Sunday, March 20, 2011

Induction and Augmentation of Labour

I'd love it if you could let me know if you found this helpful or not, and let me know if you want me to write more about anything mentioned here. Thanks!
First of all, we should discuss the reasons for which induction should not be done in and of themselves. In these cases, the risks of induction outweigh the benefits.
  • Doctor, midwife, or family’s schedule, ie. Relative is leaving town and wants to see the baby before they leave or Mom’s preferred doctor is going on vacation.
  • Mom is uncomfortable or impatient
  • Gestational age 40-42 weeks
  • To pick (or avoid) a certain birth date
 Secondly, occasions where an induction MAY be called for, but there may also be other alternatives.
  • Low amniotic fluid. To help prevent this diagnosis, make sure to drink a lot of water, especially in the days before an ultrasound.
  • Baby’s size. With the exception of some women with diabetes or a true malformation of her pelvis, a woman’s body usually will not grow a baby that she is not capable of pushing out.
  • Gestational age 42+ weeks. You can do non-stress tests (NSTs) once or twice weekly to make sure Baby is doing well.
  • Maternal illness, such as diabetes, kidney disease or high blood pressure.
  • Prelabor Rupture of Membranes (PROM). The amniotic sac breaks open before labour starts. As with AROM (see below) care practitioners do not like to allow you to go more than 12 to 24 hours with the membranes ruptured without giving birth. However, studies do not show any increased risk of infection as long as labour starts within 72 hours of ROM. Meconium staining, maternal fever (a sign of infection), and increased number of vaginal exams all increase risk.
Thirdly, when an induction is probably necessary.
  • Uterine infection
  • Fetal illness
  • Severe maternal illness
  • Preeclampsia
RISKS OF INDUCTIONIncreased risk of premature baby even if your calculations say that your baby is term.
  • Placental abruption
  • Fetal distress
  • Uterine rupture
  • Increased risk of cesarean section. Having a cesarean after a long labour or failed induction is associated with increased risk of complications than a planned cesarean.
  • Increased use of interventions including pain medications and continuous fetal monitoring.
Yes. You'll need to have a c‑section (or, preferably, wait for labour to start on its own!) rather than an induction whenever it would be unsafe to labor and deliver vaginally, including the following situations:
  • Tests indicate that your baby needs to be delivered immediately or can't tolerate contractions.
  • You have a placenta previa or a vasa previa (when blood vessels from the umbilical cord are embedded in the amniotic membranes and at risk for rupture during labor); or the cord is lying in front of your baby's head and could be compressed as his head enters the birth canal or prolapse through your cervix when your water breaks.
  • Your baby is in a breech or transverse position, meaning that he's not coming head first. (Breech babies can be birthed vaginally but should NOT be induced.)
  • You've had more than one c‑section. (Some practitioners believe that women with even one previous c‑section shouldn't be induced.This doesn't mean that you cannot birth vaginally though!)
  • You had a previous c‑section with a "classical" (vertical) uterine incision or other uterine surgery, such as a myomectomy (surgery to remove fibroids).
  • You're having twins and the first baby is breech, or you're having triplets or more. (As with a single breech, twins and triplets can be birthed vaginally, but should not be induced.)
  • You have an active genital herpes infection.
HOW - MEDICAL METHODSArtificial Rupture of Membranes (AROM or amniotomy)
  • Using an amniohook (looks like a crochet hook with a sharp point on the end), your doctor or midwife hooks the amniotic membranes and creates a tear, releasing the amniotic fluid. You may continue to leak fluid throughout your labour.
  • The procedure should not be any more painful than a regular vaginal exam.
  • If you have not been contracting, you may start having contractions or feel like your baby has dropped further in your pelvis.
  • If you have been contracting, this is called augmentation. You will likely feel the contractions increase in intensity and frequency.
  • You might not be allowed to take baths due to the risk of infection (studies do not show any increased risk, but some care providers do not allow it anyways) so you lose that pain management technique. Taking a shower should be okay, but does not provide as much relaxation (and thus pain relief) as a bath does.
  • Your temperature and blood pressure will have to be monitored for signs of infection, possibly as often as every 10 minutes.
  • There is no going back after AROM. The baby must be born. If the baby is not born after 12 to 24 hours, your doctor will probably pressure you to have more interventions or have a cesarean section.
  • Risks include:
    • fetal distress
    • failure of labour to start
    • augmentation of induction with Pitocin if labour does not start on its own
    • increased risk of infection if baby is not born within 72 hours
    • increase in fetal malposition
    • increase risk of cesarean section
    • increased pain and so increased risk of pain medications like epidurals being requested. Many women choose to just go ahead and get an epidural before AROM because the pain is so intense afterwards. This risk is lessened if AROM occurs shortly before the birth of the baby.
    • risk of catching the umbilical cord in the amniohook, causing it to bleed and putting the baby in extreme danger.
  • Synthetic form of Oxytocin, the hormone your body produces to start and maintain contractions.
  • When your body produces Oxytocin, it also produces endorphins to allow you to manage the pain (pressure) of the contractions. When given Pitocin, however, your body does not know what is coming and so you do not get the benefits of the endorphins.
  • Your body's natural production of oxytocin will slow down when you are given pitocin, so once pitocin is started, it can be dangerous to stop it or "turn it down".
  • Pitocin dosage is regulated with a medication pump. It is started slowly but the nurses may increase the dosage every time they come into the room (even if contractions are regular and strong) in an attempt to force the labour to progress more quickly.
  • You will have a continuous IV drip and continuous electronic fetal monitoring.
  • Also used to augment "non-progressive" labour.
  • Risks include:
    • fetal distress
    • possible increased intensity of the contractions and so increased risk of pain medications like epidurals being requested. As with AROM, it is pretty much a given that for most women they will end up getting some form of pain medication if they get Pitocin.
    • increased risk of cesarean section
    • uterine rupture in VBAC cases
  • Gel applied to cervix to help ripen it. May stimulate contractions to start labour. Doctors may insert up to three applications of gel to try to start labour.
  • If it doesn’t work, there is probably no harm done. You can just go home and try again later or wait for labour to start on its own.
  • Risks include:
    • fetal distress
    • possible increased intensity of the contractions and so increased risk of pain medications like epidurals being requested. However, this is much less intense then those caused by Pitocin or AROM.
    • uterine rupture in VBAC cases
Foley catheter
  • A device is inserted in between the amniotic sac and the bottom of the uterus. It is filled with a saline fluid in order to force the cervix open. It eventually falls out as the cervix dilates. You have to be dilated a little bit already in order for it to be inserted.
Stripping, or sweeping, the membranes
  • Done during a vaginal exam towards the end of the pregnancy. The woman may or may not be informed about it ahead of time.
  • The midwife or doctor places a finger inside the opening of the cervix and separates the amniotic membrane from the uterus.
  • You may be very uncomfortable during the procedure. Spotting or bleeding afterwards is common, as is feeling achy or having irregular contractions.
  • There is a risk that the amniotic sac may be ruptured during this procedure (either accidentally or on purpose.)
(Anna's note: Even so-called "natural" methods of induction are still interrupting the natural process and should be taken seriously.)

  • Labor Inducing Eggplant Parmesan
One of the methods of self‑inducing labor that's been sweeping the internet in recent years is the myth that eggplant will start labor. This maternity myth started when a news story began circulating about a restaurant in Georgia named Scalini's. Apparently the mothers of over 300 babies have gone into labor in the past 23 years, within 48 hours of eating the eggplant parmegiana. The funny part is, it may just be that the dish causes the women to go into labor, but it's not the eggplant. The herbs Oregano and Basil have properties that may cause contractions, though it is not yet known how or in what quantities. This is why, in aromatherapy circles, these herbs and essential oils are to be avoided whenever possible during pregnancy.
  • Sex to Induce Labor
Semen contains prostaglandins. Prostaglandins cause the cervix to "ripen", or soften and prepare to open. While it is debatable whether there are enough prostaglandins in semen to have any real effect, it is not a terrible way to keep hope alive and while away the last weeks of your pregnancy. Another great side effect is the fact that orgasms produce oxytocin, the hormone that causes contractions. So, between the two, there is a pretty good case for the cure for pregnancy. (In otherwords, what got you in this condition, may help to get you out of it!)
  • Evening Primrose Oil and Red Raspberry Leaf Tea
Neither will actually induce labor. While some lay midwives will argue that statement about the Evening Primrose, which is the reason it is not recommended until 36 weeks or "full term", almost all sources with experience agree that it does nothing that the body was not ready to do on its own. I will repeat this at the end of this section, to make sure you understand this, as there is a lot of confusion and misconception surrounding these two substances.
Evening primrose oil is an excellent source of prostaglandins, which we already determined readies your cervix for labor. It can be taken orally as soon as 34 weeks, and can be applied directly to the cervix at full term (36 weeks). The general recommendation is two 500mg capsules per day until week 38, at which time you increase to 3‑4 per day. The entire capsule can be inserted vaginally (inserted just before bed, it will dissolve before the first time you wake to use the bathroom), or you can use the oil on your fingers for your perineal massage, then also rub on your cervix (assuming you can reach it). Applying directly to the cervix is optimal, but the beneficial ingredients are absorbed through the external skin or the stomach also.
Red raspberry leaf tea is a uterine tonic used by Native Americans for thousands of years. It tones your uterus by helping to "focus" your Braxton Hicks contractions. Think of its job as helping your uterus do more effective exercising while you are pregnant. It does not "cause" contractions and can be safely used throughout pregnancy. It is contraindicated for those having complications "just in case", however, by most doctors who do not understand its use. Many women safely use it from the moment they learn they are pregnant at six weeks until months after delivery. (It helps to tone the uterus after delivery as well, shrinking it back to size more quickly and reducing bleeding.)
Again, neither of these actually causes labor to start!
  • Castor Oil to Bring on Labor
First let me just say that I do not recommend this method. That is because I used it with my second child and it was just about the most horrible mistake I could have made (other than maybe getting another epidural, anyway).
The theory behind this induction method is that the castor oil causes diarrhea and the diarrheal cramps cause sympathetic cramping in your uterus, another smooth muscle. This is another of the methods that "won't work if you're not already ready anyway", as the sympathetic cramping will be ineffectual if all conditions are not already optimal for labor. In my case, my contractions began 10 minutes after my first dose of oil, hours before the diarrhea began. Therefore, it could not have been the castor oil that brought on labor in my case, and I caused myself all that trouble for nothing.
There has been much debate over whether taking castor oil to induce labor will cause the baby to have its first bowel movement in the womb before birth. This pre‑birth bowel movement, called meconium, can be dangerous, because if baby inhales some of it it can cause pneumonia in the lungs. Meconium is also a widely‑held signal that the baby is in some sort of distress. Most professionals with any experience with castor oil inductions agree that this is untrue. They have found that there is no increased occurrence of meconium in castor oil induced labors over spontaneous labors.
The real danger lies in the mother when using castor oil for labor induction. With the severity of the diarrhea, a laboring woman can quickly become dehydrated. Especially in a typically highly managed hospital birth where a woman is allowed few fluids. Dehydration makes one tired and less able to endure through physical activity. Plus, not only does this endanger breastfeeding (proper hydration is necessary to make adequate milk), but a dehydrated uterus is an aggravated uterus, and an aggravated uterus causes more pain for the mother. More pain makes a woman less able to handle natural child birth and puts her and the baby at increased risk for a snowball of interventions.
  • Nipple Stimulation to Self‑induce
This is a practice often recommended by midwives when a woman is long past due or when labor is stalled. Nipple stimulation causes the release of oxytocin, the same hormone that causes uterine contractions. Many women report, however, that the contractions produced from this method are much stronger and more painful than natural labor, but are not any more effective.
Please note: In order to use this method for induction, you must stimulate the nipples for long periods of time. The usual recommendation is 15 minutes of continual stimulation on each nipple each hour for several hours. So, the amount of stimulation you may experience during intimacy, while nursing an older child, or while pumping your breasts while pregnant will not cause you to go into labor. The general recommendation on these activities is to abstain from them when your condition warrants doctor recommended pelvic rest. Please check with your practitioner before trying this.
  • Acupressure/Acupuncture for Inducing or Augmenting Labour
There are two points on your body that will cause uterine contractions. They are always warned against during pregnancy, though they are widely believed to be another labour inducing method that will not work if you are not already ready to deliver. These points are about four finger‑widths above the inner ankle on your calf, and in the webbing between your thumb and forefinger. You will know when you've found the spot because it will be very sore. You rub your calf, or pinch the webbing on your hand, in a circular motion for 30‑60 second at a time, taking 1‑2 minute breaks in between.
  • Stripping Membranes
There is a procedure your doctor or midwife can perform called "stripping" or "sweeping" your membranes. The healthcare professional will insert their finger(s) into your cervix and sweep from side to side, pulling the membranes (bag of water) away from the mouth of the cervix and the lower uterus, and in the process stretching and irritating your cervix. Sometimes this will generate local production of prostaglandins and enough of the necessary hormones to start labor. Sometimes it takes 3 or 4 attempts to begin labor. Many women find this to be a very uncomfortable, if not painful, procedure. This is a medical intervention and should be taken as seriously as any medical induction method.
  • Herbs and Homeopathic Remedies
All substances that would fall in this category, such as Blue and Black Cohosh are general considered to be as unsafe as medical interventions, and if they are to be used must be used only under the recommendation and supervision of your doctor or midwife.
  • Have a good relationship with your doctor. Make your desires known and make sure they are compatible with how the doctor practices medicine. If you are hoping for an intervention-free birth then a doctor that specializes in high-risk pregnancies and has a 50% cesarean rate may not be the best doctor for you.
  • Same thing goes for where you deliver. You are more likely to get an intervention-free birth at home, a birthing centre, or at a hospital that does not specialize in high-risk cases (assuming, of course, that your pregnancy is not high-risk.)
  • Have a birth advocate. This can be your husband or boyfriend, sister, mom, doula, midwife, or just a close friend. They will stand up for your wishes during your labour when the situation might seem confusing or intimidating to you.
  • Avoid unnecessary ultrasounds.
  • Inform yourself about as much as possible.
  • Drink a lot of water.
  • If you are in close proximity to your birthing place, then do not go there until you are in steady, progressive labour. You will know this if you cannot continue to talk through the contractions. If you go in too early, they are more likely to label it as "non-progressive" labour and pressure you to start augmentation when really you maybe should just go home and relax and go back when labour is more established.
  • Charting your fertility cycles when trying to get pregnant will allow you to pinpoint more accurately when conception took place. This will give you a more accurate due date.
  • Due dates are not “Best before” or “Expiration” dates! View it as a guideline only.

Monday, March 14, 2011

Ultrasounds: Are they safe?

During my first pregnancy, I received five ultrasounds. Not one of them was “recreational”; I did not pay to get a 3D ultrasound. I was happy each time an ultrasound was done though, to get a chance to have a peek into my baby’s life in the womb. I probably would have gotten a 3D ultrasound if I had the money. I figured that they do ultrasounds on pretty much every pregnant woman so surely I would have heard if there was anything dangerous – surely they wouldn’t do it on everyone if there was any danger, right? I did come across a study that stated that women who received 5 or more ultrasounds during the pregnancy were more likely to have a low birth weight baby. I figured that women having problem pregnancies were both more likely to have more ultrasounds and more likely to have smaller babies already and that, although there was a correlation, there was not a cause-effect relationship between the two. Besides, I thought, what’s wrong with having a small baby? I was far more concerned about having a big baby as both Hubby and I were big. I think Hubby was almost 9 lbs and I was over 10 lbs. (I later learned what the risks of a baby having a low birthweight are, but I won’t get into that right now.)

I had three ultrasounds during my second pregnancy. I received my prenatal care from midwives and it was a much more straight-forward pregnancy than my first. I was a little hesitant but my primary midwife assured me that it was safe, so I didn’t turn down any offered ultrasounds. The first was a dating ultrasound. I was eager to get this one as I’d had 4 consecutive miscarriages and wanted to see that heartbeat. We waited on this one until we could do the triple screen to test for congenital defects as well. The second was the mid-pregnancy scan, when we learned we were having a second healthy baby boy.

The last one was to check his size as I was measuring small. I told her that I measured small the first time and I have a small build anyways, but she said that I had to have the ultrasound so that she could continue to be my midwife – otherwise she’d have to transfer care to an OB as there was concern about Intrauterine Growth Restriction (IUGR). I was not happy about this. My belly was growing every week – it just wasn’t the cm per week that they want to see. I think I was 30 cm at 32 weeks and so on. I was also gaining weight every week so I did not see the need for an ultrasound. I was close to my due date and was concerned about being told that my baby was very big (despite the fact that I was measuring small, I knew that he was not small). I did not want that affecting my mental state as I birthed him, and I did not want pressure to induce if he ended up looking big on the ultrasound. Still, the alternative being transferring to OB care (where s/he would almost certainly require an ultrasound anyways), I agreed. It ended up being a very quick ultrasound (about 5 minutes). The technician asked how much my first son had been. I said “7 pounds, 9 ounces.” She said this baby would be about the same size. Phew. (She was off by more than a pound, as very often is the case. My secondborn was 8 lbs, 13 oz.)

I’m currently pregnant with our third child. I got an early one because we were not completely sure of the dating and we will be getting the 18-20 week ultrasound again this time.
Baby is that tiny blob on the right.
What is Ultrasound?
Ultrasound uses very high frequency sound waves which bounce off of the baby and back to the ultrasound wand. The computer interprets these results and draws a picture. 3-D or 4-D ultrasound takes a series of 2-D images of the baby and the computer compiles them together to make a 3-D image. Time is the fourth dimension in 4-D ultrasound.

What is it used for?
There are many things that ultrasounds are used for during pregnancy.
  • Early ultrasounds are pretty accurate at estimated gestational age, give or take a few days. Dating accuracy decreases as the pregnancy continues (later ultrasounds are not as good an indicator of gestational age).
  • Ultrasound can detect the baby’s heartbeat sooner than a Doppler, which can be very reassuring to a newly pregnant mama, especially one with a history of early pregnancy loss. Once the heartbeat is detected, the likelihood of a live birth is 82-98%, depending on the woman’s gestational history.
  • Ultrasound is useful for diagnosing many unusual things in a pregnancy, such as:
    • ectopic pregnancy (when the fertilized egg does not make it all the way to the uterus and implants in the fallopian tube. This is always life-threatening to the mother if the pregnancy continues and requires immediate removal of the fetus and sometimes the fallopian tube, depending on how much damage has been done.)
    • molar pregnancy (when the fetus does not develop normally – it grows into a random mass of cells instead of a baby.)
    • slow growth of the baby. This is done by comparing the results of an earlier ultrasound to a later one. Keep in mind that this is subject to human error as it is the ultrasound technician controlling where the computer starts and stops measuring the baby’s bones. Still, if there is a large difference between how the baby should be measuring and how it is measuring, it could be cause for concern.
    • fetal malformation. This can include some forms of dwarfism, spina bifida, cleft lip and/or palate, and problems with internal organs (heart defects, lung issues, bowel imperfections, etc.). It can also detect some clues that may suggest chromosomal abnormalities such as Down syndrome. It cannot diagnose these, however. Further testing, such as amniocentesis, is required for a diagnosis.
  • Ultrasound is used during diagnostic procedures such as amniocentesis and chorionic villus sampling to verify position of the baby and the needle to try to make sure not to stick the baby with the needle.
  • Placental location can be determined with ultrasound. The concern is usually placenta previa, which is when the placenta partially or completely covers the cervix. This necessitates a cesarean and can be life-threatening to the motherchild if normal labour is allowed to progress. As the cervix opens, the placenta detaches and can cause severe vaginal bleeding. If the placenta is only low-lying (close to but not covering the cervix) then it might migrate away and not pose any problem. Placenta previa is uncommon and is associated with scars in the uterus (mostly from a previous cesarean, abortion, or removal or uterine fibroids), a large placenta (such as with multiples), or an abnormally shaped uterus. It is almost always diagnosed before the end of the pregnancy.
  • Ultrasound can pick up multiple babies and watch for problems such as twin-to-twin transfusion.
  • Too much or too little amniotic fluid can be detected on ultrasound. Either condition can negatively affect the baby.
  • 3-D ultrasound is better at picking up smaller defects than 2-D ultrasound and, when done for medical purposes, can be done quicker than 2-D (thus lowering exposure) as it takes more images at once, which can later be dissected on the computer to get the needed images. “It took a mean time of 1.1 minutes to obtain the 3D volumes…With the standard 2D technique, the structural surveys were done in a mean time of 13.9 minutes”.
What could interfere with ultrasound?
Maternal obesity can make it difficult to get a clear image, especially with 3-D imaging or if it is very early in the pregnancy. If it is very early then a transvaginal scan may be performed instead of an abdominal ultrasound. The technician may have to turn up the intensity of the ultrasound in order to get through layers of fat on an obese mother.

Low amniotic fluid can make it difficult to get a clear image as well. Doubling your water intake for a few days before the ultrasound can ensure that the amniotic fluid levels are at a good level to get a clear image (most pregnant mothers need to drink more water than they currently are anyways).

When are ultrasounds performed?
  1. A first ultrasound is sometimes done early in the pregnancy to confirm the pregnancy and estimate gestational age. Ultrasound can pick up the gestational sac as early as 4.5 weeks, the yolk sac from about 5 weeks, and the embryo from around 5.5 weeks.
  2. If the mother opts for prenatal testing for congenital defects (called the triple or quad screen), then an ultrasound will be performed between 11 and 13 weeks. 5% of women who do this test will receive a false positive for Down syndrome. This means that for 1 out of 20 women who get this screening test, the ultrasound will show a high risk of having a baby with Down syndrome when, in fact, the baby does not have it. Around 90% of couples expecting a child diagnosed with Down syndrome prenatally will choose to end the pregnancy so accuracy is extremely important. A positive screening result is usually followed with amniocentesis (after 15 weeks) which is 98-99% accurate; however, it comes with a 1 in 200 risk of miscarriage. If you know that you would choose to continue the pregnancy if you received a positive result, then you may not want to risk it.
  3. A second trimester scan is done between 18 and 20 weeks. This is the most commonly performed scan. This is mostly to check for congenital malformations, multiple pregnancies, placental position, and fetal growth. If the parent(s) would like to know the gender and the baby cooperates, then it can often be detected at this ultrasound.
  4. A scan may be done towards the very end of the pregnancy to check the baby’s positioning if there are concerns about a transverse or breech lie, assess fetal growth, and verify placental position.
  5. Parent(s) may choose to get a 3-D or 4-D ultrasound as a “keepsake”. Most of the time they must pay out-of-pocket for these as they are not prescribed by a doctor. Some places offer a series of up to 6 ultrasounds over the course of the pregnancy.
  6. A scan may be done at any time if there are concerns about the baby or the pregnancy. This may be indicated by premature spontaneous rupture of membranes (amniotic sac breaking before 37 weeks gestation), unexplained vaginal bleeding, abnormal (increased or decreased) fetal movements, or some other circumstances.
Is it safe?
The short answer is that we don’t know. Low birth weights, speech and hearing problems, brain damage, and left-handedness (thought to sometimes be an indicator of brain damage) have been reported by small studies but have not been confirmed by larger studies. Some abnormalities have been observed in studies using animals, but this hasn’t been seen in studies with humans. I can’t word it better than I see here, so I will just cut and paste what is written.

In general, practitioners of fetal ultrasound operate on a Titanic Mentality:  Safety is assured, therefore precautions are unnecessary.  I would be happy to be proven wrong.  Tina Ureten, the operator of a chain of commercial entertainment/bonding fetal ultrasound facilities in Canada (UC Baby), made this point in a spirited response to criticism in the Aug 26, 2003 edition of The Medical Post (Canada): “Ultrasound has been used extensively by Canadian doctors and health practitioners for more than 40 years without any concern.”  This background of indifference has caused difficulties for me in trying to have output intensities given serious weighting in the tendering and selection process for new equipment.  Vendors repeatedly tell me that they have not previously been asked for this information, and without precedent or support from the wider user community it is hard for someone in a small facility to insist on treating acoustic outputs as a priority in the purchase process. 

Equipment choice can make a difference. The General Electric Logiq 9 provides satisfactory fetal imaging for most circumstances with a default Mechanical Index (MI – described in section 3) of about 0.2 using its fundamental frequency.   A recent report (4) gives an MI value of about 1 for second-trimester fetal imaging with the equipment that the authors were using (Philips HDI 5000), which is a similar value to our Toshiba Aplio. While it is not possible to know how much of the rise in acoustic intensities over time was really necessary for essential image improvements and also to satisfy increased penetration requirements in our increasingly obese populations, I have not seen a 1000-fold increase in image quality since 1980. (Anna: emphasis mine)  Comparison with mammography, where there has been intense consumer-driven demand for dose reduction and image improvements, is instructive:  “Standardization of mammography led to a decrease in mean glandular dose from 14 to 1.8 mGy with concurrent improvement in image quality” (5).

Specialized diagnostic ultrasound has been shown to have a therapeutic role in some stroke situations by helping thrombolytic treatment for blood clots involving the middle cerebral artery; this made the grade to publication in the New England Journal of Medicine (13) with commentary and mechanism speculation (14).  The device was different from those used in fetal scanning, there was a deplorable absence of ultrasound intensity measurements/calculations and the duration of exposure was beyond most fetal situations, but the point remains that ultrasound exposure in the diagnostic range of intensities can have demonstrable biological effects.

Unintended Adverse Consequences
Perhaps the most interesting example of unintended adverse consequences in obstetrics is the history of the use of diethylstilbestrol (DES) (18, 19)

Reference 18 is a Centers for Disease Control (CDC) summary with relevant links.  The drug was prescribed to prevent miscarriages; although it was shown to be ineffective in 1953 it continued to be used until the unusual complication of clear cell adenocarcinoma of the vagina in some of the daughters of women who had taken the drug in pregnancy was recognized in 1971.  If this distinctive adverse effect had not occurred when, if ever, would the increase in more commonplace problems of infertility and complications of pregnancy in women who had been exposed as fetuses have been recognized?  A reliable source tells me that she heard a radio interview some years ago in which it was mentioned that the first recognition of the DES-carcinoma of the vagina association was by a group of mothers of affected daughters conversing in an elevator and not by the preceding medical investigational interviews.

Reference 19 has an ad from 1957 recommending one brand of DES for all pregnancies.

A disturbing consequence of the ability to identify fetal gender has been termination of female fetuses in some societies; it has been estimated that up to 10 million female fetuses have been aborted in India in the last 20 years (30).

There is far more information on this website, I encourage you to read all of it.

One big risk (possibly the biggest) is over- or under- diagnosis by poorly trained technicians and/or poor equipment. The emotional strain on a pregnant mom who has received a positive screening test and is waiting for more conclusive results is huge. A couple may make the difficult decision to end the pregnancy if a poor outcome is predicted only to discover afterwards that their baby had been misdiagnosed or they may be told that their baby is fine and then be unprepared when they discover their child has special needs when s/he is born. Keep in mind that ultrasound and other diagnostic tests are not perfect and there is no way to ensure that every extraordinary circumstance is discovered before the birth. There will still be babies born with previously undiagnosed birth defects, the location of the placenta cannot always be determined, and surprise twins even pop up occasionally.

Even as a mom who did not receive a positive screening, but was just waiting to get the results back, it put a lot of stress on me. With my first, I didn’t hesitate to get the screening. With my second, I hesitated but got it. With my current pregnancy, we decided not to do the screening. I would choose to continue the pregnancy so I am okay with waiting until the mid-pregnancy ultrasound when they will check for markers of any defects just so that we can be prepared when the baby is born. The mid-pregnancy ultrasound is very important to us, personally, because we are preparing for our second homebirth. We want to make sure that the placenta location is good, how many babies we are having, and if there are any issues that the baby may have that would make it better for him/her to be born in a hospital.

For those of you that put a lot of stock in the recommendations of government organizations, here they are:

Ultrasound Equipment Used in Making Prenatal Videos for Entertainment
The Food and Drug Administration (FDA) has become aware of several enterprises in the U.S. that are commercializing ultrasonic imaging of fetuses by making "keepsake" videos. We are concerned about this misuse of diagnostic ultrasound equipment
From a medical standpoint, ultrasonic fetal scanning is generally considered safe, and should be used without hesitation when clinical benefit is expected. But ultrasound energy delivered to the fetus cannot be regarded as innocuous. Viewed in this light, exposing the fetus to ultrasound with no anticipation of medical benefit is not justified. Thus, we believe that these prenatal entertainment videos should not be performed.
Persons who promote, sell or lease ultrasound equipment for making "keepsake" fetal videos should know that we view this as an unapproved use of a medical device, and that we are prepared to take regulatory action against those who engage in such misuse of medical equipment.

Concern about Fetal Ultrasound for Keepsake Videos
In all instances, the risks of fetal ultrasound will depend on the ultrasound levels and duration of exposure. The ultrasound level is now displayed on the monitor, and this lets qualified operators assess the potential for damaging the fetus. Risks can be minimized by keeping the ultrasound level and exposure time as low as possible without losing the information needed for diagnosis.
When fetal ultrasound is done for a keepsake video, no medical information is provided to justify exposing the baby to ultrasound.

Health Canada recommends that you have fetal ultrasound only on referral from a licenced health care provider.

Health Canada's Role
Health Canada regulates diagnostic ultrasound devices under the Food and Drugs Act, the Radiation Emitting Devices Act, and the Medical Devices Regulations. This ensures the safety and effectiveness of the devices when they are used for their licenced diagnostic purposes and according to guidelines for safe use.

Health Canada has established Guidelines for the Safe Use of Diagnostic Ultrasound. The Guidelines state that ultrasound should not be used for any of the following activities:
  • to have a picture of the fetus, solely for non-medical reasons
  • to learn the sex of the fetus, solely for non-medical reasons
  • for commercial purposes, such as trade shows or producing pictures or videos of the fetus
Health Canada is also working with the Society of Obstetricians and Gynecologists of Canada (SOGC) to develop a user-friendly clinical practice guideline on the safety of obstetric ultrasound.

UK Department of Health has stated similar concerns here (It’s very long and won’t allow me to copy and paste. Scroll down to pages 64-65).

I have not been able to find any statements about ultrasound from Australia’s Department of Health and Ageing.

The general verdict is that, because we don’t really know what dangers there are, to limit ultrasounds only to those which are medically indicated – just as you wouldn’t take a drug that had unknown effects during pregnancy unless it was absolutely necessary. The current trend towards “recreational” ultrasounds for the sole purpose of a picture for the baby book or to learn the baby’s gender is disturbing. Some parents have even purchased 3-D machines in order to be able to see the baby whenever they want. “Keepsake” 3-D ultrasound booths in malls have been banned. We don’t know for certain that it is 100% safe so why risk your baby’s safety when there is no medical indication to do so? Is it really worth possibly risking your child’s health by getting unnecessary ultrasounds just for that picture for the baby book or so you can pick the colour of the nursery walls?

My personal exception to that would be if my baby was diagnosed with something that would make life outside the womb impossible, then I would likely get at least one 3-D or 4-D ultrasound session, if not more, in order to be able to see the child while s/he is alive and more fully enjoy our short time together. I have heard that there are even some companies that provide this free of charge in this circumstance.

Keep in mind that dopplers use ultrasound technology to detect the baby’s heartbeat. You may want to consider asking your doctor or midwife to use a fetoscope or pinard horn instead of the Doppler for prenatal visits and request intermittent vs. continuous fetal monitoring during labour (side note: intermittent monitoring is proven just as safe as continuous monitoring. Continuous monitoring increases rates of interventions without a corresponding bettering of fetal outcomes.)

Thursday, March 3, 2011

L's Birth Story - Part 4

What I learned during my pregnancy and birth of Baby #2 (now L)

Between the births of my first and second children, I did A LOT of research on pregnancy and childbirth. I literally started writing my birth plan for #2 about 2 weeks after #1 was born. Around the time he was 18 months old, I started wanting another baby. The only reason I wanted to wait even that long was so that he’d be walking on his own – due to the risk of preterm labour, I didn’t want to be carrying a heavy toddler everywhere during my pregnancy. Hubby wasn’t ready though, and it was 2 more years before God decided to bless us with L.

My cousin’s wife during her pregnancy received prenatal care from midwives. She told me how they spent 45-60 minutes per appointment and talked about how the pregnancy was going, how she was feeling, and anything else she wanted to talk about with them. I was very impressed by this. I felt comfortable with my doctor in that I was confident that she would find anything wrong AND (this was huge) she’d come to the hospital and “deliver” my baby rather than me having to use the on-call doctor. However, our appointments were 5 minutes long on average. She’d take my blood pressure, check the baby’s heartrate, measure my fundal height (height from my pubic bone to the top of my uterus), and I’d leave a cup of pee with the receptionist. If I had any questions or concerns, I frequently had to stop her on her way out the door in order to ask them. Her replies were rushed, as she had many patients and was often overbooked and running behind. We could count on waiting 1-2 hours past the start of our scheduled appointment time in order to see her. I did like her as a doctor. She rarely puts pressure on us to do things that we don’t want to do. She’s just very, very rushed.

So when I learned I was pregnant in the spring of 2008, I immediately called a group of midwives. They were closed so I left a message and got a message on my machine to call them back before I was 6 weeks along to make sure I got in as they’re usually booked up by 7 weeks. Wow. Unfortunately, I miscarried that baby so I never called them back. I was so devastated that, despite my passion for pregnancy and childbirth, I wasn’t able to read any books or watch any shows about it for a couple of months. After I had healed for a bit, I decided to get more involved in the birthing community through doula work. Hubby and I didn’t feel ready for another pregnancy, but I still loved pregnancy and childbirth and didn’t want to be totally cut off from it. I’d wanted to do this for years and it felt like the right time. I signed up for a doula workshop through DONA and sent in my fees. About a week before the workshop, I learned I was pregnant. After 4 consecutive miscarriages, I was very concerned but also hopeful. It was pretty special doing the workshop while pregnant as I was looking forward to this baby’s birth. It was very emotional as we heard other women’s birth stories and learned how to support women in the childbirthing process.

I was only 3.5 weeks pregnant when I called the midwives this time. The receptionist laughed that I’d called so early, but I wanted to make sure that I got in. They booked my first appointment for when I’d be 10 weeks along and it was a LONG wait – both for fear of miscarriage and because of my excitement to meet my midwives. I was under the false impression that all midwives were like the famous Ina May and had never even heard the term “medwife”. Hubby and I met our primary midwife, Wendy Wong, and the appointment took about an hour. What a huge transition from the 5 minutes at the doctor! I was already convinced when I walked in the door that I wanted midwifery care, but since it was our first time with them, she explained what they do and don’t do (They don’t do epidurals, cesareans, etc but they can be in the room with us still for emotional/informational support. They do pretty much anything else.) She told us that they’re experts at taking care of low-risk pregnancies but also know how to recognize signs of problems – in order to determine that a woman is low-risk, she explained, they have to first rule out any problems that would place her in the high-risk category. She gave us a list of what would put a women into high-risk and would require that she seek maternity care elsewhere. Some of the things on the list were questionable, “red flags” were how she put it. If I had one red flag (twins, VBAC, breech, etc) then I could possibly remain under their care, but if she saw more than one, then she’d likely recommend that we transfer to an OB. There were a lot more to the list but that’s all that I remember now. I remember thinking, “wow, that’s a long list and I’ve read lots of birth stories where the midwives handled these issues just fine, even when there was more than one issue in the same woman.” But I figured it was probably just a CYA thing and wouldn’t be much of an issue. Besides, I didn’t have any of those issues so far. The only exception was the preterm labour last time. However, since he hadn’t been born early, she said it didn’t really count but they’d still watch for it.

At the next appointment, my mom and I met my backup midwife, Tracy Franklin. I’m not sure why, but I didn’t feel as comfortable with her initially as I did my primary (this feeling didn’t last though and I soon felt even more comfortable with her than with my primary). She took about an hour again, as we told her the medical history from both sides of the family.

I think it was about halfway through the pregnancy before we decided to prepare for a homebirth. Hubby was uncertain of it. He fully supported other women’s right to choose a homebirth, but didn’t feel comfortable with it for HIS wife. We watched BOBB (Business of Being Born) together. The first birth is a wonderful, peaceful waterbirth at home. He said, “Can you have a birth like that if you birth at home?” Knowing how many variables there are to birth, I didn’t promise him that my birth would be exactly like that, but did tell him that I *could* have a birth like that. It was an option. It definitely would not happen in the hospitals as no hospitals close to us allow waterbirth. He said then he would support it, as long as no issues showed up during the pregnancy that would necessitate a hospital birth. I was so happy to hear this!

We spent most of the appointments discussing what could happen during the birth and grilling the midwives about what they’d do.
- What if my water broke and there was no labour? How long would they wait before recommending induction? (72 hours from time of SROM – if I hadn’t started labour by then they’d recommend induction. Of course, it was imperative to keep EVERYTHING out of there – no vaginal exams, no s*x to try to induce labour, etc. There’s hardly any risk of infection as long as nothing going inside and introducing bacteria to an otherwise usually sterile environment. They said I could still take baths because bacteria can’t swim and the nature of the birth canal keeps itself clean) I was satisfied with this. Many doctors induce labour immediately when the water breaks, or maybe give the women a few hours if they’re exceptionally patient doctors, and they do copious amounts of VEs, and restrict access to water – showers only, no baths.
- What if I went into preterm labour? (Then they’d have to transfer care to an OB, but they’d still try to stay there with me and assist during the birth.)
- What if the baby got stuck? I don’t know what made me ask this question – probably just covering all my bases. (They’d put me flat on my back, McRobert’s position. I did not like this. I asked about the Gaskin maneuver (hands and knees) and she said they used to do that but now do McRobert’s. She said I could try the Gaskin maneuver but if that didn’t work, they’d do the McRobert’s. I was satisfied that I could at least try it. In the end though, I was not given the option to try it.)
- I asked them about not doing immediate cord clamping/cutting. She (Wendy) said that was fine, as long as the baby was doing well. If the baby needed oxygen or suctioning, they’d have to take him over to the table (had to be a flat surface, preferably at waist height in case paramedics had to deep suction him). She said this did not happen a lot, and usually just when there was meconium present. I asked her what about studies that showed that suctioning did not improve outcomes for babies born with meconium and may in fact cause them to gasp for air, increasing the chance that they will aspirate some meconium. Suctioning can also cause oral aversions, negatively affecting breastfeeding. She asked me to email her the link to the study, which I did, but I never heard a response about it and didn’t see her again until the day after the baby’s birth.
- They said if I had Strep B, I could still have a homebirth. They’d come as soon as I was having contractions to give me the first dose, leave a hep-lock in and leave for awhile and then come back closer to the birth and give me the second dose. I thought that was pretty cool. I didn’t have it so it was a non-issue.

Overall, I was pretty satisfied. On the areas where what they routinely did conflicted with what I wanted, they agreed to make compromises as long as it was still safe. This CAN be a warning sign. Frequently care providers, especially doctors but occasionally midwives, will revert to what they always do, regardless of what you’d asked them for. For example, many doctors will reassure first time moms that they only do episiotomies when they feel it is absolutely necessary. What they do not tell her is that many feel that an episiotomy is necessary for every single first time mom. Some doctors will “allow” a woman with a prior cesarean to do a trial of labour (TOL), and then something will happen (or not actually happen, but the doctor will invent it or say s/he is afraid it might happen) at every single one of these births that the doctor feels requires a cesarean. If your doctor says s/he will allow TOL but has close to a 100% repeat cesarean rate, RUN don’t walk to find a new caregiver.

One HUGE warning sign was when Wendy was going over what would probably happen at the birth. We’d already decided to prepare for a homebirth. She started out with, “When contractions are x amount apart and x seconds long, (I forget the numbers now, it’s been awhile) then you’ll go in to the hospital. If I’m already there or close by then I’ll come assess you, otherwise a triage nurse will check you and if you are not dilated enough they will send you home. If you are, then they’ll page me to come. If you’re past 4 cm, then I’ll break your water (AROM).” I stopped her there and asked why she would break my water. She said, “Oh, I just usually do that in order to speed things up.” I told her I did not want AROM as it often makes the labour a lot more difficult, unbearable even, without pain medication. She looked at me very strange (I suppose wondering what kind of a woman does not want something that could speed up the labour) but agreed not to break it for no reason but routine. I expressed that I wanted to be consulted and to give my permission before ANY interventions were done, which she agreed to. I was still uneasy that she’d assumed I’d end up at the hospital even though I wanted a homebirth and that she routinely did AROM at 4cm. I wondered what else she did routinely that she might be forgetting to tell me about. This, combined with the suctioning discussion made me question if I wanted her at the birth but I felt I didn’t really have a choice. Midwives are booked up by 7 weeks here and I was close to full-term. I had long talks with Hubby about what I wanted and he assured me that he’d defend me and would make sure I got what I wanted in case something else was being pressured on me. In the meantime, I prayed that she would be off-call at the time and I’d get my back-up midwife. As it turned out, this is exactly what happened.

All of this to say, I learned that it’s worth putting effort into seeking out caregivers that have the same birthing philosophy as you do. I was afraid that I would offend her by asking her too many questions or by requesting a different midwife. I even mistakenly assumed that all midwives were the same and provide the same type of care that I’d read about – with utmost trust in women and their ability to birth their own babies without intervention. Midwives are people too and as such, are as different from each other as anyone else is. Most people put more effort into finding a good mechanic than finding a good health care provider during pregnancy and childbirth.

Soon after L’s birth, I wrote the following paragraph at the end of his birth story:
“I wouldn’t say that it was the best birth I could have asked for. I would have loved to have been in less pain. I would have loved for his head to have been straight in the birth canal instead of skewed to the side. However, a lot did go right. I actually prefer my secondary midwife and ended up having her as my primary for the birth. Had I been in the hospital, I most likely would have gotten an epidural. Considering his size and how difficult it was to get him out with no pain medication, had I been numbed, I most certainly would have had at least an episiotomy, and probably a vacuum assisted delivery or caesarean. I’m very glad to have avoided that (despite having begged for it during labour). I’m glad that I was able to approve of every intervention (homeopathics, AROM, pitocin) instead of it just being done out of routine. I had wished for a totally intervention free birth, but everything that was done had a purpose so I’m completely okay with it. My baby is perfect and I couldn’t ask for more than that.”

Over time, though, my opinion has changed. I do believe that some of the interventions were unnecessary. I didn’t even think of them as interventions at the time. Vaginal exams, holding back the cervical lip, and birthing flat on my back did not seem to “intervene” with the birthing process. However, I got so hung up on the numbers that I believe the VEs were detrimental. I know that women can go from barely dilated to baby in arms in less than an hour. I know that women can stay at 7 cm for hours or even days. Believe it or not, babies will be born even if there is no vaginal exam! I know, crazy talk eh? Putting fingers up there is not in any way required by nature for a baby to be born. There are other ways for midwives to tell how dilated a woman is (yes, really! See the link below) than performing a VE. I forgot to mention this to my midwife yesterday, so I’m glad that I am writing this as it reminded me to bring it up next time.

Also, it was due to the VE that I was asked to change from the only comfortable position that I found during the labour. I was leaning over a birthing ball. I think this was taking the baby’s head off the cervix, allowing him to find a better position to be born in. However, because the baby’s head was not putting full pressure on the cervix, it closed up a little bit. Had my midwife and I just trusted my body, I believe I would have stayed in that position for longer, baby would have turned his head straight, and we would have gone on from there. Instead, I got upright, put his head right back on the cervix – still tilted, and this caused continuing incredible pain, a cervical lip, and possibly, why he was stuck.

I also felt pushy at one point. My body was making small bearing down movements. I pushed with it once and it didn’t feel right so I stopped. MW performed a VE and said I wasn’t 10 so not to push. So I worked against the urge my body had to push, possibly prolonging the dilation. Those small, grunty pushes can push the baby’s head against the cervix and assist it to open up. Telling me not to allow my body to push encourages me to distrust my body. Perhaps the MW could have encouraged me to allow my body to push if it wanted to, but that I didn’t need to push along with it if it didn’t feel right.

Holding back the cervical lip was probably unnecessary. My firstborn was born with a cervical lip, as are many babies, and no one held it back. I could have attempted to push without anyone holding it back to see if it moved out of the way, or moved to hands and knees to put more pressure on that part of the cervix. Instead, the MW offered to push it aside and, seeing a possible quicker way to the end of the labour, I consented. This meant that I HAD to push flat on my back so that she had access to the cervix so that she could push it out of the way. Having her push it to the side was extremely painful. I put up with it, hoping that it would all be over soon.

Pushing flat on my back was extremely uncomfortable. I had wanted to try other birthing positions and was disappointed that that was the very first position that I was asked to get into to try pushing.

I learned a lot during the pregnancy and birth of my firstborn and learned still more during that of my secondborn. I hope that with all of this knowledge and experience, and having midwives that are much more on the same line of thinking as I am about pregnancy and childbirth that the birth of baby #3 will be all I imagined it to be. Don’t get me wrong. I know birth is unpredictable. I just want to be listened to, respected, and left alone to do what I need to do as much as possible. I like the analogy of a lifeguard. I know how to swim, however, even with a pool full of people who all know how to swim, there is still a lifeguard just in case something unexpected happens. Most of the time, they sit on the sidelines and watch. This is what I want in a midwife. Someone who trusts that I know how to birth and I’m capable of birthing, and just sits and watches in case something extraordinary happens and I need her.

I was going to blog about my midwife appointment yesterday, but I think this is long enough so I’ll blog about it another day.

Here are some links that I found useful that you may too: