The more I am around birth the more I have opportunity to see that these interventions we have can be both blessings and curses to laboring mothers.  The more I am around birth the more I see births that truly did need medical intervention.    And on the flip side the more I am around birth, the more I see births that certainly could have done without so much fiddling.

And so I get to Christine’s post on Pitocin.  I think it’s great because it cautions parents not to  blindly enter into an elective induction or augmentation simply for the sake of time when mama and baby are both doing fine.  I have supported labors where the labor was progressing just fine and the OB ordered Pit simply because that’s how she rolls, and then watched as the baby quickly became distressed.  I have also supported labors where a little Pit at the end of a long labor kept the mom out of the OR by giving her body the nudge it needed to finish well.

So to all you pregnant women check out the link, learn a little about Pit, watch the video clip and then file that info away for your labor or your discussions about inducing your labor. . .

And to you mama’s who have labored before with Pitocin -  I’d love to know what your experiences with Pit have been.  Love it?  Hate it? Necessary? Unnecesary?

My personal Pit experience was with number two.  I was unnecessarily induced.  I was in early labor and didn’t realize it and was asked to come in for an induction.  At that point in my life I didn’t even think to question the advice so we went home (THAT should have been a clue that the induction was NOT a medical emergency!!) got our stuff and returned for the induction.  Well, I certainly didn’t need it.  Within two hours of starting the Pit, I was in the throes or transition and my dear little daughter was almost born in the elevator on the way to the delivery room.  (She was born overseas in a maternity clinic that had a LABOR floor and a DELIVERY floor.  You have no idea how sensible the whole L&D combo is until you are trying not to birth your baby in the hospital’s elevator!)  I would have much preferred my body’s slower pace because it would have been so much more manageable.   Spreading out all that work over a little more time would have been so much nicer.

So there’s my little trip on Pit.  What’s yours??

Some of these situations we cover are  not necessarily dangerous for the mom or baby, they just change the options that are given to the couple.  Being post-date or going past the due date is one of these.  Depending on your caregiver’s policy induction may highly encouraged anywhere from 39 weeks 6 days to 41 weeks 6 days.  That is a BIG difference.  And if both mom and baby are fine, then they have a lot of options including refusing an unnecessary induction at 40 weeks on the dot.

Another option-changer is breech position of the baby.  While there is a movement in Canada to encourage vaginal delivery of breech babies, the recommended route here in the US right now is surgical.  And since many OB’s do not have the proper training or experience with vaginal breech deliver, I am not comfortable advising moms to ask for vaginal breech delivery with inexperienced caregivers.  So, for parents who find out before the onset of labor, there are many things they can do to encourage the baby to turn: lots of positions for mom to try, chiropractic adjustments, acupuncture, etc can be effective at turning many babies.

So when preparing for these discussions tonight, I came across Dr. Onyeije’s presentation on avoiding a Cesarean.  It mirrors so many of the things I try to stress in class, the  most important being finding a caregiver who shares your perspective on birthing.

That one thing can pave the way to avoiding so many difficult situations for a pregnant couple.  If you are wanting a natural childbirth and go to a practice with a high rate of intervention, then you will probably be very discouraged.  If you want every bit of technology used on you and your baby from the first twinge and you are with a more laid back practice, you will be so frustrated when they send you home from the hospital when you are at 3cm and still in early labor. It makes SUCH a difference.  I they to encourage couples that statistically they will not be the exception.  Exceptions are out there, but you can’t expect to be the exception for the particular practice you are using.

So here it is: 

So what does this have to do with healthy low-risk pregnant mothers?  Well, a lot actually.  Let’s say that this healthy low-risk mom finds herself and her baby still healthy and low-risk but she is now 41 weeks pregnant and her provider is recommending an induction.  Not an uncommon scenario. She is not ready to depart from the natural process at this point and expresses that she is not comfortable going in for the induction.  Should this resolution pass, her provider could now threaten to deny her insurance coverage by classifying her as non-compliant or hostile.

I am assuming she is an average expecting mother who does not have an extra $5,000  to $15,ooo laying around just in case she is denied the health care coverage she pays for monthly.  This being the case,  her choices are now:  one, showing up at the appointed hour for her cocktail of artificial hormones that she does not want,   or two, letting labor unfold on its own and facing  major hospital bills, an insurance battle, and oh, that’s right, adjusting to her new life caring for a newborn.

Whatever happened to Informed Consent?  This is where the care provider makes a recommendation for the patient, explains the risks and benefits of the procedure and allows the patient to make the decision that she feels most comfortable with.  The patient is the one who has to live with the consequences of any decision made about her care, so she and her partner should be the one to make the final call.

Already as a childbirth educator I know of situations where a mother has arrived at her hospital in early labor.  Once she finds out that she’s only 3cm, she wishes to return home and come back later when she’s farther along in active labor.  This is where the care providers in the hospital tell her that that’s fine, but she’ll have to sign out AMA (against medical advice)  and it’s most likely that her insurance won’t cover her visit.  So, the mom now chooses to stay to avoid an huge insurance hassle and faces the likelihood of many more interventions simply becasue she’s in the hospital longer than she intended.

This has major implications for birthing women, but I will say for all of us as well.  So here is a list of questions for informed consent that I give every couple in my classes:

Informed Consent Questions

•  Is Mom OK?  Is Baby OK?

•  Is this an emergency or do we have time to talk?

•  What are the benefits of doing this procedure?

•  If we do this, what other procedures or treatments might we end up needing as a result?

•  What else could we try first or instead?

•  What would happen if we waited and hour or two before doing this?

•  What would happen if we did not do it at all?

If this passes it will be all the more important for women to make sure that they and their providers share the same perspective on childbirth.

I spoke with a woman last weekend who would love to have a home birth but her insurance won’t cover one.  And the homebirth practice she was considering would cost her close to $7,000.  So then I asked her about going with a group of midwives who have an alternative birthing center.  She informed me that the only maternity reimbursements that her insurance provides are for MD’s.  She is healthy and low-risk and cannot even consider maternity care from a midwife.

I have heard of women whose coverage wouldn’t apply to the birth  if they were “allowed” to go past 41 weeks.  So in order to make sure that the birth was covered by their insurance they must undergo a costly, invasive, medical induction that increases their chances of a cesarean simply becasue their insurance policy arbitrarily states that it must be so.

So now we turn toward Texas where a judge recently ruled that Medicaid is not required to reimburse birthing centers for their facility fee when a woman using Medicaid gives birth there.  Medicaid will continue to reimburse hospitals (at a much higher cost) when women birth there, but the more cost effective option of the birthing center is being denied any reimbursement.  Also this ruling is not limited to Texas; it would apply nationally. Once again a medical plan is not even giving women  a choice when there exist several good options.  I’m not advocating that all low-risk women must give birth in a birthing center, only that if they have that option in their area they should be able to consider it.

If you would like to communicate your opinion about this ruling you can go here to do so: Consumer Letter to Congress

Childbirth Connection has great information on evidence-based maternity care and an excellent discussion of how current reimbursement practices actually encourage more intervention and less tolerance of supporting normal physiologic birth.  Pages 59-67 of their report Evidence-Based Maternity Care: What It Is and What it Can Achieve adress these concerns specifically.

As a childbirth educator and a doula I see my role as helping women to see the full range of options they have in various cincumstances so that they can make an informed decision about their care.  Unfortunately, the reality is that unless these women happen to be of certain means, their options are in reality much more limited than they appear at first glance.

1. Her choice of careprovider made ALL the difference.

She was induced 9 days after her due date with her first baby which started her on the road to her first cesarean.  She also comes from a family whose babies like to come at or around 42 weeks.  So she had two questions when interviewing providers: Do you support VBACs? and Do you wait until 42 weeks with VBACs before encouraging induction?  If the answer to either of those was “No,” she went on to interview someone else.

This was an excellent decision because when she got to the hospital in labor 42 weeks to the day, the doctor on call from her practice clearly wasn’t as comfortable with her VBAC as her regular provider.  If she had been with another doctor,  she could have waited until she went into labor on her own, but she surely would have had much more pressure to induce or schedule another cesarean.

2.  She was  VERY informed.

She read and researched a LOT while pregnant and knew the risks of each of the procedures that were common in her situation (induction, augmentation of labor, etc) and had prepared alternative suggestions that she was more comfortable with.  Being informed was so helpful to her in labor when the doctor on call reminded her of the dangers of VBACs including a ruptured utuerus and dead baby.  She was able to remain calm, remind the doctor that the risk of surgical complication was statistically greater than the dangers posed by VBAC, ask for some juice and continue on with her labor.  She was amazing.

3. You have to deal with the birth you are given.

On her birth plan it was clearly written that she wanted as much freedom of movement as possible.  She knew that as a VBAC she would have continuous electronic fetal monitoring and she would be limited in movement by the length of the wires tethering he to the machine.  Not ideal, but not stuck in bed either.  Then her blood pressure remained high.  So she was instructed to lay down in bed on her left side to reduce her BP.  In that moment she had to choose:  be more comfortable by moving around and jeopardize her chance at VBAC completely,  or lay in bed, deal with the increased discomfort of her labor and stay on the path to a VBAC.   She valiantly chose the latter, watched her BP drop significantly  as she labored on one side or the other,  and stayed on that path to pushing out her baby on her own.

It was amazing.

“We have a secret in our culture, and it’s not that birth is painful. It’s that women are strong.” - Laure Stavoe Harm