Induction and perception

You all know how I feel about induction. Pinky has just posted about how tough inductions can be:

Like most L&D nurses, I hate to induce a primip with a long thick and closed cervix. Especially when she is not 42 weeks. Some babies go 42 weeks. We hate to see the 3 day induction. Which goes like this: 1st evening you get cervadil. Next morning we start pitocin even if you are still not ripe. Repeat cervadil in evening or maybe put in misoprostal next morning repeat pitocin. We might turn the pitocin off a few times if the floor gets busy during the day so you get set back a few times. By the 3rd day the woman and her partner are begging for a C-section. We hate to do this. Sometimes she pops into labor and delivers a baby no problem. But that is usually if she has a ripe cervix in the 1st place or by the end of 12 hours of cervadil. ...

Funny thing is no matter how much you tell folks about how the 3 day induction will suck, most will sign up for it. They must think, "Oh I won't be the 3 day induction and if I am I will get a c-section." I think most people down play the risk of c-section. Either they down play it or the catastrophize it. In my book a c-section is to be avoided if possible. It really is a big surgery but not a catastrophe. Most abdominal surgeries can be done by laproscopy. We have not figured out the laproscopic c-section.

It got me thinking about a blog I was following recently. Sometimes my google alerts kick up blogs of expecting moms and I end up scanning through them. This woman decided on an induction at 41+2 and wrote "I know I know, there are a lot of people out there that are against inducing, but [husband] and I are not." There are many ways the story could unspool, but the way it ended up was an induction beginning Sunday night, lasting through Monday night, and ending with a c-section on Tuesday morning due to exhaustion and slow progress. So, pretty consistent with Pinky's description.

This woman seemed OK with having ended up with a c-section, and I think it's great that she felt happy about her experience. But to me, it was illustrative of how choices with real consequences can start being treated as philosophic differences. I'm sure I would be placed into the class of one of the "lot of people out there" against inducing, but I am not "for" or "against" induction. Rather, I think that induction, particularly used electively and/or when the body is not ready (as measured by a Bishop's score), carries risks and that individuals should be aware of these risks.

Making the choice to use or not use an intervention involves a set of risks and benefits that every individual has to weigh for themselves. And one of the risks of induction is that it will be long, exhausting, slow, and result in a c-section which, as Pinky points out, carries real risk of its own. That's easy to ignore, though, when the discourse becomes whether people are "for" or "against" epidurals, inductions, c-sections, etc. That obscures the reality that these are not "chocolate or vanilla" choices of personal preference. It makes it easy to ignore the 3-day inductions and c-section complications, or at least to perceive them as common outcomes of labor (and so not consequences of the induction) vs. common outcomes of induced labor. It's hard because I think many people are trying to spread the word about the risks of induction. But if it's coming across as another "pick your flavor" choice, it's obviously not coming across correctly.

Links - how important is birth? problems with research, VBAC questions, and more

Enjoy Birth and Stand and Deliver and Talk Birth all meditate on the importance of birth - how it shapes women, how it shaped them - and whether or not it is important in shaping women as mothers. All provoked by this post at Sweet Salty. Excellent food for thought.

No Fat Talk Week - I personally celebrate this 52 weeks a year, and invite you to join!

Winning entries from the National Advocates for Pregnant Women writing contest. How's this for a title: “In the Manner Prescribed By the State”: Potential Challenges to State-Enforced Hospital Limitations on Childbirth Options. I like!

Melissa lists questions to ask a VBAC provider.

Amy at Science & Sensibility asks Do We Need a Cochrane Review to Tell Us That Women Should Move in Labor?. She says, "Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice." Read the rest on how this is a bass-ackwards way to go about things. It's alerted my eyes to look for the same issues in breastfeeding research.

Aaaand a new favorite (via, as so often, The Unnecesarean), Arwyn explores the analogy between athletics and childbirth:

"Everyone has heard of and no one doubts the existence of “runner’s high”, so why do we start plugging our ears and rolling our eyes and flapping our tongues when we speak of “birthing high”? ... Even discounting that, or in its absence, there is potential for pride and a sense of accomplishment: something we value so much in athletics, yet scoff at in childbirth, where our effort benefits both us and another. We deny women that pride in accomplishment (for which support of athletics is so vital to girls’ sense of self and women’s equality), that boost in self-esteem and feeling of competency, right when we need it most: at the start of parenting, one of the most demanding journeys a person can undertake."

And that's enough for tonight!

Update your links

On my short list of blogs you should be reading (besides mine) is Jill's The Unnecesarean. She recently had a sad case of domain-stealing, so update your links from Unnecesarean.com to TheUnnecesarean.com (or add it now if you haven't yet).

Just recently she has had in-depth information and discussion on how refusing an unnecessary c-section led to loss of custody, the outcome of charges against a doctor for being abusive towards a woman in labor, and noted the new Cochrane Review stating that use of antibiotics for GBS in labor is not supported by evidence. See? You don't want to miss this! And I can't link to all of it (just a lot).

Electronic fetal monitoring = FAIL?

This is what I learned in epidemiology. When deciding whether to use a test, you need to look at several characteristics, including:
Specificity: How good it is at correctly identifying negatives (does it successfully identify healthy people?)
Sensitivity: How good it is at correctly identifying positives (does it successfully identify sick people?)
Reliability: How consistent is it - will it give similar results with multiple retests? If it is subjective, do multiple assessors give similar scores?
Validity: Does it actually measure what you are trying to measure?

So how does electronic fetal monitoring measure up, according to this recent New York Times article?

Sensitivity & specificity:

...in more than 99 percent of cases, predictions based on the tracings that the baby would have cerebral palsy have proved wrong.

Reliability:

Doctors differ greatly in how they interpret tracings. In a study in which four obstetricians examined 50 fetal heart rate tracings, they agreed in 22 percent of the cases. Two months later, the same four doctors re-evaluated the same 50 tracings and changed their interpretations on nearly one of every five. Furthermore, when the baby’s outcome is already known, interpretation of the tracings is especially unreliable, the guideline report says.

Validity:

...monitoring the fetus during labor does not affect the risk of cerebral palsy, because 70 percent of cases occur before labor begins and only 4 percent result solely from a mishap during labor and delivery.


So EFM doesn't accurately measure risk to the baby and is interpreted very differently by different clinicians, and even very differently by the same clinicians at different times.

“Honestly, the technology got rolled out before we knew if it worked or not,” Dr. George A. Macones, an obstetrician at Washington University in St. Louis, said in an interview.

Oh, so maybe we should perhaps reduce routine continuous EFM?

Apparently not - just interpret it better, with three new categories of risk:

[ACOG] hopes the revised guidelines will reduce misinterpretations and inconsistencies in the understanding and use of readings on fetal monitors, although experts are not optimistic that the rate of Caesareans will drop.

I don't think it would take an expert to tell you that.

5 things that being a doula changed about me

I think being a doula changes everyone who does it, to some extent, but I think it may have changed me a little more than average, because I took kind of an unconventional path to becoming a doula. There are many reasons people go through doula training and start attending births, but probably most start out with a real passion for natural birth and for supporting women during this special time in their lives. I thought those things were really interesting, but I also wanted a job. I was graduating college and I wanted a job where I would move to a new city, try out this whole "public health" thing, and hopefully get some new skills out of it. And I got a job in Denver that fit those criteria, through AmeriCorps, where I would do various things including be trained and work as a doula.

If I hadn't been hired for that job, I would have taken one in Minneapolis working for a refugee health organization on issues like tuberculosis control and mental health services. My guess is I would never have pursued doula training independently - I would have been interested, but never interested enough to actually put the money and time in.

So unlike other people who go through doula training, I didn't have any strong belief systems about birth going in. I had always been fascinated by birth - I watched "A Baby Story" religiously in high school. But I thought the epidurals on "A Baby Story" looked pretty sweet, and based on the stories my aunt told about her labors I had already decided that someday I'd get me one of those. I had started to get more familiar with issues of medicalization by writing my senior thesis on breastfeeding, but knew little about birth. I was not at all comfortable with homebirth - I thought it sounded unnecessarily risky. But that was kind of it.

By the end of the year I had attended over 30 births, all in hospitals, taught childbirth classes, newborn care classes, and done breastfeeding support. How did all that change a birth neophyte?

1) I became much more proactive about all aspects of my own health care. I no longer expected that health care providers would just tell me the "right" thing to do, because I realized that in many situations, there was no one "right" thing to do. Instead, I followed up medical advice with my own research and judgment. I asked more questions in the doctor's office ("What do these numbers mean? What would be normal? What if instead of taking action, we wait to see what happens?") Ultimately, I realized that I made my own medical decisions - and always had, even if that decision was just to do what the doctor said.

2) Correspondingly, I also came to believe that the goal of all women's health care should be empowerment. Pregnancy and birth are a great time for women to begin to take ownership of their health care, because it's such a crucial time period and involves so many health decisions. But why wait until then? Every significant interaction with the health system - annual paper smears, check-ups - should be a chance to involve women in their sexual and reproductive health.

3) When it came time for me to give birth, I no longer wanted the automatic epidural. Yeah, it looked pretty sweet on "A Baby Story". But they didn't show (or at least attribute) the stalled labors, or women itching and itching because of the medications, or such heavy epidurals that women had no idea how or where to push, or epidurals with a "hot spot" of pain. They didn't discuss how a woman with an epidural can't move around to speed her labor or move a malpositioned baby. I wasn't anti-epidural: I saw them as a great tool, where women stuck at 6 cms. for hours finally relaxed, and progressed to complete in 30 minutes. But applied indiscriminately, it seemed like they caused more problems than they solved.

5) I no longer wanted to give birth in a hospital. Over 30 hospital births taught me that anything I wanted that was out of the norm would likely be an uphill battle, and that a lot "norm" practices caused problems. It's not like I saw all uncomplicated births. I saw c-sections for fetal distress. and instrumental deliveries, and shoulder dystocia, but none of them made me feel like I would be better off in the hospital - just that I'd be fine with a hospital easily accessible if needed. Watching women spend their whole labor fighting just to have their wishes respected was exhausting and depressing. There were the occasional exceptions - like the birth story I just posted - but those (like that story) resulted from "textbook" labors where women got exceptionally lucky (not a single nonreassuring heart tone, 1 centimeter of dilation per hour, etc.)

5) I became more aware of disparities in our health system, and more committed to working to overcome them. I am coming from a place of relative privilege in getting all empowered and owning my health care and thinking about out-of-hospital birth. I have the race, class, educational, and financial privilege to easily contemplate all of these things. The women I worked with did not. Many of them did not speak English, nearly all were on Medicaid, very few had access to higher education, most were women of color. They did not have many options for their medical care and they did not have anyone suggesting to them that things could be different. When I get excited about spreading the word about birth alternatives, I have to remind myself that while I may want to make sure all my friends hear my spiel, this is one of the ways privilege works. We need to change not just our own attitudes, but the system. That's ultimately why I'm getting my MPH now - because being a doula and fighting the system one person at a time wasn't enough.

What has being a doula/involved in birth work/learning more about these topics changed about you?

How to make a birth plan

Notice I didn't say write a birth plan! Why? Labor Nurse has a great post up about why writing your birth plan for hospital staff should be the last step in getting your needs met. It's a long and very comprehensive post about what questions to ask your care provider and on a hospital tour, why choosing the right provider and birthplace is so important, and what parts of your birth plan you should negotiate with your provider before ever walking through the hospital door. All this ultimately informs what you need to write down for hospital staff - and it's probably going to be a lot more user-friendly and helpful than some stock plan you print off the internet.

Oh, the induction

A Twittered induction-turned-cesarean. A cesarean for a baby who is just "too big" - at 7 lbs. 12 oz.

One more story to add another little nudge to our culture's perceptions that babies are too big, that all c-sections are necessary, that induction has nothing to do with it.

How to overmonitor birth even more than we already do!

I wanted to highlight a little bit of ridiculousness I found out about via Birth Activist's great post on Creepy obstetric and childbirth technology patents. Introducing...the Birth Track!

Let's discuss a few things on the Birth Track website.

First, "Currently, cervical dilatation and head station are assessed by the physician/midwife manually during vaginal examination. In the usual procedure vaginal examinations are performed numerous times during normal labor."

As Birth Activist so succinctly puts it, the alternative would be to do fewer vaginal exams. Furthermore, what are the problems with numerous vaginal exams? 1) they're uncomfortable for the mother; 2) they increase the risk of infection; 3) they can make people nervous about "lack of progress". Given that the monitors in question are attached to the cervix I can't imagine how numbers 1 & 2 will be improved, and I think 3 would be made even worse.


"The cervical dilatation measurements are performed by a small Ultrasound unit, that is placed on your abdomen, similar to the fetal monitor belt. Also three sensors are attached: two to the cervix and another one which is incorporated into the fetal scalp electrode."

I love how they try to downplay the fact that the monitor is attached to your cervix. "It's monitored by an external monitor! Also 3 internal ones." Note how they assume your water is (has been artificially) broken so you can use a fetal scalp electrode. Oh, wait, note how they assume that you'll be using a fetal scalp electrode (it screws into the top of the baby's head).


"You will have continuous information regarding the progress of labor and you will know the position of your baby every second."

Fabulous! Because continuous information has been proven to improve outcomes. Oh wait - it hasn't? It's been proven to do nothing, except increase the number of unnecessary c-sections? Oh.


"Your partner will be able to be an active participant in the labor process as he/she follows the progress of the partogram on the screen next to your bed."

Being an active participant because you watch labor progress on screen is like being an actor because you watch TV. It's a sad comment on what we think "active participation" in labor is.