Tuesday, January 12, 2010

10 Childbirth Myths

1. "Before cesareans, women were dying all the time in childbirth."

* Yes, there were high maternal and infant mortality rates before we had the tools for a "safe" cesarean. But the main factors that contributed to this, are often unknown or not researched by women. "In the early 19th century, doctors would go catch babies without first washing their hands and, worse, would do so after performing autopsies on patients who had died from childbirth fever. This not only assured transmission, but biased that transmission so that the most virulent forms of the organism (i.e., those that killed women while they were still in the hospital) would be transmitted." ( Germ Theory of Disease ) The first antibiotic wasn't created until the 1920's. Even then, the use of penicillin didn't become widespread until the 1940's. So if the Aseptic Technique didn't become known until the late 19th century, and we didn't have access to antibiotics until the 1940's, how is it hard to understand that women and babies were dying more so because of the spread of disease, rather than the inability to birth safely without a cesarean. I have no doubt that some women and babies died because of not being able to get the baby out fast enough...but that really does take a back seat to disease, if you look at things correctly according to the history of medicine and what we've learned. It wasn't just women and newborns dying...it was a widespread thing during that time. Older children were lost to disease, men, and non-pregnant women alike. In Wales in 1838, the death rate from the Measles was 70.49 per 100,000. By 1968 when the Measles Vaccine came to use, the death rate was down to 0.11 per 100,000. My point in bringing up the measles? To show that the GENERAL death rates were very high before we had the Aseptic Technique, Antibiotics, and Vaccinations. Should we be afraid to go out in public where other people will be coughing, sneezing, and breathing around us because the disease rate was very high over a century ago? Of course not. Same reason that women should not be afraid to give birth because the maternal and infant mortality rates were high.

In my previous posting of this, I also mentioned pelvic deformities from the use of corsets. This WAS a factor in women's inability to pass the very baby she grew, because when girls began binding their waists and hips from a young age, it DID change their pelvic structures. This may have been seen in the prominent families only, but it was still a factor. I can't help but believe as well ( and feel free to write me off on a person belief, lol ) that labor and birth would be a hell of a lot more painful if your pelvis suffered from years of binding.

2. "I have to be induced because my baby is getting too big."

* The accuracy of ultrasound for detecting macrosomia seems to run between 50% to 65% or so. This is VERY low accuracy to be telling a woman that her baby is getting too big to birth safely. From Kmom's Website:

Pollack et al. (1992) found that only 64% of the babies estimated to be macrosomic (big) actually were. Levine et al. (1992) found that HALF of the ultrasound predictions of fetal weight were incorrect. Delpapa and Mueller-Heubach (1991) found that 77% of ultrasound fetal weight predictions exceeded actual birthweight and only 48% were even within 500g (about one pound) of the actual birth weight. Furthermore, 23% were more than 1 pound overestimated, and 50% of the babies predicted to be macrosomic weren't macrosomic at all.

Late in pregnancy, ultrasonography just isn't an accurate way of estimating the size of the baby, when it comes down to the decision of forcing a baby out before he's ready, or heading to the OR. And regardless of baby's size, you'll never know what you can do until you try. ; ) Had someone told me 4 years ago, when I was scared into my c-section for "suspected macrosomia" ( he was only 8.8lbs and spent 9 days in the NICU for severe respiratory distress from the c-section ), that I would go on to deliver a 10.10 posterior baby ( in my home no less, no meds )...I would have told them that they were crazy. That it is impossible to deliver a baby that big without a cesarean, or major damage in the least. ( I had only one stitch, by the way )

I also think that women don't know that the pelvic girdle is NOT a fixed, solid structure. During pregnancy and labor, a hormone called Relaxin softens the ligaments that join the surrounding pelvic bones. The degree of pelvic expansion achieved will vary depending on the factors in an individual woman's labor. For example, squatting increases the opening of the pelvic outlet considerable, compared with the lithotomy position. It will also depend on whether or not mom was induced. ( The hormone is still there, but an induction is a mean of trying to evict a baby who is not ready ) There are factors that come into play, but there are ways of increasing the pelvic outlet size to facilitate a vaginal delivery. Baby's heads are made to mold as well.

3. "I had to have a c-section because my baby's cord was around his neck, and he could have DIED!"

* I am saddened to hear this from women. Obstetricians are doing a great job of justifying the reason for the cesarean, by throwing in things like this. Approximately 1 in 3 babies are born with at least a 1x nuchal cord ( wrapped around the neck ). I personally have been present for the delivery of a baby who had a 3x nuchal cord, wrapped not only around the neck, but across the shoulders as well. She was born quite safely at home. While studies DO show a higher incidence of fetal bradycardia ( heartbeat of less than 100bpm ), they show no significant difference in the APGAR scores in babies with a nuchal cord, compared to those without. Interesting. ; )

From The Journal Of Family Practice:

Several studies have shown that this cord compression results in reduced blood flow to the fetus and subsequent changes in the umbilical artery blood gases.[3,25,31-33] If compression is high enough to occlude the artery, the fetus is unable to exchange carbon dioxide adequately, resulting in hypercapnia and subsequent acidosis. Acidosis is significantly more common in newborns with nuchal cords.[33] This acidosis is of a "mixed" (68%) or a pure respiratory (23%) type and is corrected quickly by prompt ventilation of the newborn.

Paradoxically, despite the higher incidence of bradycardia and acidosis, the Apgar score is not dramatically affected. The present study was unable to demonstrate a significant difference in the mean 1-minute Apgar score between the two groups, although the nuchal cord group did tend to have a larger percentage of infants born with a score of less than 7. This difference was absent at 5 minutes after birth when the second Apgar score was given, suggesting that any possible effect is only transient. Similar findings by other suggest that nuchal cords are not a major cause of fetal asphyxia.

It is interesting to note that the Apgar scores in the nuchal cord group of this study were comparable to those of the control group, despite the much higher occurrence of fetal distress noted during labor. It may be that the Apgar score is a better indicator of the newborn's health at the time of birth than the fluctuations in heart rate noted during labor.

4. "Once your water breaks, you HAVE to deliver within 24 hours."


A retrospective cohort study of women delivering at two New York City hospitals between 1988 and 1990 was conducted to assess the outcomes of two kinds of management for PROM. The patient populations of the two hospitals were similar. One institution practiced induction of labor if spontaneous labor had not begun within 12 hours of rupture of the bag of waters; the other hospital, with nurse-midwifery management ( not ignorant DEMs we're talking about! ;) ), admitted the women but did not induce unless signs of infection occurred.
The records of 909 women with PROM at term were reviewed. Those who were managed conservatively experienced one-third the rate of cesarean sections, with no increase in intrauterine or neonatal infections. Though the expectant management women spent as long as five days in the hospital, the average hospital stay was only a half-day longer than those who were managed with early induction. -Journal of Nurse-Midwifery, Vol. 38 No. 3, May/June 1993

A HUGE factor in acquiring an infection when premature rupture of membranes has occured, is the number of vaginal exams done after the water has broken. With each exam done, the risk of infection is increased. In keeping the risk of infection at it's lowest, it is important to keep everything out of the vagina - even gloved hands. Unfortunately, this doesn't happen often in the hospital.

Morales WJ and Lazar AJ. Expectant management of rupture of membranes at term. South Med J 1986; 79(8): 955–958.

Women with term uncomplicated pregnancies (including women with previous cesarean) and PROM who were not in labor were randomly assigned to expectant management (monitoring for infection or fetal distress) (N=167) or induction (N=150). No digital exams were done until active labor. Most (85%) began labor within 48 hours. Women randomized to induction had internal electronic fetal monitoring and pressure catheter. "Failed induction" was defined as failure to enter active-phase labor after 12 hours of regular contractions.

The cesarean rate was 7% for women managed expectantly compared with 21% for induced women. No cesarean was done for failure to progress in expectantly managed multiparas versus a 15% cesarean rate for this cause in induced multiparas. Infection rates after cesarean section (24% versus 5% [no p value]) reflected the "well-documented significant increase in postpartum endometritis after abdominal delivery." Intrapartum infection and endometritis rates after vaginal birth were increased in the induced population (12% versus 4%, p <0.01). No infant in either group was infected. "These findings...support the observation that, contrary to previously accepted belief, prolonged interval between rupture of membranes and delivery does not increase the maternal and neonatal infection rate. Rather, with PROM the interval from digital examination to delivery is the critical parameter in the incidence of infection."

5. "Once a Cesarean, Always a Cesarean."

* This used to be true, but mainly because doctors were using classical incisions ( vertical ) during cesareans, instead of the low transverse that is done now. With a classical incision, the incision stems upward into the uterus, where it contracts. The lower segment usually does not contract as hard as the upper segment. The main risk in a VBAC ( Vaginal Birth After Cesarean ) is a Uterine Rupture ( where the uterus opens ). This risk is approximately 0.3-0.7%. Which means that in a VBAC, you have a 99.3-99.7% chance of NOT rupturing, if you don't induce labor. When you induce, the risk of rupture is increased. The risk of a cord prolapse, which is a life-threatening emergency for baby, in ANY labor is up to 2%. Does that mean that no woman should take the risk of ANY vaginal birth, and all should be c-sections? Of course not. So then why do women believe that the *LESS THAN 1%* risk is too high? Mostly because their doctors ( One thing that many women don't know - OBs are trained *surgeons* ) play up the risks of VBAC, and underplay the risks of cesareans. A VBAC is not only a viable option to consider, but one that is encouraged by all of the major health organizations, including ACOG ( American College of Obstetrics and Gynecology ).

6. "It's not a big deal to induce, as long as you're 'term'".

* Well, this depends on what you consider to be a big deal. According to every recommendation there is, induction of labor SHOULD NOT be done unless the risk of remaining pregnant FAR outweigh the many risks that come with an induction...and suspected macrosomia doesn't fall into this category, not even according to ACOG. Sadly, the majority of women induce out of convenience ( wanting to have baby by a certain date, wanting to get an additional tax credit before the new year - and YES...I've heard this more times than I can count! ) or because they have been told their baby is getting "too big", or because they're tired of being pregnant.

From the AAFP:

The Epidemiology of Induction Has Changed. The increase in the frequency of term labor induction has been well established,2-4 yet the change in incidence rates varies considerably by indication. Macrosomia has increased the most as an indication, 22.5-fold since 1980, despite evidence that induction for suspected macrosomia has shown potential benefit only in women with type 1 diabetes mellitus.5,6 Post-term pregnancy, the most common reason for labor induction (10 percent of live births), had only a 2.3-fold increase. Of note, induction rates have shown large variations across maternal classes, with higher induction rates being found in white, non-Hispanic women (25.3 percent), women with more than 12 years of education (24.6 percent), and women with private insurance (24.5 percent).2 Higher induction rates are found in community hospital settings (increased elective inductions), compared with university or federally controlled hospitals (increased inductions because of medical conditions).8

Elective Induction of Labor Is More Common. The rationale for elective induction is mutual convenience, allowing a pregnant woman to handle logistic issues such as child care and transportation, and to know that her expected birth attendant will be present for delivery. Given that most induced births occur between 10 a.m. and 8 p.m., it is reasonable to presume that the physician and staff will be alert and better able to respond to an emergency. However, elective induction is not without potential risks, including iatrogenic prematurity, uterine hyperstimulation, nonreassuring fetal heart rate tracing, and greater likelihood of operative delivery, shoulder dystocia, and postpartum hemorrhage. While these complications are rare in multiparous women, nulliparous women have significantly higher rates of cesarean delivery, instrumented delivery, epidural analgesia, and neonatal intensive care unit admission.9,10 Because the risk of cesarean delivery with elective induction is potentially as high as 2.8 times that for spontaneous labor, it is difficult to advocate elective induction in a nulliparous woman.10-12

Technically and Ethically, care providers are NOT supposed to be inducing for ANY reason other than true medical necessity. But an induction of labor is more convenient for them as well, because it can be scheduled according to their liking, and it's much easier to proceed to a cesarean if the induction is taking too long.

Elective inductions also increase the risk of Iatrogenic Prematurity ( Physician caused prematurity ).

From PubMed:

Flaksman RJ, Vollman JH, Benfield DG.

In a series of 1,000 newborn infants referred to a regional neonatal center, 32 iatrogenically preterm infants were identified. All had been delivered following elective termination of uncomplicated, apparently term pregnancies, without prior documentation of fetal lung maturity or ultrasonic determination of fetal biparietal diameter. Associated acute morbidity included asphyxia neonatorum in 10, respiratory distress syndrome in 24, and pneumothorax or pneumomediastinum in nine patients. One infant died. Hospital costs totaled $150,643, for a mean of $4,701 per patient. The unexpected premature births were associated with major parental grief reactions and alterations in their daily activities, Iatrogenic prematurity is a major regional health care problem which, when viewed on a national basis, may affect thousands of newborn infants and their families annually. Our data suggest the need for more accurate assessment of fetal maturity, before elective termination of pregnancy, by well-established techniques.

7. "Epidurals don't pass to the baby, they're not risky."

* Dentists usually will not administer anesthetics to pregnant women. Doctors caution against using even the most mild of medications. Doctors warn against smoking in pregnancy, drinking in pregnancy, and consuming unhealthy food. Babies who are born after epidural births are more likely to need resuscitation, more likely to be lethargic, more likely to have lower apgar scores, and LESS likely to be breastfeeding at 6 months of age. Epidurals have a very high risk of causing BP problems in mom - causing the need for a c-section. Epidurals often cause labor to slow or stall completely, which then facilitates the need for pitocin. Pitocin often causes the baby to go into distress, along with the cocktail in the epidural, and then facilitates the need for a c-section. Epidurals lead to the interventions of an IV, continuous monitoring ( which have up to a 95% error rate...meaning that up to 95% of the babies who were c-sectioned for "fetal distress" were perfectly fine and not in distress at all. ), pitocin. Epidural births often end in the need for an instrumental delivery. Epidurals often take away the ability to push effectively, combined with the fact that you're on your back, or in a half-sitting position, pushing a baby UP over the pubic bone.

Risks of Epidurals ( The full summary can be found HERE ):

* Limited Mobility - 100%
* Low Blood Pressure - up to 50%
* Fever, mom - up to 24%
* Urinary Retention - up to 68%
* Post Partum Urinary Incontenence - 27% with an epidural, 13% without
* Shivering - 33%
* Nausea - up to 30%
* Vomiting - up to 13%
* Itching - between 8-100% ( varying degrees )
* Backache Immediately After Birth - 53%
* Incomplete Pain Relief - up to 25%
* Slower 1st Stage of Labor - up to 4.8 hours longer
* Longer 2nd Stage ( pushing ) - up to 55 minutes longer
* Instrumental Delivery - up to 80%. 6 out of 9 studies indicate that less than 50% of women with an epidural had a spontanious vaginal delivery.
* Fever in the baby ( that result in a sepsis work up ) - 30%
* Fetal Distress - 10-15%
* Malpositioned Baby - up to 26%
* Lower Apgar Scores- up to 17%
* Baby Having to Endure Sepsis Work Up ( which includes spinal tap ) - up to 34%
* Baby Being Treated with Antibiotics - up to 15%
* Effects on Breastfeeding - Women who used epidurals were less likely to still be breastfeeding at 6 months. ( 30% vs. 50% )
* Cesarean - 2-3 times as likely with an epidural.

8. "I had to be induced because they found low fluid."

* The modern route of action for this is completely backwards. Amniotic fluid is essentially the baby's urine after the 36 week mark. ( http://gynob.com/amniotic.htm ) If you're not drinking enough water, the baby is not able to process the amniotic fluid. When low fluid is found via u/s the practice is SUPPOSED to be to have the woman go home, drink at least 2 liters of water, and have the fluid levels re-checked by a *different* technician ( readings can be off depending on who's doing it as well! ) within 24 hours. Studies have shown that oral re-hydration is a perfectly acceptable method of increasing amniotic fluid, as well as effective. of the time, the fluid levels will have gone up. In those that don't, the practice is SUPPOSED to be to have her repeat above, and see what levels are again, by a diff. technician. If the levels still ARE low ( under 5 ), then it should be left up to the mom, will FULL INFORMED consent to make a decision. She should have time to go home and research, without being pressured. Sometimes this will necessitate an induction, but there are better ways to go about an induction without bombarding your baby with drugs. ( Foley catheter induction, no drugs, no pain meds...go from there ).

From PubMed:

One approach to treating oligohydramnios during labor is to perform an amniotomy followed by amnioinfusion to increase the fluid inside the uterus.[5] However, if expectant management is desired, maternal hydration can increase the AFI. Oral or IV maternal hydration has been studied as a treatment for oligohydramnios in women with otherwise healthy term pregnancies.[5] In the second trimester of pregnancy, the majority of the amniotic fluid is produced through fetal urine production and is reabsorbed through fetal swallowing. Amniotic fluid is also reabsorbed via the fetal lungs and by the placenta.[15,16] Maternal hydration and maternal osmolarity affect the amount of amniotic fluid available to the fetus for urine production and reabsorption near term.[15,17] In a systematic review, Hofmeyr[5] found that amniotic fluid volume is increased in women who have reduced or normal AFI and who drank 2 liters of water or who received IV hypotonic hydration; isotonic IV hydration had no measurable effect.[5] The amniotic fluid volume, assessed 6 hours later, was shown to increase by an average effect size of 2.01 (95% CI, 1.43-2.60) with oral hydration, and 2.3 (95% CI, 1.36-3.24) with a hypotonic IV solution. While no clinically important outcomes were assessed in any of these trials, hydration is a simple, inexpensive, and noninvasive method that may apply to clinical situations. Leeman and Almond[3] reported an increase of 30% in the AFI in women who consumed 2 liters of water 2 to 5 hours before repeat ultrasound, compared to women who were not orally hydrated. They recommend that maternal hydration should be considered before retesting the AFI 2 to 6 hours later, in cases of isolated oligohydramnios.

9. "Stripping Membranes is perfectly harmless."

* During a membrane sweep, the care provider inserts his/her fingers into the cervix, hooks the finger in between the cervix and the amniotic sac ( if even possible...most women that request this aren't barely a fingertip dilated ), and sweeps all around in between the two. On top of being EXTREMELY uncomfortable, and often painful, this does NOT guarantee induction of labor. This poses the risk of infection, because the care provider is pushing vaginal bacteria up INTO the cervix, and in between the cervix and sac. There is also the added risk of weakening the lining of the amniotic sac, causing the waters to break prematurely. If *this* happens, which is not uncommon, then you're on the clock. Your body wasn't naturally ready for labor, so it'll probably take the longer of the scenarios described a few paragraphs above regarding the time limit on water breaking...and your care provider usually WILL be quicker to add intervention. After all, it *started* with intervention. ; )

10. "I pushed for hours and my baby would not come out. I NEEDED a c-section."

* Unfortunately, Cephalopelvic Disproportion ( CPD ) is widely misdiagnosed. According to the American College of Nurse Midwives( for those of you who believe that you don't count as a midwife unless you're a CNM ), CPD occurs in only 1 out of 250 pregnancies. If you have been diagnosed with CPD, this does not automatically mean that you will have this problem in future deliveries. According to a study published by the American Journal of Public Health, over 65 % of women who had been diagnosed with CPD in previous pregnancies, were able to deliver vaginally in subsequent pregnancies. And as seen in many, many women on the ICAN list...often go on to deliver *LARGER* babies than the baby that was sectioned out of them for "CPD". ; ) ( A beautiful montage from the women of ICAN...although not scientific I know. ) But with an epidural rate of as high as 85-95% in some hospitals...you're not often going to see a woman be able to get up and get into a good squat, or into the hands and knees position. Some with a "Walking Epidural", but not the average woman with an epidural.

Another issue brought up ( Thank you Heather! ) is a malposition in the baby. This isn't often talked about when you're under the care of an OB, because unfortunately palpation seems to be a lost art. I ask women ALL THE TIME who are under the care of an OB, what position their baby is in. They say "Head down". I ask if they know which way the baby is facing, etc...and they say no and look at me like I've got two heads. Malposition can be a HUGE factor in a woman unable to push her baby out. Malpositions are usually more common with induced labors - especially when AROM is involved, and labor where mom is in bed with an epidural instead of up and moving around. I think that Optimal Fetal Positioning ( OFP ) should be a part of EVERY pregnant woman's education prenatally. There are women who have done everything "right" ( IMO, and the opinion of many midwives ) - made sure that their diet was nutritious, planned a natural birth with minimal to none intervention, avoided drugs, stayed mobile, pushed with the urge....and STILL ended up pushing for hours and ending in a cesarean. Malposition can play a serious role in a cesarean becoming necessary, but is often simply labeled "CPD".

A wonderful site to learn about OFP is Spinning Babies.

There are so many, many other myths that can and should be dispelled. So many women believe what they are told, instead of doing the research for themselves. If you'd like to learn more about Obstetrical myths, there is an EXCELLENT book by Henci Goer. "Obstetrical Myths Versus Research Realities". Every myth dispelled is referenced by medical study. These are not opinions, they are backed my medical research. Maybe sometime soon I will add to this list. : )