been a breeze, suddenly become extremely painful and my hips shoot with pain during each and every one. My husband, bless his soul, holds my hand during each contraction. At 6 am Tuesday morning he calls the midwife to see if she could stay with me while he went to work. By 7 am my first born is at daycare and my midwife has arrived. I am still 2 cms dilated but I have effaced to about 60% and the baby has moved to below my pubic bone. A lot of progress. Then comes the bad news. He has turned so that he is facing my right hip and therefore his shoulders are at a 90 degree angle to where they should be. That means that every contraction has been forcing his shoulders down on my hips and flexing my hips a bit. However, I feel I am in a good place at home so we stay. My husband gets up to get ready for work. The midwife asks what he is doing and when he asks should he go to work she tells him not to if he values his marriage!

We continue to labor at home until about 2 pm. My midwife is concerned. I have not rested. I have not been drinking much nor have I been eating. In fact, the quarter of a sandwich that I ate was hard bargained for by my husband. She is afraid that my body is going to get too tired to push especially since I cannot stop moving about long enough to rest a little. She is calling my OB, my husband is packing us to leave (I told you I was not ready!) and I am screaming at my back-up midwife to put something waterproof on the bed. She is trying to convince me nothing is needed because I am going to the hospital when my water breaks. All over my bed. With no rubber sheet on it. Excited, I am checked again and again found still to be about a 2 cm dilated. The sheets are then tested with some strip that could tell the midwife if it is amniotic fluid. The strip turns dark purple. Not only is it amniotic fluid but there is a good chance there is meconium in it. Now the hospital is not open for debate. We have to go.

At the hospital I try position changes and the fabulous jetted tub. My mother-in-law arrives (we flew her in from Oklahoma) and I labor a little longer without any pain medications. My problem is that I have lost a hold of the contractions and cannot get back on them. It is not the actual contractions or the baby moving up and down, it is the fact my hips were completely destroyed by laboring so long with the baby so low in an unfavorable position. I am, I will admit, screaming for an epidural but am not allowed one until I am six cms. I am a TOLAC (trial of labor after c-section) after all and that is my OB’s orders to maximize my chances of a VBAC. Though I curse his name I am deeply grateful for that edict. I now had a chance to get on top of the pain. Unfortunately, I could not.

When I hit 6 cm I get the epidural. I can still feel and move my feet. I ask the anesthesiologist if this is normal and am told they do not heavily medicate TOLACs; but I do have my joy buzzer if I need more meds. Here is where things go south on rails. The epidural does not hold. (Psst, no one is worried about my slow progress, they are worried about my epidural not holding.) I get the first dose of the epidural again. My blood pressure tanks. It is so low I am starting to pass out lying down. I get medication to boost my blood pressure. The epidural stops working again. I get a new first dose but I think the doctor is just adjusting my joy buzzer. So, at the same time he gives me the first dose I hit my joy buzzer, effectively giving myself a double dose. It is while he is doing this that my nurse registers that I have a fever and subsequent blood work reveals an infection. I fall asleep, though pass out might be better a better term. About an hour after I fall asleep the nurse comes banging in waking everyone up and shakes me. Freaked out we ask if the baby is okay. She is more concerned about me as my oxygen saturation rate is at 65. I should mention here that my baby is a tank. NOTHING WAS EVER WRONG WITH MY BABY. Go figure.

By now my fever is not responding to medication, my blood pressure is staying way too low and my epidural has worn off again. My OB wants me checked in 30 minutes and if no progress has been made I am to be given a C-section or he is afraid I might have an emergency while trying to push. The anesthesiologist is called in again to re-up the epidural. We can hear the disbelief in his voice. The reason? I am on all fours in my bed laboring. With as many times as I had the initial dosing my legs should be jelly. He cannot put in more of the medication because I am having a contraction. It is 3 minutes long with very little, if any, rest in between. My nurse, bless her heart, is sure that this is transition and I will be pushing soon. I think she is more excited than my husband and I. It was a belly drop then when we found out that no, it was not transition but hyper-stimulation of the uterus. Not only that but my vitals took a dive during that contraction. My tank? He was doing just fine.

Once again the anesthesiologist is called in. He pulls out my epidural line and puts in a brand new one for the C-section. Not only is it a hurry to get me open and baby out because my vitals are not great but because we are not sure if the epidural will hold. Baby comes out screaming with a lovely APGAR of eight. The epidural holds until the last few staples are going in. I felt those.

So, how, you ask, is this a healing experience? Some would say it was worse than the first. It is healing because everyone, and I mean EVERYONE, was on my side. My midwife answered every question and helped in every way. She made my pregnancy easy by helping me identify when I needed to take something and being superwoman would do me no good. She helped me keep my Braxton-Hicks/prodromal labor under control and was with me every step of the way. My OB worked with her to maximize the efficacy of my care. He ENCOURAGED the home birth but informed me of his practices surrounding a hospital VBAC should I need to come in. He told me only his VBAC success stories, medicated and non-medicated. That built my confidence that he’d do everything to see my wishes through should I have to come in. The nurses at the hospital left us to our own devices and only came in if absolutely necessary. They hid all the monitors so we could not worry about numbers or lines. They cheered me on through tough contractions, were excited when it looked like I might make it, comforted me when another C-section was ordered and delayed checking me even when directly asked by my doctor. Our night nurse 'forgot' to check on me at the required 30 minute interval because I was doing alright and baby was great. Why mess with what is working? Everyone was working for me, cheering for me and wanting this as bad as I did. The support I had this time around was not given to me my first go around. It did heal me.

What are my OB and I planning? A VBA2C. Well, in a few years. ;)

Published in Birthing Stories

When it comes to birth, there are so many options and so many questions to think about it is enough to make any mother's head spin.  Should I consent to cervical checks? My provider is talking induction, is that a good choice for me? While every mother has the right to make a decision for herself and for her child, those decisions can be difficult when you don’t know the facts. Listed here are a few of your options in birth, along with the pros and cons of each. When you educate yourself on your birth choices, you are more likely to do what you feel is best for you and for your baby. You’re also more likely to have positive feelings about your birth experience.

Inductions have become very common.  The rate of induced labor was as high as 23% by 20091. It is suggested that the rate of induction is as high as 42% (possibly higher in some areas) as of 20122. A medical induction of labor typically consists of a vaginal suppository such as Cervidil, or Pitocin given via intravenous line, the use of a Foley catheter, or sometimes by additional methods or a combination of two ore more methods. Sometimes inductions are used for medical purposes, when baby needs to come out quickly but mom wishes to try to avoid a cesarean. Others are “elective” inductions.

Perhaps mom wants to induce labor because her pregnancy is difficult and/or she is tired of being pregnant. In some cases, the birth is to be scheduled for a convenient date. In other cases, the mother has talked to her provider and has been convinced that induction is a good way to go. In some instances it is suspected that she is carrying a large baby that will only get larger and more difficult to push out, or perhaps the baby is full- or post-term. For some mothers, knowing that they will have their baby in their arms by a certain date brings them relief and they are more comfortable with that. 

Inductions CAN be beneficial at times. If mom has a medical problem and continuing the pregnancy poses more of a hazard for baby than letting him continue to grow undisturbed (such as preeclampsia, diabetes, kidney disease, or cancer), the benefits for an induction for mom and baby may very well outweigh the risks. 

Induction can be beneficial to mom and baby depending on different factors. If it is medically indicated that the baby needs to be born sooner, induction may be the way to go. And in many full-term mothers and babies, induction is successful. If the cervix is favorable and baby is ready, an induction can go smoothly and without any complications. But medical evidence (such as a high cesarean rate of 1 in 3 mothers4) indicates that if mom and baby are healthy, it is best to allow baby to come when he is ready. Check out the Bishop Score (a tool used to predict how successful an induction may be) and talk with your provider for more information on risks and benefits associated with induction of labor.

However, an induction can make labor more difficult. In many hospitals, it is common practice to require induced mothers to be hooked up to an IV, a blood pressure cuff, and to external fetal monitors due to the increased risks. For most women who wish to remain active in their labor, this can prove to be an issue. It is difficult to remain mobile when you are tethered to so many machines that have short cords. Medications used to induce labor such as Pitocin can trigger unnaturally strong and irregular contractions, which sometimes come without a break in between. For some mothers, these contractions are too painful and they request an epidural, which has risks of its own and may lead to birth by forceps, vacuum extraction or cesarean section.

For most low-risk pregnancies where mom and baby are both healthy, an unnecessary induction of labor can carry more risk of harm to both than benefits. For the first time mother, an induction of labor more than doubles her risk of a cesarean section3. Since there is no way to be absolutely certain of how far along a mother is in her pregnancy (unless she is 100% sure of her conception date), there is always a risk of inducing a baby that is not ready to be born. Some mothers have electively been induced only to realize that their baby's lungs were not fully developed, and that their baby was a lot smaller than previously estimated. 

Sometimes induction doesn’t work for mother and baby, or it has undesired results. Inducing agents can cause fetal distress, or in rare cases, uterine rupture- which can be an emergency situation. In some cases where the mother has an unfavorable cervix, induction doesn’t work or baby becomes distressed, ultimately resulting in a cesarean section.

For some mothers, they are unsure whether they wish to have a vaginal birth or to opt for a cesarean birth. A cesarean birth has its pros and cons. By acquiring knowledge on the topic of cesarean birth, you can make the best decision for yourself and for your baby.

A cesarean birth has some perks. For the percentage of women who fear the pain of labor and/or the pushing phase of birth, a cesarean birth may be preferred.  Other mothers wish to have a set date for their baby to be born versus going into labor at what may be an inconvenient time. In some cases, it is thought that a mother’s pelvis is too small for her to birth vaginally. Vaginal birth after cesarean (VBAC) is not an option for her so she opts for a cesarean delivery. A mother who delivers by cesarean without being in labor will typically not have the soreness, nor any tears or stitches associated with a vaginal delivery. She will not be in labor for hours on end; in a scheduled cesarean section a baby can be born within the hour, then mom and baby will be sent off to their recovery room and/or nursery.

A cesarean delivery also has its downsides. While it can be a lifesaving procedure, medical evidence indicates that when used for convenience rather than necessity, a cesarean delivery may pose more health risks for both mother and baby5

For baby, risks are minimal but include risk of being cut. Risks to baby are also similar to induction risk in the sense of scheduling a cesarean too early and baby being born prematurely. For mother there are more risks6. There are immediate risks of hemorrhage, infection, of medical supplies being left inside the abdominal cavity, of other organs being damaged, of blood clots of the leg or lungs, or in very rare cases, risk of death. Evidence shows that mothers who deliver by cesarean are more likely to develop adhesions from scar tissue, or to have problems with future pregnancies (for example: infertility, miscarriage, and problems such as placenta previa or placenta accreta)7. 

Postpartum, a mother who underwent a cesarean delivery will typically have a longer, more difficult recovery as she has undergone major abdominal surgery. She will have to keep an eye on her incision to be sure there is no sign of infection or it doesn't open, and the incision will have to remain clean and dry. Caring for a newborn is difficult even without having undergone surgery, so mom will need extra help if possible. 

When giving birth, you have many options and many decisions to make. Mothers can benefit from doing some extra research over the course of pregnancy. Learn about all of your options, along with the benefits and risks of each, and make the best decisions for your family. Talk with your partner and care provider and discuss your preferences and birth wishes. 


Sources


1. Care Process Model: Management of Labor Induction 2012 Update. https://kr.ihc.com/ext/Dcmnt?ncid=51061830

    Surprising Facts about birth in the United States. http://www.babycenter.com/0_surprising-facts-about-birth-in-the-united-states_1372273.bc?page=3

2. State of Maternity Care. http://www.improvingbirth.org/2012/11/state-of-maternity-care/

3. Time for a Change? Induction of Labor Increases Odds of Cesarean Delivery. http://www.theunnecesarean.com/blog/2010/8/2/time-for-a-change-induction-of-labor-increases-odds-of-cesar.html#sthash.bYYuSWTI.dpbs

   Induction of Labor. http://ican-online.org/induction-labor

   Labor Induction Boosts C-Section Risk. http://health.usnews.com/health-news/family-health/womens-health/articles/2010/06/22/labor-induction-boosts-c-section-risk

4. Why is the National US C-Section Rate So High? http://www.childbirthconnection.org/article.asp?ck=10456

    Cesarean Birth (C-Section). http://www.medicinenet.com/c-section_cesarean_birth/article.htm

    C-Section Rates in US Stabilize After Eight Years of Steady Increase. http://www.news-medical.net/news/20120619/C-section-rates-in-US-stabilize-after-eight-years-of-steady-increase.aspx

5. Pros and Cons: Elective C-Section. http://abcnews.go.com/Health/story?id=3291512&page=1

    ACOG: Vaginal Delivery Recommended Over Maternal Request Cesarean. http://www.acog.org/About_ACOG/News_Room/News_Releases/2013/Vaginal_Delivery_Recommended_Over_Maternal-Request_Cesarean

6. and 7.  Risks of a Cesarean Procedure. http://americanpregnancy.org/labornbirth/cesareanrisks.html

    C-Section: Risks. http://www.mayoclinic.com/health/c-section/MY00214/DSECTION=risks

    Cesarean Section- Risks and Complications. http://www.webmd.com/baby/tc/cesarean-section-risks-and-complications

There is a proverb that states: “The axe soon forgets, but the tree always remembers.” The message in this proverb, that one person's actions (soon forgotten) can leave a lifelong scar on the soul of another, is sobering. Applied to the doctor/patient relationship, it is heart-rending. Surgical patients, including mothers having c-sections, have faith in their anesthesiologists and OBs to adequately manage their pain so they can focus on the physical recovery afterward. But for many women undergoing c-sections, recovery includes a psychological recovery from the trauma of feeling their procedures, often compounded by a lack of validation that the trauma even occurred. They are left wondering: Did this really happen? Could this have been prevented? Did the drugs fail, did the doctor fail, or did I fail? I propose the answer is buried in a larger, two-fold problem: first, doctors in general, particularly in the US, create unnecessary trauma because of how they view birth and laboring women, i.e. as a disease needing treatment and objects to be controlled; second, there is a basic misunderstanding of how anesthetic drugs affect different laboring women when they are applied in a universal, one-dose-fits-all approach.

In preparation for this article, I asked mothers to send me their stories if they had felt any or all of their c-sections, including details about the drugs used (if known) and the general location of their experience. There were a variety of drugs involved in the responses I received, and locations ranged from the US to Canada. The one common thread, however, was how the women were treated when it became clear their anesthesia was not working (the following are just two samples of the many stories I received; names have been changed):

I was wheeled into the OR; they gave me a spinal block because the epidural had been turned off...I remember the nurses joking about something while they pinned up the drape and rubbed something cold on my stomach. I asked for my husband, and was told he was on his way. Then I told the anesthesiologist that I could feel the straps across my ankles, thighs, and that there was someone touching my foot. He said, 'Oh, it's normal to think that you feel that.' The next thing I remember, my world was nothing but pain and fire. My voice was choked, I couldn't scream or even utter a sound. I was alone, no husband or mother, no one to speak for me. The nurses were still laughing and joking. My son's head had already been delivered by the time they let my husband into the OR... By this time, I was gasping for air and close to passing out. My husband started yelling at the anesthesiologist, that I was about to pass out. The anesthesiologist looked at my wrist, put what I found out later was Ketamine into a syringe then into my IV. At this point I blacked out. The nurses told me later that I was fighting them and crying over my 'dead baby.' I honestly don't remember. About 4 hours later, I got to see and hold my son. [My doctor] came in later that day to check on me, and I sent him out demanding anyone but him. The next doctor didn't believe me about what had happened. So, I talked myself out of talking about it...” (Chelsey, Virginia, USA)

The doctor made the first incision and I remember it felt very strange, and he asked if I could feel it, or if it just felt like pressure. I did not know what pressure was supposed to feel like. I told the doctor I wasn't sure. He made the second incision and I groaned. At this point, he told my husband that he had gone too far to turn back, and could not give me any pain killers because it would harm the baby. I groaned loudly for the rest of the procedure, which seemed to last forever. One of the nurses came up to me and said, 'I think you're scaring the doctor, please quiet down.' The first thing I said to my husband after my child was born was, 'Did I curse in front of our baby?' I could not remember if I had yelled profanity during surgery. I saw my child with my blurry vision, and they started giving me morphine in my back. I did not get to see my child for 8 ½ hours after that.” (Lisa, North Carolina, USA)

The stories I received, while pointing out a clear failure in adequate anesthesia, also pointed out a complete disregard for the patient and the severity of the trauma being experienced. A clue to why this happens can be found in the description of birth trauma provided by Penny Simkin and Phyllis Klaus in their book, When Survivors Give Birth:

In the language of obstetricians, 'traumatic birth' refers to births that incur serious physical damage to mother or baby. For example, a sudden emergency cesarean perhaps with inadequate anesthesia; shoulder dystocia; severe perineal damage; fetal asphyxia; vacuum extractor or forceps injuries; severe hemorrhage; newborn disabilities or death... Women who undergo such trauma also suffer psychological trauma... The psychological trauma is frequently unacknowledged by the woman's caregivers and sometimes by her loved ones.”1

The medical community openly acknowledges the existence of physical trauma in birth, but disavows the psychological trauma that goes with it. Why the disconnected view of a human being as both physical and psychological? Are doctors unaware that they are causing harm, or do they view “harm” and “trauma” differently than their patients do? Understanding the historical medicalization of birth offers important insight into this current mindset. In Rediscovering Birth, following a description of twilight sleep2, Sheila Kitzinger describes this medicalization of birth as a move from supportive human touch (midwives at home), to restraining, and even punitive human touch (OBs and nurses trying to control a mother under the influence of birthing drugs), to nonhuman (or apparatus) touch:

Delivery tables were designed with handcuffs, ankle cuffs attached to lithotomy stirrups, and shoulder restrainers on either side of the patient's neck to prevent her raising her head and shoulders from the table... In the 1980s, with the electronic revolution in obstetrics, catheters and wires connected to electronic machinery also took the place of human hands, and the use of spinal, caudal and epidural anaesthesia ensured that patients did not toss and turn or move away when an examination or manoeuvre was attempted. The woman was fixed like a laboratory specimen under bright lights, or like an offering on an altar, as gowned and masked professionals conducted the delivery in a shrine-like theatre where the obstetrician served as high priest in the drama of birth.”

Patients go to doctors to be healed, to have a problem fixed. Once a laboring mother becomes a 'patient', birth becomes the problem or illness needing to be healed. The mindset of the doctor is that the patient does not know how to fix the “birth problem” on her own, and may even harm herself (and/or her child) if she tries to. The doctor sees himself or herself as a source of salvation where salvation isn't needed, controlling a chaos that doesn't need to be controlled, and all at the expense of the mother's humanity. Michel Odent describes his experience with this mindset as an OB as follows:

[Early in my practice] I had known little of the world but doctors and patients. I had looked at people from a narrow medical perspective; I had shared the conventional view of childbirth as a 'medical problem' requiring technical 'solutions.' I had grown used to hearing doctors speak of pregnant women as 'patients'”... Today obstetrics still focuses on the role of the doctor and his preoccupation with how best to control and master childbirth. Especially in the United States, this attitude has resulted in the systematic concentration of normal births in environments equipped with advanced technology and routine electronic surveillance. Modern obstetrics knows nothing and cares less about the fact that labor, birth, and early nursing are integral parts of a woman's sexual life.”3

In an environment in which a woman is seen as an objectified patient, and birth is seen as a problematic event in need of medical intervention, is it any wonder that an OB, nurse, or anesthesiologist would ignore the cries from the operating table or dismiss the traumatic experience as normal or “all in her head”? Would a patient undergoing heart surgery be allowed to suggest to his or her surgeon that the doctor wasn't doing his procedure correctly? Doesn't the doctor know best? These are all arguments I have heard from medical professionals addressing a mother contradicting her OB or challenging the anesthesiologist that she could still feel. The problem with this mindset is the basic concept that birth is an illness. Birth is not a broken heart or festering wound. Until we change this basic misconception among medical professionals, we will see many more forests full of scarred trees. But this is only half of the problem.

The other half of the problem leading to the traumatization of women in birth, particularly in c-sections, is a lack of understanding and lack of precision in the use of anesthetic drugs. For c-sections, women are commonly given either a spinal or epidural block; both allow the mother to be awake during surgery so they can see their baby after birth. When a spinal or epidural block are inadequate for surgery (i.e. a woman is able to feel all or part of the procedure), this is referred to as neuraxial block failure. To understand why this happens, it is important to first understand these two types of blocks and the drugs used to achieve them.

A spinal block is an injection of a local anesthetic and narcotic into the intrathecal space (space containing the fluid surrounding the spinal cord); an epidural is a similar injection into the epidural space (a fat-filled space outside of the membranes surrounding the spinal cord and spinal fluid). According to theadequatemother (a Canadian blogger, mother, and anesthesiologist):

"A spinal interrupts nerve transmission in the spinal cord itself, an epidural interrupts nerve transmission in the nerve roots as they exit from the spinal column through the epidural space. A spinal requires less volume of drug because the intrathecal space is smaller. It also has a faster onset compared to an epidural. For an epidural to work for a c-section, many levels of nerve roots need to be frozen. The medication has to spread up and down in the epidural space and enough volume has to be injected for it to reach all the nerve roots that carry sensation to the surgical site. Although the incision for a c-section is usually confined to a small area, the freezing has to work on the entire peritoneum (the membrane lining the abdominal cavity, not the perineum which is the skin and muscle located between your vagina and anus)." 4

The use of one block over another has shifted through the years as new drugs became available, and depending on which one was seen as causing fewer side effects or giving the anesthesiologist more control. The drugs used currently and their doses vary depending on the anesthesiologist, hospital, and even the country in which they are being administered. Bupivacaine is one example of a commonly used drug for both epidurals and spinal blocks. The main difference between epidural and spinal block use of Bupivacaine is the amount of drug given. For obstetric use, 0.5% hyperbaric Bupivacaine is used, given in 10mL increments for epidural injection, but 2mL or less for spinal block. In researching for this article, this spinal block amount was a major point of differentiation between the US and other parts of the world (namely the UK and Nepal). One article out of Manchester, looking at cases of epidural and subsequent spinal block failure in c-sections concluded:

"The ideal dose of this drug [Bupivacaine] for Caesarean section remains uncertain. However, the use of less than 2mL is associated with a substantial risk of inadequate block. The use of 2.5mL has been reported to be satisfactory in several series.”5

Another study6 out of Nepal noted a failure rate of 6.0% for a 2.20mL solution of Bupivacaine in c-sections, meaning 6.0% of women receiving this drug needed additional anesthesia or were put under general anesthesia. In stark contrast a study7 out of New York showed that women receiving lower doses of Bupivacaine had a significantly higher anesthetic failure rate during c-section:

" In our previous study, almost all mothers (19 of 22) given 0.5% hyperbaric Bupivacaine (7.5-10mg [1.5-2.0mL]) for spinal anesthesia in cesarean section required narcotic supplementation because of visceral pain."

The study goes on to show that their current study comparing two dose levels of Bupivacaine showed women given a 25% higher dose had significantly lower failure rates. One study group was given Bupivacaine in a range of 1.5-2.0mL, the other group was given a range of 2.0-2.5mL. In the first group, 70.5% reported moderate to severe pain after delivery associated with peritoneal traction (exteriorization of the uterus and closure of the peritoneum). In the second group, 31.6% reported this. [Note: All mothers reporting moderate to severe pain received additional intravenous medication.]

In short, while Bupivacaine will still fail some women, the rate of failure is significantly reduced simply by using a slightly higher initial dose. Currently in the US, anesthesiologists tend to add a narcotic rather than using a higher initial dose of Bupivacaine. Narcotics have their own list of possible side effects; for example, Ketamine can cause double vision, motor incoordination, delirium, hallucinations, irrational behavior, and temporary elevation of blood pressure and pulse rate.8 For a woman who is already in a state of stress and panic from feeling their surgery, adding these neurological symptoms is literally a nightmare.

What is the solution? I think the best option is one suggested by a thinking, feeling mother/anesthesiologist (quoting again from theadequatemother):

"When I discuss anesthetic options with my patients and we are discussing a spinal or epidural block, I always mention the possibility of block failure as well as methods to address it such as conversion to general anesthesia. When a block fails, there is a human tendency to dismiss it... oh, well, the patient is just nervous, or, well, it's not that bad, right? Clearly she's just feeling tugging, not pain, and tugging is normal. But that doesn’t do either myself or the patient any service. They will get increasingly distressed and I’m just putting off the inevitable. We need to face our failures head on and deal with them and fixing the problem of a neuraxial block that doesn’t provide adequate anesthesia for a c-section requires time – time for a discussion to occur with the patient regarding options and preferences, and time to repeat the injection or set up for and establish a safe general anesthetic. Best to fix the problem as soon as it is identified.”

If OBs and anesthesiologists take it upon themselves to see their birthing mothers as human beings, rather than sources of illness, if they communicate with mothers before surgery about the risks and options, and above all, if they work with mothers as participants in their own births rather than static objects to be controlled and silenced, then we will see real change.

There is a moment toward the end of the movie The Lorax when the main character stands against the socially accepted norm in support of what is right, proclaiming, “I am Ted Wiggins, and I speak for the trees!” Women must feel empowered to speak for themselves, and doctors must be willing to listen and validate. If this does not happen, other women and men must speak for them, until someone listens. The women who have been ignored, shushed, yelled at, and belittled while suffering through a neuraxial block failure will always bear and remember the scars of the axe used against them. Unlike the proverbial trees, however, they do not have to stand in silence waiting for the next axe, and we can add to their voice to make it heard, beginning now. I am Jeanne-Marie Floyd, and I speak for the trees.

 

1Simkin, Penny and Phyllis Klaus. When Survivors Give Birth. Seattle, WA: 2004.

2Twilight sleep refers to the drug Scopolamine. This link provides a good history for this drug.

3Odent, Michel. Birth Reborn. Medford: BirthWorks Press, 1994.

5Beck, G. N. and Griffiths, A. G. Failed extradural anaesthesia for Caesarean section. Complication of subsequent spinal block. Anaesthesia, 1992; 47: 690-2.

6Shrestha, AB, et al. Failure of subarachnoid block in caesarean section. Nepal Med Coll J, 2009; 11(1): 50-1.

7Pedersen, Hilda, et al. Incidence of Visceral Pain during Cesarean Section: The Effect of Varying Doses of Spinal Bupivacaine. Anesth Analg, 1989; 69: 46-9.

8From the MSDS on Ketamine.

 

Published in Birth Voice
Friday, 08 February 2013 18:00

The Cascade of Interventions

The Cascade of Interventions aka the Snowball Effect

In a hospital setting where your care providers are actively managing your labour, once you have one intervention it makes more interventions more likely to be needed in order to remedy the effects of the previous ones.

In our Western society culture, there has been a tendency to turn pregnancy and childbirth into a medical experience. One intervention can lead to another in a cascading sequence of questionable procedures, many made necessary only because of a previous intervention.

We are lucky to live in the time of modern medicine, however medical interventions such as labour induction, pain relief, and cesareans—measures that have saved many lives—have been overused.

When you intervene uneccessarily with nature's role, generally there is a waterfall of effects that occur because one things leads to another.

Doctors need to inform their patients of all the risks instead of assuming we don't need to know. It is our bodies, after all...

Facts - did you know that:

  • The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent.
  • In the past twenty years, the cesarean section rates have nearly quintupled in the US to 23.8% in 1989 and nearly quadrupled in Canada to 18.3% in 1987-8.
  • Of 11,814 women admitted for labor and delivery and attended by midwives to 84 freestanding birth centers in the US, 15.8% were transferred to the hospital and 4.4% had a cesarean section. Although the women were lower than average risk of a poor pregnancy outcome, their cesarean rate is one-fifth of the national average.

This is a wonderful representation of how one intervention can snowball into the next from "Thinking Woman's Guide" by Henci Goer.

1. Changing into the hospital gown

Putting on the hospital gown shifts the balance of power from woman to hospital.  Her perception of herself shifts, and she sees herself as a patient, in the care of “experts,” rather than as a woman confident in her ability to birth on her own terms. This simple act may also make the woman feel less comfortable, feel cold or she may be concerned about modesty as well, which increases stress and makes relaxation harder.

2. Continuous Electronic Fetal Monitoring (EFM)

The major effect  of continuous EFM is that it keeps the mother immobile in bed. The use of EFM is not evidence-based, and even ACOG (American Congress of Obstetricians and Gynecologists) admits it has had no effect in improving outcomes for babies .  Evidence shows that Intermittent EFM with a handheld Doppler is just as effective as continuous EFM at identifying babies in distress.  The only effect continuous EFM has had is that it has increased the cesarean section rate.

3. Getting the IV

IV’s restrict a woman’s mobility and make it easier to administer fluids and medications that can interfere with natural birth.  Sometimes, IVs can be helpful, especially if a woman is unable to tolerate oral hydration, or in an emergency situation.  In normal labor, women need to be free to move their bodies throughout labor, and should be encouraged to change positions frequently.  Having an IV can hinder that. The IV is also simply uncomfortable, annoying and may interfere with her focus on relaxing with contractions as well and make holding hands with her support person more uncomfortable or impossible. Even a hep lock can be bothersome in the same ways. The perception that having an IV readily available is helpful in an emergency is not evidence based. Many times this IV port is not working well enough to handle an emergency and must be restarted.

4. Labour Augmentation with Pitocin

The use of synthetic oxytocin (Pitocin®) makes labor more painful for the mother, and more difficult for the baby to tolerate. There are studies that show Pitocin may interfere with the body's natural ocytocin hormone production which may hinder the mother's natural efforts in the pushing stage, may contribute to postpartum hemorrhage and may interrupt her bonding with her baby, contributing to postpartum depression. http://www.birthresourcenetwork.org/resources/54-pitocin-the-whole-story

5. Pain Relief

Because the contractions are so intense with Pitocin, the mother frequently will choose to receive an epidural for pain relief.

6. Restriction of Movement

An epidural keeps a woman confined to bed for the duration of the labor and birth.  Being unable to move restricts the woman’s ability to help her baby get into a good position for birth. It may also hinder the baby's ability to move, too.

7. Contractions Slow Down

Epidurals can slow labor progress, which results in increasing dosages of Pitocin® to increase contraction intensity and frequency, which can lead to an even greater need for pain relief and greater risk of fetal distress.

8. Progress Slows or Stops

Assuming the woman reaches full dilation, the epidural can interfere with the woman’s ability to push effectively.

9. Fetal Distress

Hard contractions, combined with reduced blood pressure and the lack of blood flow to the baby, can cause the baby to go into distress.

10. Cesarean Section

After having exhausted all of the tools at the obstetrician’s disposal, this one option remains.

 

 

Published in Labour
Friday, 27 April 2012 11:17

The Truth of Cesareans

Cesarean Sections, also known as a c-section, is the surgical removal of the baby directly from the uterus.  While many women now elect to skip labor altogether (and their practitioners usually oblige,) others are determined to avoid a c-section at all costs. C-Sections are major abdominal surgery despite the short duration of the procedure.  An epidural or spinal block is typically administered, although in a true emergency the mother will often receive general anesthesia and be completely sedated for the procedure.  The baby is usually born within the first 15 minutes of the procedure and another 30-45 minutes are spent closing the incision.

Maternal risks involved with having a c-section include blood loss, adhesions, organ damage, infection, and extended recovery time.  Many mothers who have had a vaginal birth and then a c-section report significantly increased pain and healing time.  Having a c-section also increases the risk of needing a c-section for subsequent births.  VBAC (vaginal birth after cesarean) is a hot topic among the birthing community.  Many OB’s will encourage a mother who has already had a c-section to elect to have another one rather than attempting VBAC citing risks for uterine rupture.

Babies born via c-section are at an increased risk for lower APGAR scores, breathing difficulties, and injury from the procedure.  Elective c-sections (performing the procedure before labor begins) also increase the risk of premature birth, since gestation is an approximate estimate rather than an exact science.  Some mothers carry all of their children past 42 weeks and go on to have natural deliveries with healthy babies.  Other moms go into labor naturally around 38 weeks and have the same outcome.  Waiting for labor to begin decreases many of the risks to the baby because the hormones from both the mother and baby work together immediately before and during labor.  It is suggested that in a healthy pregnancy, the baby in some way triggers labor (possibly when her lungs have matured enough) through a biological process that we have yet to determine.  Electing for a delivery before the baby has finished gestating is likely to increase complications after birth.

It should be noted that cesarean section may be the best option in a few circumstances where it is best for the safety and wellbeing of the baby, the mother, or both.  Some of these situations include placenta previa, placental abruption, uterine rupture, cord prolapse, fetal distress, preeclampsia, and active genital herpes in the mother.  There are a number of other reasons for a c-section, (including gestational diabetes, baby being in the breech position, failure to progress, and previous c-sections) but these reasons alone are not often reason enough to elect for a c-section prior to the onset of labor.

Many moms who are having c-sections are speaking to their provider of having an assisted-cesarean where the mother assists bringing the baby out of the uterus.

For more information about VBAC, please visit ICAN, VBACFacts, and Improving Birth. The risk of catastrophic complications from a VBAC are significantly lower than the risk of a repeat cesarean. Please do your own research and decide what is the best decision for your situation. 

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